key: cord-024077-7o3qhfk3 authors: behrens, kevin g. title: clinical ethical challenges in the covid-19 crisis in south africa date: 2020-04-17 journal: nan doi: 10.18772/26180197.2020.v2nsia5 sha: doc_id: 24077 cord_uid: 7o3qhfk3 nan is a critical need and an ethical obligation for ethics guidelines for decision-making about treatment allocation to be in place before the pandemic reaches the level where tragic choices need to be made. the question now is, what would an ethically sound policy for rationing in a health emergency look like? in a recently published paper entitled "fair allocation of scarce medical resources in the time of covid-19", emanuel et al. write that the literature on resource allocation in pandemics emphasizes four main values that should inform policies: "maximizing the benefits produced by scarce resources, treating people equally, promoting and rewarding instrumental value and giving priority to the worst off ". (2) they go on to make six recommendations derived from these four principles. it is not possible to discuss these in any detail here, and only the four most pertinent recommendations will be briefly discussed in the following. (2) their first recommendation is that the most important value when faced with a pandemic is the maximizing of the benefits of scarce resources. they assert, "priority for limited resources should aim both at saving the most lives and at maximizing improvements in individuals' post-treatment length of life".(2) given the lack of time and information in this pandemic, they go on to claim that it is "justifiable to give priority to maximizing the number of patients that survive treatment with a reasonable life expectancy and to regard maximizing improvements in length of life as a subordinate aim".(2) several recent publications broadly agree with this position.(3-6) emanuel et al. acknowledge that there are many possible ways of seeking a balance between saving more lives and saving more life years, but whatever means of balancing is chosen ought to be applied consistently. (2) this recommendation applies as much in south africa as anywhere else. the biggest challenge it presents in our context relates to the existing inequalities in our healthcare system, where the private sector is far better resourced than the public sector. organs of state ought to be considering ways in which the total pool of resources available in the country can best be employed to maximize the benefits for all citizens, not only the privileged. this can only be achieved through intense cooperation between the two health sectors. the second recommendation responds to the value of "promoting and rewarding instrumental value".(2) emanuel et al. submit that health-care workers, other front-line carers and workers who keep infrastructure running should be granted priority for treatment and the allocation of vaccines. the reason for this is not because these individuals are more worthy than others, it is because they are instrumentally important in the response to the pandemic. also, this assurance could encourage health-care workers to accept the higher risks and continue caring for patients in these circumstances.(2) prioritizing health-care workers is even more justified in south africa where we already have such a shortage of qualified practitioners. the authors also warn against possible abuses of the principle of giving regard to instrumental value by "prioritizing wealthy or famous persons of the politically powerful above first responders and medical staff …. such abuses will undermine trust in the allocation framework".(2) this warning is particularly pertinent in our context in which corruption and nepotism are rife. policies and procedures for the allocation of resources in this crisis need to clearly emphasize equity and fairness and exclude the prioritizing of persons of high social status, solely on the grounds of their status. recommendation three deals with handling patients whose prognosis is much the same. the authors assert that the best way to ensure equality in these cases is to use a random method of allocation, such as lottery. they reject a first-come, first-served process on the grounds that this advantages those closest to health facilities and could encourage crowding at facilities in a time when social distancing is crucial.(2) this recommendation is particularly apt in south africa where transport challenges and distance to health facilities already severely disadvantage some of our most vulnerable citizens. recommendation six asserts that fairness requires that "there should be no difference in allocating scarce resources between patients with covid-19 and those with other medical conditions".(2) since we already have a high burden of disease in this country, it is clear that there will continue to be patients that will face serious and life-threatening conditions, not related to the corona virus. they have the same right to fair treatment as covid-19 patients. another important recommendation made in several recent publications is that treating clinicians should not be the decision-makers in rationing processes at all, but rather that a multidisciplinary triage team of experts be appointed to fulfil this role.(4-6) the critical care society of south africa (ccssa) acknowledges that this may be difficult in many contexts in south africa but advises finding other ways of ensuring that treating clinicians are kept at a remove from these decisions, such as co-opting experts from other institutions or geographical areas to perform this task. (6) recent publications also raise the ethically fraught issue of possibly needing to make decisions to discharging patients from icu beds or ventilators to make way for other patients with better prognoses, despite the risk of critical consequences. generally, they propose that this is not only ethically justified but also it is, in fact, morally obligatory. (2, (4) (5) (6) furthermore, emanuel et al. claim that "the decision to withdraw a scarce resource to save others is not an act of killing and does not require the patient's consent". by now, it has become commonplace to make decisions to withdraw life-sustaining treatment where patient or proxy consent is given, or (with or without consent) in cases where continued treatment is futile. decisions of this nature are made in south africa all the time. it is rare to make decisions to withdraw treatment that is not futile in order to make way for a patient with a better prognosis. however, this is clearly in-line with the principle of saving the most lives and maximizing the benefits of scarce resources in an emergency. if decisions like these will need to be made, it only serves to amplify the need for treating physicians to be protected by giving the responsibility for triage decisions to a separate committee. furthermore, patients from whom treatment is withdrawn should be provided with appropriate palliative and supportive care. (4) (5) (6) this short article provides little more than some general principles and recommendations. for an excellent, adaptable example of a practical rationing procedure for south africa, see the ccssa recommendations(6) and a useful summary flow chart.(7) additional ethics resources related to the crisis can be found at https://www.thehastingscenter. org/ethics-resources-on-the-coronavirus/ and https:// www.nuffieldbioethics.org/topics/health-and-society/ covid-19. ethical framework for healthcare institutions and guidelines for institutional ethics services responding to the coronavirus epidemic. the hasting center fair allocation of scarce medical resources in the time of covid-19 new york state department of health the toughest triage -allocating ventilators in a pandemic covid-19 pandemic: triage for intensive care treatment under resource scarcity allocation of scarce critical care resources during the covid-19 public health emergency in south africa. <https:// cr itic alc are.org.z a/wp-content/uploads/2020/04/ allocation-of-scarce-critical-care-resources-during-the-covid-19-public-health-emergency-in-south-africa. pdf> summary of allocation of scarce critical care resources during the covid-19 public health emergency in south africa key: cord-314138-odmx6ng8 authors: ryu, sukhyun; ali, seikh taslim; jang, cheolsun; kim, baekjin; cowling, benjamin j. title: effect of nonpharmaceutical interventions on transmission of severe acute respiratory syndrome coronavirus 2, south korea, 2020 date: 2020-10-17 journal: emerg infect dis doi: 10.3201/eid2610.201886 sha: doc_id: 314138 cord_uid: odmx6ng8 we analyzed transmission of coronavirus disease outside of the daegu-gyeongsangbuk provincial region in south korea. we estimated that nonpharmaceutical measures reduced transmissibility by a maximum of 34% without resorting to a strict lockdown strategy. to optimize epidemic control, continuous efforts to monitor the transmissibility are needed. i nfection with severe acute respiratory syndrome coronavirus 2 (sars-cov-2) was identified in south korea on january 20, 2020 (1) . by april 21, 2020, a total of 10,683 cases of coronavirus disease in south korea had been confirmed and 237 persons had died (2) (figure 1, panel a) . a large number of covid-19 cases and deaths resulted from superspreading events in the daegu-gyeongsangbuk provincial region of south korea (figure 1 , panel b). on february 23, 2020, during the early phase of the outbreak as the number of covid-19 cases increased, public health authorities in south korea raised the infectious disease alert to its highest level (3) . subsequently, enhanced screening and testing in the community (operation of drive-through screening centers and designation of private hospitals where covid-19 screening testing was available) were implemented (4, 5) . on april 19, 2020, public health authorities in south korea started to relax social distancing measures, which had been implemented on march 21, 2020; as of april 21, 2020, the covid-19 epidemic in south korea had been contained. recent studies have examined how public health interventions can contain covid-19 outbreaks (6, 7) . however, in the absence of information on public health measures against transmission of sars-cov-2 in south korea, we estimated the transmissibility of sars-cov-2 and evaluated the effects of the public health measures implemented outside the daegu-gyeongsangbuk provincial region in south korea. we collected data published by local public health authorities in south korea, including the city or provincial departments of public health. the data comprised date of exposure; date of illness onset; and the source of infection, including contact history and demographic characteristics (e.g., patient birth year and sex). we extracted these line list data of cases by using an electronic data-extraction form. we divided the study into 2 periods, before and after the declaration of highest public alert: period 1 (january 20-february 23, 2020) and period 2 (february 24-april 21, 2020). we restricted our analysis to all other regions in south korea that excluded daegu-gyeongsangbuk provincial region, where there were superspreading events and the data have not been made publicly available (8) . over the entire 3-month study period (january 20-april 21, 2020), data were collected for 2,023 cases, which accounted for 98% of the 2,066 reported cases from the south korea ministry of health and welfare. the median case-patient age was 42 (range 1-102) years, and 820 (41%) case-patients were male (table) . we analyzed the statistical differences in patient age and sex between periods 1 and 2 by using the χ 2 test but did not identify any significant differences. the proportion of cases imported from daegu-gyeongsangbuk provincial regions was 31% in period 1 and we analyzed transmission of coronavirus disease outside of the daegu-gyeongsangbuk provincial region in south korea. we estimated that nonpharmaceutical measures reduced transmissibility by a maximum of 33% without resorting to a strict lockdown strategy. to optimize epidemic control, continuous efforts to monitor the transmissibility are needed. decreased to 5% in period 2. however, during the same periods, the proportion of cases imported from abroad and cases occurring in large clusters increased from 8% to 30% and from 5% to 23%. we analyzed the time interval between illness onset and laboratory confirmation for 818 symptomatic case-patients. we estimated the mean time interval from symptom onset to confirmation of co-vid-19 during periods 1 and 2 by fitting 3 parametric distributions (weibull, gamma, and log-normal) and based our selection of best fit on the akaike information criterion (9) . we found the log-normal distribution to be the best fit for this time interval, with a mean of 4.6 (95% ci 0.0-12.4) for period 1 and a substantial reduction to 3.4 (0.0-9.0) for period 2 (appendix, https://wwwnc.cdc.gov/eid/ article/26/10/20-1886-app1.pdf). to estimate the incubation period, we analyzed data from 181 case-patients for whom precise contact history with other confirmed case-patients was known. the incubation period was estimated by fitting 3 parametric distributions and best fitted by the log-normal distribution; the overall estimated median incubation period was 4.7 (95% ci 0.1-15.6) days (appendix). we identified 44 clusters of infection and 79 case-patients who had had clear exposure to only 1 index case-patient among these clusters (appendix). overall, serial intervals were negative for 8 of the 79 transmission pairs. we estimated the serial interval distribution by fitting a normal distribution to all 79 observations (10). we estimated a mean (± sd) serial interval to be 3.9 (± 4.2) days (appendix). in mid-february 2020, the number of cases rapidly increased; the largest proportion of cases was among persons who had been infected in daegu-gyeongsangbuk provincial region and traveled to other regions of south korea (figure 2, panel a) . to investigate the effectiveness of nonpharmaceutical interventions implemented in south korea (appendix), we estimated the instantaneous effective reproduction number (r t ), a real-time measure of transmission intensity, from daily onset of cases and our estimated serial interval distribution by using the epiestim package in r (11, 12) . r t is defined as the mean number of secondary infections per primary case with illness onset at time t; r t <1 indicates that the epidemic is under control. we present the daily estimates of r t from february 16, 2020, because the stable estimate of r t was not available due to the low number of confirmed cases (figure 2, panel b) . at the end of period 1, on february 21, mean r t peaked at 2.53 (95% credible interval [cri] 1.90-3.25) and then started to decline faster to <1 by february 29. r t further declined and remained at <1 during the rest of period 2, indicating the potential effect of nonpharmaceutical interventions implemented over time (figure 2, panel b) . specifically, mean r t was 2.03 (cri 1.89-2.17) before the 1-week period when the declared public alert was at the highest level and reduced to 1.37 (cri 1.27-1.47) in the following 1-week period, corresponding to a 32.59% (95% ci 23.78%-41.41%) reduction in transmissibility. similarly, along with the high public alert, the implementation of strict social distancing measures on march 12, 2020, was associated with an r t reduction of an additional 9.75% (95% ci 7.23%-12.29%). combined nonpharmaceutical interventions, including enhanced screening and quarantining of persons with suspected and confirmed cases and social distancing measures, were implemented over time. our results suggest that those interventions, without a lockdown, reduced the transmissibility of sars-cov-2 in regions outside of the daegu-gyeongsangbuk provincial region, in south korea. our study has some limitations. first, in our analysis of the changes of transmissibility of sars-cov-2, we did not include the large clustered cases reported as superspreading events because in these large clusters, the reporting date may not be a good proxy for the date of infection and would overestimate r t (13) . second, it is uncertain how many cases were still undetected. this proportion may potentially mislead the actual time trends of number of infections in the population. third, we based our estimation of time delay on self-reported data, which are not free from reporting (recall) bias. fourth, government-generated data, including dates of symptom onset, were not available; therefore, we retrieved online case reports, which could have resulted in some inaccuracies in the information used in our analyses. however, the daily numbers of confirmed cases from the collected line list we used was similar to the numbers in the official daily reports (appendix). our findings suggest that the nonpharmaceutical interventions implemented in south korea during the covid-19 outbreak effectively reduced virus transmissibility and suppressed local spread. however, the population of south korea is still susceptible to further outbreaks or epidemic waves. because social distancing measures will be relaxed while opportunities for importation of infections from abroad continue, ongoing monitoring of the effective reproductive number can provide relevant information to help policymakers control a potential second wave of covid-19. a) the epidemic curve shows the daily number of patients with confirmed cases and symptom onset. for case-patients who did not report any symptoms on the date of case confirmation (n = 1,205 cases; 60% of total), the date of confirmation was plotted instead. b) daily estimated r t and 95% cri of r t ; shading indicates the area below the epidemic threshold of r t = 1. the vertical dashed line indicates the start of the highest public alert on february 23, 2020. cri, credible interval. korean society of epidemiology 2019-ncov task force team. an interim review of the epidemiological characteristics of 2019 novel coronavirus korea centers for disease control and prevention. the updates of covid-19 in republic of korea kcdc risk assessments on the initial phase of the covid-19 0utbreak in korea drive-through screening center for covid-19: a safe and efficient screening system against massive community outbreak korean ministry of health and welfare. list of public relief hospitals evolving epidemiology and transmission dynamics of coronavirus disease 2019 outside hubei province, china: a descriptive and modelling study impact assessment of non-pharmaceutical interventions against coronavirus disease 2019 and influenza in hong kong: an observational study coronavirus disease-19: the first 7,755 cases in the republic of korea information theory and an extension of the maximum likelihood principle serial interval of covid-19 among publicly reported confirmed cases a new framework and software to estimate time-varying reproduction numbers during epidemics improved inference of time-varying reproduction numbers during infectious disease outbreaks first-wave covid-19 transmissibility and severity in china outside hubei after control measures, and second-wave scenario planning: a modelling impact assessment we appreciate the south korea public health authorities' response to covid-19. dr. ryu is an assistant professor of preventive medicine at konyang university, daejeon, south korea. his research interests include infectious disease epidemiology with a focus on public health interventions. key: cord-340342-ft2034hh authors: rumpel, c.; ann, v.; bahri, h.; calabi floody, m.; cheik, s.; doan, t.t.; harit, a.; janeau, j.l.; jouquet, p.; mora, m.l.; podwojewski, p.; tran, t.m.; ngo, q.a.; rossi, p.l.; sanaullah, m. title: research for development in the 21st century date: 2020-07-29 journal: geoderma doi: 10.1016/j.geoderma.2020.114558 sha: doc_id: 340342 cord_uid: ft2034hh nan a recent discussion in geoderma dealt with the occurrence of helicopter research in soil science, an unethical practice, characterized by little involvement of local researchers and indigenous populations, and small benefits to local scientific communities (minasny et al., 2020) . the topic is crucial and will, undoubtedly, cause vibrant discussions. this paper was written by an international interdisciplinary team composed of researchers from 4 continents. we provide a historical perspective on soil research for development integrating the viewpoints of the developed and developing world. we critically assess the way in which countries tackle international research collaboration and provide a way forward towards fruitful partnerships in the 21 st century. it has been pointed out that helicopter research can be identified by an international author list, including one or two local researchers at the end of the list (minasny et al., 2020) . research papers are the most visible result of international research collaboration and may reveal the individualism of our societies. however, such a view may be quite limited, because publications are the outcomes of scientific exchanges, which are only possible after the formulation of scientific questions and hypotheses, acquisition and analyses of data, the utilization of infrastructures such as laboratories and experimental or observatory fields, often after obtaining funding from projects. since international research projects mainly originate from western countries (e.g. the european h2020 projects), a subtle dependency arises between soil scientists from the global north (i.e., countries, whose gross domestic product (gdp) identifies them as developed) coming with their own research agenda and budgets and local scientists from the global south (i.e., countries, whose gdp identifies them as developing countries) benefiting, directly or indirectly, from this cooperation. inevitably, the risk of such a system is to create an unbalanced relationship, which may ignore local priorities. this typically occurs when tropical soils are used as models for doing fundamental research (e.g., the dynamics of carbon or the relationship between soil ecology and soil formation) by scientists from the global north, while local scientists in developing countries could be more interested in applied aspects such as the relation between specific soil management practices and agricultural yield. another mostly invisible aspect of helicopter research refers to the training of master and phd students from the global south on topics which are undoubtedly priorities from the global north but not necessarily those of their own countries. similarly, the implementation of long term observatories (e.g., ecological field stations or critical zone observatories) in developing countries, which are run with funds from developed countries are often not (yet) considered as a priority by local governments. however, even if international cooperation is often unbalanced and helicopter research remains an issue, a historical perspective offers some reasons for optimism. an example is the evolution of the french institute of research for development (ird). this institute was formerly called orstom and has colonial origins. it comprises >2000 staff working in over 40 countries in a variety of disciplines concerning environmental, health and societal subjects. the french researchers and technical staff are hired to do research in developing countries. their role evolved from doing colonial research in the interest of france towards a collaborative oriented research approach intended to make a lasting contribution to the economic, social and cultural progress of developing countries. soil science researchers from ird nowadays develop inclusive approaches emphasizing interdisciplinary sustainability research aligned with the 2030 agenda for sustainable development. their mission is to do research, training and innovation in the global south, with the global south and for the global south (ird, 2018). partnership with researchers from developing countries is viewed as key. how do these institutional principles translate into the practical work of the french researchers working in developing countries? firstly, it is important to mention that the researchers sent overseas (29% of the staff, ird, 2018) are placed within partner institutions and are thus in close contact with local researchers. however, due to the fact that their placement in countries is more dictated by the geopolitical interest of france than by the local research agenda and demand, independent ird researchers are in danger of becoming free-riders working on subjects of their own interest with funding from the north. this can indeed lead to helicopter research (e.g. rumpel et al., 2006) . however, due to their placement within the countries' partner institutes instead of ird owned research stations, this research most often still had an impact on the local research environment, as it focused on capacity building through training of master and phd students, and technical staff from their host institutions. in order to further equal the relationship between scientists from france and from developing countries, since a few years ird has established new programs favoring co-construction of research projects giving funding and autonomy to associated young research teams (jeai), mixed international laboratories (lmi), mixed international units (umi), and international research laboratory networks (gdri) involving south-south collaborations. as a result of this new policy, co-authorship of scientific articles by authors from ird and scientists from developing countries increased. for example, a bibliometric analysis showed that over 90% of the 62 ird-involved articles published in geoderma since 2005 with fieldwork in developing countries have also a co-author from the local country. this percentage increased to 95% in 2012, and to 100% in the last 4 years. the ird has an open access policy for developing countries (rossi, 2017) with 7821 studies referring to soil science, largely accessed by researchers from the global south. the ird instruments and ird interventions in developing countries have positive as well as negative aspects. positive aspects relate to the funding of research and involvement of local groups and, in recent years, to the encouragement of south-south collaboration. but depending on the context, negative aspects in terms of loss of sovereignty and even competition with local groups are also occurring, especially in countries where language barriers exist and ird researchers therefore are not completely integrated into the local research environment. in such a situation, little benefit of the research is to be expected for local stakeholders, who in the end do not care if published papers are "helicopter research" or "non-helicopter research". when doing research for development intended to address local needs as well as global challenges, stakeholder involvement may thus be crucial (giller, 2020) . initiatives to establish international collaboration are not limited to northern countries. an excellent example for successful establishment of south-north collaboration comes from chile, which until recently was a developing country and could not afford to establish sophisticated soil research laboratories all over the nation. to overcome this limitation, the national foundation for science and technology (conicyt) launched several governmental funding programs to encourage south-north collaboration. one of their strategies is based on funding of research leaves for chilean phd students to spend several months overseas in international laboratories (conicyt/internship scholarships abroad). to favor international collaboration and exchange, chilean research projects usually involve funding for one international expert per year, who is invited to visit a chilean lab and to contribute to the science (fondecyt/regural/iniciacion). to further enhance international cooperation, conicyt in 2000 developed the international cooperation program (pci), to encourage establishment of global research networks. this program has specific funding opportunities to identify northern partners to promote local research. an example of this is the ecos-conicyt program for chilean-french collaboration established in 2005. last year a joint call with the german max planck institutes, which also promotes south-north interactions, was launched. through supporting such actions, the country makes sure that the foreign contribution is benefitting the local research agenda. similarly, peridot is the franco-pakistani collaborative program, providing opportunities to pakistani and french researchers to carry out joint research activities. the main agenda of this program is to develop new scientific and technological cooperation between french and pakistani higher education institutions and research laboratories by supporting the mobility of researchers from both sides. drawbacks of such programs include the fact that they provide travel support instead of research money, which would be necessary to ensure equality when common research projects are developed. international research collaboration is thus strongly context dependent. sovereignty should be one of the guiding principles. it is therefore important to respect (1) ethical rules in terms of interest of local research communities and indigenous people, and (2) regulations, such as the protocol of nagoya on access to genetic resources and the fair and equitable sharing of benefits arising from their utilization (un, 2011) and others for the sampling and sending soil samples to a laboratory in the north when there are no analytical possibilities in their country of origin. this is especially important in developing countries with a colonial history. the grand challenges of our time require rapid, profound transformations in soil management practices and in our approach to research and training. the covid-19 crisis has proven to be a pressure cooker for more inclusive approaches to teaching and international exchange through virtual lecturing, webinars and even free conferences including participants from developed and developing countries. we should take advantage of this crisis to adopt such technologies for more inclusiveness in global research collaboration. as radical transformations are needed to adapt to global threats, lessons are also to be learned from developing countries. a typically example is the highly efficient management of the covid-19 epidemic crisis in asia as compared to europe and america. therefore, international collaborations, in particular south-south collaboration and south-north collaboration are extremely important (lal, 2019) . researchers from the global north should acknowledge that since the establishment of the sustainable development goals (sdgs), all nations can be considered as developing countries, as a country may be rich in terms of gdp, but may fail to reach environment-related sdgs (gore, 2015) . in the 21st century, a global focus on development is tempting as it offers opportunities for addressing universal issues such as climate change, food security, etc. holistically (horner, 2019) . for soils, which are important for multiple development issues, international collaboration is required, which needs to take into account locally specific pedoclimatic and socio-economic conditions. to guarantee equality in the relationship between researchers from north and south, and to encourage sovereignty of south-south collaboration, global funding programs are urgently needed. finally, helicopter research may be universal, unintended and related to human nature with american researchers publishing results from france without french contributors (hupy and schaetzl, 2008) or researchers from developing countries publishing research carried out with researchers from developed countries but without including them as co-authors. regulations such as the nagoya protocol and publication ethics are thus necessary and need to be respected in soil science research to make sure that research is a source of global solutions, equal collaboration and sharing of common findings rather than creating tension and exclusion. grounding the helicopters the post-2015 moment: towards sustainable development goals and a new global development paradigm towards a new paradigm of global development? beyond the limits of international development soil development on the wwi battlefields of verdun adapting african agriculture" by southsouth cooperation: conservation agriculture and sustainable intensification free access to scientific publications for developing countries: the research archive of the french national institute for sustainable development (ird) global soil science research collaboration in the 21st century: time to end helicopter research black carbon contribution to soil organic matter composition in tropical sloping land under slash and burn agriculture geoderma xxx (xxxx) xxxx the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. key: cord-297047-ew9l9yjd authors: ali, shahmir h.; misra, supriya; parekh, niyati; murphy, bridget; diclemente, ralph j. title: preventing type 2 diabetes among south asian americans through community-based lifestyle interventions: a systematic review date: 2020-08-21 journal: prev med rep doi: 10.1016/j.pmedr.2020.101182 sha: doc_id: 297047 cord_uid: ew9l9yjd ethnic south asians americans (saas) have the highest relative risk of type 2 diabetes mellitus (t2dm) in the united states (us). culturally tailored lifestyle interventions have the potential to promote south asian diabetes prevention; however, the extent of their use and evaluation in us settings remains limited. this systematic review characterizes and evaluates outcomes of community-based lifestyle interventions targeted towards t2dm indicators among south asians living in the us. a prisma-informed search of pubmed, embase, cochrane, web of science, and clinical trial registry databases using key words pertaining to south asians migrants and diabetes indicators (glucose and insulin outcomes) was conducted of community-based lifestyle interventions published up until october, 31 2019. of the eight studies included in the final synthesis, four interventions focused on cultural and linguistic adaptations of past chronic disease prevention curricula using group-based modalities to deliver the intervention. hemoglobin a1c (a1c) was the most common outcome indicator measured across the interventions. three of the five studies observed improvements in indicators post-intervention. based on these findings, this review recommends 1) greater exploration of community-based lifestyle interventions with high quality diabetes indicators (such as fasting blood glucose) in ethnic south asian american communities, 2) expanding beyond traditional modalities of group-based lifestyle interventions and exploring the use of technology and interventions integrated with passive, active, and individualized components, and 3) development of research on diabetes prevention among second generation south asians americans. in 2017 approximately 30.3 million people in the us were living with diabetes, creating 27 an epidemic cost of 327 billion [1, 2] . ethnic saas have a disproportionately high burden of 28 t2dm; ethnic asian indians for instance have a 2.8 times greater relative risk of t2dm as 29 compared to whites and 1.3 greater risk compared to the asian aggregate [3] . in clinical and 30 research settings, the primary outcome indicators used to measure and screen for t2dm include 31 measures of blood glucose, such as a1c, fasting plasma glucose (fpg), the oral glucose tolerance 32 test (ogtt), and measures of insulin resistance, such as the homeostasis model assessment 33 (homa) and the quantitative insulin sensitivity check index (quicki) [4, 5] . lifestyle factors 34 (such as poor diet and exercise) have been recognized as key contributors to the sharp rise in t2dm 35 states attracts a significantly greater population of highly educated, first-generation south asian 42 migrants [11] [12] [13] . the significant differences in socio-demographics, relevant to intervention 43 design between south asian migrants living in the us versus those in the uk and europe, suggests 44 the need for region-based intervention analysis. likewise, given the rise of pre-diabetes in the 45 united states, preventing diabetes incidence is also of paramount importance [2] . 46 47 although diabetes management remains a concern among many ethnic south asians in the 49 united states, there has been a growing impetus to focus attention on diabetes prevention among 50 individuals with pre-diabetes and patients who have not yet developed diabetes but may be at-risk 51 [14] . diabetes prevention programs focus on promoting health-protective lifestyle changes; 52 however, these programs must be tailored in a culturally sensitive way to optimize programmatic 53 effectiveness [14] . 54 55 in the united states, the large, multi-ethnic, multi-center diabetes prevention program 56 (dpp) has provided robust evidence for diabetes prevention [15] . however, the program lacks a 57 separate analysis of ethnic south asian community outcomes. its generalizability for the asian 58 american migrant community has also been criticized, in part, due to limited cultural relevance in 59 the diet, exercise, and behavior change components of the program [16] . indeed, with the observed 60 need for cultural precision in diabetes prevention campaigns, there is a gap in understanding the 61 impact that existing diabetes prevention interventions (with varying levels of cultural sensitivity 62 in design) have had on at-risk subpopulations such as ethnic saas. 63 64 community-based lifestyle interventions are particularly promising for diabetes prevention 65 among ethnic saas. the strength of this approach lies in a number of key aspects [17] . first, 66 targeting an intervention at the population level among individuals with varying levels of risk 67 allows for maximum reach and access to intervention materials, especially relevant for 68 communities such as ethnic saas who may not be able to afford or seek clinical services [18] . clinicaltrial.gov, and google scholar. authors of protocols, registered trials, and studies with 91 only baseline data were individually contacted to assess if post-intervention data was available for 92 inclusion (three contact attempts were made of each author). 93 the detailed search strategy employed in the formal database search is displayed in table 95 1. key words used included community-based lifestyle intervention related terms informed from 96 past systematic reviews along with terms focused on south asian immigrant populations (those 97 ethnically identifying as indian, pakistani, bangladeshi, sri lankan, nepalese, bhutanese, or 98 maldivian), and terms relating to diabetes, including glucose or insulin indicators (a1c, plasma 99 blood glucose, 2h post load glucose, insulin sensitivity, among others) [20] . 100 a screening reliability test was conducted by two independent reviewers (sa and bm) of 103 60 abstracts within the full screening sample, followed by complete abstract and title screening. 104 studies conducted on ethnic saa populations above the age of 18 were within the scope of the 105 study. a study was included if it satisfied the following criteria. first, the study had to focus, at 106 least partly, on a specific south asian population (including the seven identified south asian 107 nationalities) that were residing in the us at the time of study. second, the study must discuss a 108 community-based intervention defined as an "approach directed to a population rather than 109 individuals, implemented in community settings rather than hospital or health care settings, and 110 approaches coordinated through friends, family, neighbors, community members, worksites, 111 schools or primary health care centers" [20] . third, the study had to include at least baseline data. 112 fourth, the study had to include biomarkers commonly used to assess diabetes risk: blood glucose 113 or insulin related indicators. a study was excluded if it was a review, lacked an ethnic saa sample, 114 focused exclusively on diabetes management among individuals with t2dm, or lacked a 115 community-based component (e.g., exclusively structural or clinic/hospital-based). 116 117 a data extraction form was developed by the study authors and pilot tested before being 119 implemented for the final study sample. data extracted included study participant characteristics, 120 intervention characteristics, and outcome variable data. full-text assessment and data extraction 121 were conducted by two independent reviewers (sa and sm), and the senior author (rd) served as 122 a tiebreaker when a consensus could not be reached. if demographic information for control and 123 intervention group was presented separately, a weighted average was calculated for the variables 124 of interest. 125 the national heart, lung, and blood institute (nhlbi) study quality assessment tool was 127 applied to all included studies by two independent reviewers (sa and sm). one of two nhlbi 128 checklists were used, depending on study design: controlled intervention studies or before-after 129 (pre-post) studies with no control group [21] . given the heterogeneity in the study designs, the 130 checklists were supplemented by a brief narrative quality assessment focused on aspects of 131 feasibility, acceptability, retention, and the meaningful role of cultural and community-based 132 design and adaptation measures. eight studies were included in the final qualitative synthesis, including two randomized 144 controlled trials [24, 25] , two two-group pre-post studies [26, 27] , three one-group pre-post studies 145 [23, 28, 29] , and one experimental study with only baseline data [30] ( the quality of the studies was generally good for their study design, with all but two studies 175 scoring in the ("good") category on the three-option ("good, fair, poor") nhlbi assessment tool. 176 most studies were pilot studies and did not include a control group. among controlled studies, a 177 few used randomizations but others, such as islam et al., did not due to negative community perceptions toward randomization [26] . most studies compared the characteristics of those who 179 dropped out of the study with those who stayed in the study (with issues of time-commitment being 180 a salient reason for attrition across the interventions); however, only one study included a full 181 qualitative process evaluation through participant interviews to understand barriers and facilitators the structure of the community-based lifestyle interventions varied considerably (table 4) . diabetes prevention among ethnic south asians americans is a major public health 278 concern. this review sought to systematically assess characteristics and effectiveness of 279 community-based lifestyle interventions involving t2dm blood glucose and insulin indicators. greater socio-economic advantage, more favorable attitudes towards physical activity, exercise 332 more, and have less pressure to conform to traditional norms of diet and exercise [38] [39] [40] . indeed, the fact that almost all studies in the current sample did not specifically exclude second-generation 334 or us-born ethnic saas suggests a need for greater sampling of second-generation south asians 335 (or potentially interventions specifically targeting the community) to provide a better 336 understanding of the general applicability of community-based lifestyle interventions and provide 337 implications for future work. specifically, mixed-methods formative research among second-338 generation ethnic saas my identify certain foods or exercise behaviors more salient or culturally 339 acceptable in this sub-population compared to first-generation migrants, which can then directly 340 be integrated into diabetes prevention interventions targeting the community. suggest that significant trends may not be reflected across all diabetes prevention outcomes [24] . 362 indeed, there is evidence highlighting the extent to which different blood glucose or insulin 363 resistance outcomes may have uniquely salient roles in explaining diabetes prevalence across 364 racial groups, including among ethnic south asians [42, 43] saa diabetes prevalence observed that low β-cell function and insulin resistance was particularly 366 high among south asians and called for further research to identify the biological pathways and 367 mechanisms behind diabetes progression among ethnic south asians [43] . similarly, the 368 measurement of a1c in distinguishing between individuals with pre-diabetes and those without 369 diabetes (the main focus of diabetes prevention interventions) has been shown to be lower than its preventing t2dm among ethnic saa communities remains a pressing public health 397 concern in the us, and community-based lifestyle interventions present a promising opportunity 398 to address this challenge. this review provides information on the potential efficacy and gaps 399 pertaining to community-based lifestyle intervention design to inform further research and health 400 promotion activities in this field. based on the findings of this study, we have the following economic costs of diabetes in the u.s asians versus whites: results from the united states national health interview survey assessment of insulin sensitivity/resistance screening for type 2 diabetes. diabetes care globalization of diabetes. diabetes care a four-stage model explaining the higher risk of type 2 diabetes mellitus south asians compared with european populations culturally tailored self-management interventions for south asians 456 with type 2 diabetes: a systematic review lifestyle-tailored interventions for south asians with type 2 diabetes 458 living in high-income countries: a systematic review educational interventions for migrant south asians with type 2 461 diabetes: a systematic review asian immigration to the european union people born outside the uk. uk office for national statistics key facts about asian americans, a diverse and 469 growing population international diabetes federation: a 473 consensus on type 2 diabetes prevention translating the diabetes prevention program: a comprehensive 475 model for prevention training and program delivery type 2 diabetes among asian americans: prevalence and 478 prevention community-based prevention, in an integrated framework for assessing 480 the value of community-based prevention. 2012, national academies press washington 481 dc south asian americans leading together (saalt). health care issues affecting south 483 asians in the united states south asian americans leading together (saalt) /09/health-care-issues-affecting-south-asians-in-the-united-486 key: cord-302813-963ypqow authors: tegally, h.; wilkinson, e.; lessells, r. j.; giandhari, j.; pillay, s.; msomi, n.; mlisana, k.; bhiman, j.; allam, m.; ismail, a.; engelbrecht, s.; van zyl, g.; preiser, w.; williamson, c.; pettruccione, f.; sigal, a.; gazy, i.; hardie, d.; hsiao, m.; martin, d.; york, d.; goedhals, d.; san, e. j.; giovanetti, m.; lourenco, j.; alcantara, l. c. j.; de oliveira, t. title: major new lineages of sars-cov-2 emerge and spread in south africa during lockdown. date: 2020-10-30 journal: nan doi: 10.1101/2020.10.28.20221143 sha: doc_id: 302813 cord_uid: 963ypqow in march 2020, the first cases of covid-19 were reported in south africa. the epidemic spread very fast despite an early and extreme lockdown and infected over 600,000 people, by far the highest number of infections in an african country. to rapidly understand the spread of sars-cov-2 in south africa, we formed the network for genomics surveillance in south africa (ngs-sa). here, we analyze 1,365 high quality whole genomes and identify 16 new lineages of sars-cov-2. most of these unique lineages have mutations that are found hardly anywhere else in the world. we also show that three lineages spread widely in south africa and contributed to ~42% of all of the infections in the country. this included the first identified c lineage of sars-cov-2, c.1, which has 16 mutations as compared with the original wuhan sequence. c.1 was the most geographically widespread lineage in south africa, causing infections in multiple provinces and in all of the eleven districts in kwazulu-natal (kzn), the most sampled province. interestingly, the first south-african specific lineage, b.1.106, which was identified in april 2020, became extinct after nosocomial outbreaks were controlled. our findings show that genomic surveillance can be implemented on a large scale in africa to identify and control the spread of sars-cov-2. in march 2020, the first cases of covid-19 were reported in south africa. the epidemic spread very fast despite an early and extreme lockdown and infected over 600,000 people, by far the highest number of infections in an african country. to rapidly understand the spread of sars-cov-2 in south africa, we formed the network for genomics surveillance in south africa (ngs-sa). here, we analyze 1,365 high quality whole genomes and identify 16 new lineages of sars-cov-2. most of these unique lineages have mutations that are found hardly anywhere else in the world. we also show that three lineages spread widely in south africa and contributed to ~42% of all of the infections in the country. this included the first identified c lineage of sars-cov-2, c.1, which has 16 mutations as compared with the original wuhan sequence. c.1 was the most geographically widespread lineage in south africa, causing infections in multiple provinces and in all of the eleven districts in kwazulu-natal (kzn), the most sampled province. interestingly, the first south-african specific lineage, b.1.106, which was identified in april 2020, became extinct after nosocomial outbreaks were controlled. our findings show that genomic surveillance can be implemented on a large scale in africa to identify and control the spread of sars-cov-2. severe acute respiratory syndrome coronavirus 2 (sars-cov-2) is a novel betacoronavirus, first detected in china in december 2019 1, 2 . since then, the coronavirus disease (covid-19) has developed into a global pandemic, resulting in several waves of epidemics around the world, infecting nearly 30 million people, and causing > 900 thousand deaths by 15 september 2020 3 . lockdown and travel restriction measures have varied from country to country, dictating the profile of local epidemic outbreaks. through the unprecedented sharing of sars-cov-2 sequences during this pandemic, including from one of the first cases in wuhan, china (mn908947.3) 2 , genomic epidemiology investigations globally are playing a major role in characterizing and understanding this emerging virus [4] [5] [6] [7] [8] [9] . sars-cov-2 has typically been classified into two main phylogenetic lineages, lineage a and lineage b. while both lineages originated in china, lineage a spread from asia to the rest of the world, whereas lineage b predominantly spread from europe, both circulating widely around the world 10 . the covid-19 epidemic in south africa is by far the biggest in africa, with > 600,000 individuals infected and > 15,000 deaths by mid-september 2020. the first case of sars-cov-2 infection in south africa (sa) was recorded in kwazulu-natal (kzn) on 5 march 2020 in a returning traveler from italy. around mid-march, cases of community transmission were reported across the country. the profile of sars-cov-2 epidemiological progression in south africa was largely influenced by the implementation of lockdown measures in the early phases of the epidemic and the subsequent easing of these measures. on 26 march, the governmentimposed nation-wide lockdown included the prohibition of all gatherings, travel restrictions, and closure of non-essential businesses and schools 11 . although the epidemic was growing, lockdown measures were progressively eased on 1 may and on 1 june to mitigate negative impacts on the country's economy. restrictions were further relaxed first on 17 august, once the peak of new daily infections had passed, and again on 1 october (fig 1a) . the epidemic in south africa can generally be characterized by two important phases, one dominated by travelrelated "early introductions", and the second being the period of "peak infections" (fig 1a) . we monitored the likelihood of sars-cov-2 transmission by estimating the effective reproduction number, r, which provides a measure of the average number of secondary infections caused by an infected person 12 . typically, a growing epidemic is characterized by r > 1 and r < 1 indicates a slowed progression. at the start of the epidemic, we estimated the r value to be > 3, quickly falling after the start of lockdown to a value of < 1. a subsequent jump in the r value to > 1 was found to be concurrent with the timing of a number of localized outbreaks in the country, including nosocomial outbreaks 13 . the r value again dropped to < 1 at the beginning of august, coinciding with a decrease in the daily number of positive cases recorded ( fig 1a) . genomic epidemiology is important to understand sars-cov-2 evolution and track the dynamics of transmission across the world 4-9 . by 15 september 2020, at the tail end of the epidemiological peak in the country, we had produced 1365 high-quality sars-cov-2 whole genomes (>90% coverage; publicly shared on gisaid 14 ) in our laboratories as part of the network for genomic surveillance (ngs-sa) consortium 15 . these whole genomes were sampled in eight of the nine provinces of south africa and in all the districts of kwazulu-natal province, (supplementary fig s1) , and represented consistent sampling from the beginning of the epidemic and corresponding to important events of the epidemiological progression ( fig 1a) . we estimated maximum likelihood (ml) and molecular clock phylogenies for a dataset containing 7213 global genomes, including 1365 south african genomes, sampled from 24 december 2019 to 26 august 2020 ( fig 1c) . time-measured phylogeographic analyses estimated at least 101 introductions into south africa. the bulk of important introductions happened before lockdown from europe, where the epidemic was most quickly progressing at that time ( figure 1b ). although at least 67 introduction events are inferred to have occurred after lockdown, these represent only 5% of the genomes that were sampled following lockdown ( fig 1c) . in the early phases of the epidemic, before april, 34 introductions were inferred from 35 genomes sampled (97.1%), which we call "early introductions" (fig 1b) . the small number of apparent introductions after lockdown can be explained by more intensive genomic sampling at later stages, which likely revealed introduction events linked to previously undetected transmission chains. the early introductions were mostly isolated cases with a few instances of small onward transmission clusters, in contrast with large transmission clusters during the peak infections phase ( fig 1c) . the time period between these two phases was inferred to be characterized by localized transmission events which saw the emergence and spread of new lineages, which were later amplified during the peak of the epidemic. the south african genomes in this study were assigned to 42 different lineages based on the proposed dynamic nomenclature for sars-cov-2 lineages 10 . this included 16 south africa specific lineages, defined as being lineages that are presently predominant in south africa by cov-lineages.org as of 15 september 2020 16 (supplementary fig s2) . one of these has been assigned a novel sars-cov-2 main lineage classification, lineage c, the parent of which is lineage b.1.1.1. extensive sars-cov-2 genomic sampling, which spanned the whole duration of the epidemic and increased during its peak, allowed for such lineage emergence to be observed, similar to the uk's genomic investigation of sars-cov-2 17 . we focused on the three largest monophyletic lineage clusters (c.1, b.1.1.54, b.1.1.56,) that spread in south africa during lockdown and then grew into large transmission clusters during the peak infections phase of the epidemic (fig 1c) . dominance of the epidemic by novel sa-specific lineages likely happened due to lockdownimposed travel restrictions fueling a largely local epidemic. accordingly, these three main lineages account for 42% of all sampled south african sequences. in addition to the three most widespread lineages in south africa, our analysis also focused on an early lineage, b.1.106, that emerged during nosocomial outbreaks in kzn province. this lineage was responsible for 16% of the infections in kzn at the start of april, but its prevalence decreased as the outbreaks were controlled. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october 30, 2020. ; is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october 30, 2020. ; https://doi.org/10.1101/2020.10.28.20221143 doi: medrxiv preprint b.1.1.54, b.1.1.56, and c.1 represent the three largest monophyletic clusters associated with south africa-specific lineages that emerged and spread in the country following lockdown and into the peak of the epidemic. they contain 320, 104, and 151 genomes, respectively, which represents 42.1% of the total genomes in this study (supplementary table 1 ), with a clear overrepresentation in later stages of the epidemic (fig 2d) . genomes belonging to these lineages were sampled in five adjacent provinces of south africa and in all 11 districts of kzn province (fig 2b, 2c, supplementary figure s3) , and corresponded to timepoints spanning from april to august 2020 ( figure 2b, 2c) . we compared ct scores for genomes that we generated (n=1122) and show that there is no significant difference between the ct scores of sequences belonging to these three lineages and the others (supplementary fig s4) . this suggests that the fast spread of the lineages of interest is likely a result of localized outbreaks and expected transmission dynamics, rather than caused by any fitness advantage. in order to better understand the spatiotemporal diffusion of south african specific lineages, we used a continuous phylogeographic model that maps the phylogenetic nodes to their inferred geographical origin locations (fig 2a) . bayesian mcmc analysis in beast suggests these lineages emerged during the early phase of the south african epidemic between february and may 2020 (supplementary fig s6) . our phylogeographic reconstruction suggests that lineage b.1.1.56 emerged in the city of durban (ethekwini, eth) around mid march 2020 (95% hpd jan -april 2020). it appears that from june onwards, this lineage quickly disseminated throughout kzn to all of the districts. this occurred when the country moved from lockdown level 4 to 3, which allowed greater movement of people and goods between districts. lineage c.1 most likely emerged in early may 2020 (95% hpd 2020-04-24 -2020-05-24) in the city of johannesburg, located in gauteng province, from where it quickly spread to the adjacent north-west province, where it caused a large nosocomial outbreak 18 . furthermore, the lineage spread through two independent events to the northern province of limpopo and to northwestern kzn. from this location, the lineage further spread into all districts of kzn and to the adjacent free state province. unfortunately, lineage b.1.1.54 showed poor temporal signaling (supplementary fig s5) and therefore bayesian spatiotemporal analyses could not be performed for this cluster. a closer look at the cluster (from the ml timetree) is, however, shown in supplementary figure s6 and indicates that this lineage was first sampled in kzn and gauteng and later spread in large numbers in the provinces of kzn, north west and the free state. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october 30, 2020. ; (fig 3a) . this is relatively higher than the number of acquired mutations in other sequences, which is consistent with these three lineages having emerged more . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october 30, 2020. ; recently than the rest, hence accumulating more genomic changes. sequences are assigned lineages based on the presence of certain lineage-defining mutations (supplementary fig s7) (fig 3b, in black) , including the 23493 a>g (spike d614g) mutation, with additional mutations that differentiate them (fig 3b, in red) . sequences in b.1.1.54 have the 12503t>c (nsp8: y138h) and 29721c>t mutations in > 90% frequency, similar to 22675c>t for b. 1.1.56, and 4002c>t (nsp3: t428i) , 10097g>a (3c-like proteinase: g15s), 13536c>t, 18747c>t and 23731c>t for c.1 (fig 3b) . the early hospital-linked lineage b.1.106 was defined by the 16376c>t (helicase: p47l) mutation. five of these mutations, 12503t>c, 16376c>t, 18747c>t 29721c>t and 22675c>t, are predominantly present in south african genomes, with just a few occurrences in the rest of the world (fig 3c and supplementary fig s8) , whereas the rest of the lineage-defining mutations are also common in the rest of the world (supplementary fig s8) . there are two other high prevalent mutations on the spike protein in the b.1.56 and c.1. lineages, 22675c>t and 23731c>t, but these are both synonymous mutations. . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october 30, 2020. ; major contributor to linage amplifications in south africa were hospital outbreaks for example, as previously mentioned, lineage c1 was amplified in a nosocomial outbreak in the north west province in april 2020 18 before spreading to kzn and other provinces. another south african lineage, b.1.106, also emerged in a nosocomial outbreak in kzn in april 2020. this was a large outbreak that infected 100 heath care staff and 65 patients, and dominated most of the early infections in durban, south africa ( figure 4b ). this nosocomial outbreak attracted national . cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october 30, 2020. ; attention as it was responsible for 14% of the infections in kzn and over 45% of the national deaths in early april 2020. we used genetic sequencing, together with active outbreak investigation to understand how the virus entered and spread in this hospital 13 . this lineage also spread to the population and caused a second nosocomial outbreak in a nearby hospital that infected 15 health care workers ( figure 3a ). these two nosocomial outbreaks were identified within days of the first infection and were followed with very active infection and prevention control measures 13, 19 . the b.1.106 lineage largely subsided following the outbreak investigations and isolation of all infected individuals. the b1.106 lineage's prevalence at the population level decreased quickly after june 2020 (figure 4 ). we report an in-depth analysis of the spread of sars-cov-2 in south africa, showing that the bulk of introductions happened before lockdown and travel restrictions were implemented at the end of march 2020. however, despite drastic lockdown measures, the pandemic spread quickly, cc-by-nc-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october 30, 2020. ; causing over 600,000 laboratory confirmed infections. in order to track the evolution of the virus, we formed the ngs-sa, a consortium of genomics and bioinformatics scientists that worked with national government laboratories to quickly generate and analyze data in the country. we produced 1,365 sars-cov-2 whole genomes and mapped the emergence of 16 south african specific novel lineages. these lineages became established during the hard lockdown and spread widely in the country. we find that three main lineages were responsible for almost half of all the infections in south africa. despite a relative sequencing bias in kzn, we were able to detect these major lineages across multiple provinces. it is therefore likely that more extensive sampling throughout the country could pick up the spread of these lineages all over the country, especially as lockdown levels were eased and mobility increased. indeed, recent data from cape town also identified the c1 lineage, which is the most geographically widespread lineage in south africa. genomic data was also used in real-time to identify and control nosocomial outbreaks. for example, the b.1.106 lineage, which was the first south african lineage to be identified, was used to understand how the virus spread inside a large hospital in the country. the lessons learned in this outbreak were used to quickly control a second nosocomial outbreak. the active outbreak investigation itself may have limited the spread of this lineage. our analysis therefore shows that a number of sars-cov-2 lineages, each with unique mutations, emerged within localized epidemics during lockdown even as the introduction of new lineages from outside south africa was being curbed. it is currently unknown if any of the mutations originating in south africa have a fitness advantage in terms of transmission, viral replication, or a reduced immunogenicity in the south african population. that many of the mutations are synonymous and that differences in ct values do not seem to be appreciably affected by the infecting viral strain argues against selection for fitter variants. it is important to note that the four main lineages in south africa contain the d614g mutation on the spike gene. we are currently investigating limits to crossreactivity between strains. limited cross-reactivity may lead to effects such as antibody dependent enhancement (ade) in response to a vaccine with a non-native strain. ade occurs in infections such as dengue when a previously infected individual is infected with a second strain of virus, which antibodies from the first infection can bind to but not neutralize 20 . in conclusion, this study further emphasizes the usefulness of integrating genomic surveillance methods to understand sars-cov-2 spread in local settings. furthermore, genomics data can also be used in real-time to inform and consolidate national outbreak investigation and response strategies in africa. the proximal origin of sars-cov-2 a new coronavirus associated with human respiratory disease in china covid-19) situation reports genomic surveillance reveals multiple introductions of sars-cov-2 into northern california. science (80-. ) introductions and early spread of sars-cov-2 in the new york city rapid sars-cov-2 whole genome sequencing for informed public health decision making in the netherlands an emergent clade of sars-cov-2 linked to returned travellers from iran spread of sars-cov-2 in the icelandic population a territory-wide study of early covid-19 outbreak in hong kong community: a clinical, epidemiological and phylogenomic investigation a dynamic nomenclature proposal for sars-cov-2 lineages to assist genomic epidemiology disaster management act: regulations to address, prevent and combat the spread of coronavirus covid-19: amendment | south african government a method to monitor the effective reproductive number of sars-cov-2 study tells 'remarkable story' about covid-19's deadly rampage through a south african hospital gisaid global initiative on sharing all influenza data. phylogeny of sars-like betacoronaviruses including novel coronavirus (ncov) krisp severe acute respiratory syndrome coronavirus 2 (sars-cov-2) vi sars-cov-2 lineages rapid implementation of sars-cov-2 sequencing to investigate cases of health-care associated covid-19: a prospective genomic surveillance study cluster outbreak at north west hospital: 106 patients and nurses infected with covid-19 report into a nosocomial outbreak of coronavirus disease 2019 (covid 19) at netcare st. augustine's hospital acknowledgements: this research was funded by the south african medical research council (samrc), mrc ship and the department of science and innovation (dsi) of south africa. krisp is funded by a core award of the south african technology innovation agency (tia). we key: cord-335404-s48psqth authors: mukandavire, zindoga; nyabadza, farai; malunguza, noble j.; cuadros, diego f.; shiri, tinevimbo; musuka, godfrey title: quantifying early covid-19 outbreak transmission in south africa and exploring vaccine efficacy scenarios date: 2020-07-24 journal: plos one doi: 10.1371/journal.pone.0236003 sha: doc_id: 335404 cord_uid: s48psqth the emergence and fast global spread of covid-19 has presented one of the greatest public health challenges in modern times with no proven cure or vaccine. africa is still early in this epidemic, therefore the extent of disease severity is not yet clear. we used a mathematical model to fit to the observed cases of covid-19 in south africa to estimate the basic reproductive number and critical vaccination coverage to control the disease for different hypothetical vaccine efficacy scenarios. we also estimated the percentage reduction in effective contacts due to the social distancing measures implemented. early model estimates show that covid-19 outbreak in south africa had a basic reproductive number of 2.95 (95% credible interval [cri] 2.83–3.33). a vaccine with 70% efficacy had the capacity to contain covid-19 outbreak but at very higher vaccination coverage 94.44% (95% crl 92.44–99.92%) with a vaccine of 100% efficacy requiring 66.10% (95% crl 64.72–69.95%) coverage. social distancing measures put in place have so far reduced the number of social contacts by 80.31% (95% crl 79.76–80.85%). these findings suggest that a highly efficacious vaccine would have been required to contain covid-19 in south africa. therefore, the current social distancing measures to reduce contacts will remain key in controlling the infection in the absence of vaccines and other therapeutics. the coronavirus disease 2019 (covid-19) originated in wuhan, china, in december 2019 and has rapidly spread around the world [1] . as this is a new and novel virus, there is a huge scientific evidence gap and therefore limited understanding of the epidemiology of sars--cov-2, the pathogen that causes the disease covid-19. currently, the epicentre of the virus is a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 in europe and new york in the united states of america [2] . in africa, the virus is just starting to set its foothold, with south africa now reporting the majority of cases in the continent. the first case of the covid-19 in south africa was reported on the 5 th of march 2020 [3] . measures to contain the epidemic culminated in the declaration of the state of disaster leading to a national lockdown on the 26 th of march 2020 with gauteng, western cape, kwazulu-natal and the free state provinces reporting most of the covid-19 cases. the map in fig 1 shows the distribution of covid-19 confirmed cases in south africa before the government mandated a lockdown. gauteng province appeared to be the "epicentre" of covid-19 in south africa for a number of reasons. first, the province has the largest population density [4, 5] and the urban population is poor with 20% of its population being food insecure [4] . second, gauteng province has two international airports including or tambo international airport handling over 21 million passengers annually [6] . third, the volume of people that use public transport runs into millions daily creating social networks and patterns that are key in accelerating the spread of the disease. finally, the province is the country's economic hub, and many people (including international visitors) travel in and out of the province daily [4] . with the majority of confirmed cases early in the outbreak having been linked to international travel [7] , it is not surprising that the most affected provinces (gauteng, western cape and kwa-zulu-natal) have international airports with direct flights to affected global regions (fig 1) . the cases in the free state province have mainly been attributed to a cluster transmission resulting from a mega church gathering [8] . with covid-19 having been declared a global pandemic [9] and the urgent need to have an effective vaccine to control the pandemic [10] , there is a need to understand the utility of mass vaccination campaigns for this pandemic. critical in the early stages of the disease is the need to clearly understand the spectrum of disease severity and transmission characteristics of the disease in order to identify optimal control measures. many of the control measures suggested for this pandemic have been attributed to the lessons learnt in wuhan, china [11] . the challenges associated with real-time analysis of an evolving epidemic are well articulated in [12] . these include testing capacity and delayed appearance of symptoms and asymptomatic carriage. the impact of covid-19 on south africa may differ from that on china and other regions such as europe and north america. south africa has unique circumstances, for example, it has the highest numbers of people living with hiv, with a significant proportion not on treatment, and one of the largest tuberculosis (tb) burdens in the world [13, 14] . moreover, underlining disease conditions such as diabetes, hypertension and chronic obstructive pulmonary disease are prevalent in south african and these are known to be risk factors for covid-19 infection and mortality [15] . the age distribution for south africa is also different from china and europe as its young population accounts for the majority of the population [16] . data from china and other settings have shown that sars-cov-2 is more infectious than influenza, and has an incubation period of about 5 days (median time) and a doubling time of 3 days [17, 18] . however, we have a limited understanding of the infectiousness of the virus in settings with different populations and a huge burden of other chronic conditions such as africa. mathematical models provide important insights in the understanding of emerging infectious diseases and informing public health policies. several mathematical models have been used to understand covid-19 transmission dynamics and inform public health policy [12, 19, 20, 21, 22] . the reproductive numbers of the covid-19 epidemic in china have been determined in several modelling studies (table 1) . here, we adapt a susceptible-exposed-infected-removed (seir) compartmental model to quantify early transmissibility of covid-19 in south africa and explore the potential utility of a vaccine in containing the disease. the seir model has been used to model respiratory infections including middle east respiratory syndrome (mers) [23, 24] , covid-19 in wuhan china [11] , influenza [25, 26] and global tracking of covid-19 [27] . in addition, we estimate the reduction in effective contacts after the implementation of the severe and extreme shutdown of the society, and this is critical in determining the impact of social distancing in the south african context. we use a standard deterministic compartmental seir model to simulate covid-19 in south africa. the model classifies the human population into four epidemiological compartments at any time t, the susceptible s(t), exposed e(t), infected i(t) and the recovered r(t). the total population is thus given by susceptible individuals are infected upon interaction with infectious covid-19 individuals and the rate of daily generation of newly infected cases is given by λ(t) = βs(t)i(t)/n, where the parameter β is the effective contact rate, i.e. the contact that will result in an infection. the lockdown effect is modelled with parameter, �2(0,1) where �'0 implies an ineffective lockdown and �'0 implies a completely effective lockdown. the effective contact reduction term multiplies the effective contact rate in the model to give (1−�)β. exposed individuals in the e(t) compartment become infectious at a constant rate σ and move to the i(t) class. infected individuals i(t), recover at a constant rate γ to the removed class r(t). the schematic model flow diagram is presented in s1 fig. the model assumptions result in the following system of differential equations. following a similar approach in [37] , we use a markov chain monte carlo (mcmc) within a bayesian framework (in r fme package [38] ) to fit the model to the cumulative data of confirmed covid-19 cases in south africa and estimate the magnitude of the epidemic using the basic reproductive number and quantify required vaccines' attributes to stem similar outbreaks. we used data on covid-19 cases published by the south african department of health from the 5 th of march 2020 to 28 march 2020 prior to the lockdown to estimate the basic reproductive number [39] . we set the model lockdown effect parameter � = 0 when estimating the basic reproductive number. the percentage reduction in effective contacts after the lockdown � was estimated by fitting the model to cumulative covid-19 cases reported a week after the lockdown (from 29 th march to 11 th april 2020). cumulative data for covid-19 cases reported in south africa from the 5 th march to 11 th april 2020 is shown in s1 table. in the fitting, we set the lockdown effect parameter � = 0 and varied β, σ, γ (within parameter ranges in s2 table) and initial infected population in order to estimate the basic reproductive number. in estimating the lockdown effect, we varied � and kept parameters used to estimate the basic reproductive number constant. gaussian likelihood was used to draw model parameter posteriors assuming uniform non-informative priors while the variances were regarded as nuisance parameters. the mcmc chain was generated with at least 100 000 runs for the final fitting excluding the burn-in period. chain convergence was examined visually and using the coda r package [40] . uncertainty of each estimated parameter was evaluated by analysing the mcmc chains and calculating the 2.5% and 97.5% quantiles to give the 95% credible interval (cri). the basic reproductive number (r 0 ), is as a measure of the average number of secondary cases generated by a primary case and is an important statistic for quantifying intervention programmes [41, 42] . using an intuitive mathematical approach, the reproductive number of model system (1) is given by r 0 = β/γ. the corresponding minimum vaccination coverage (c) for covid-19 vaccine for different vaccine efficacy scenarios was estimated using the mathematical expression c � ð1 à r à 1 0 þ=s where s the proportional reduction of the susceptibility for individuals partially immunized. estimates of effective contact rate (β), the incubation period (1/σ), infectious period (1/γ), the percentage reduction in effective contacts (�) and the basic reproductive number, r 0 for south africa are shown in table 2 . the mathematical model (of the seir type) was fitted to the cumulative covid-19 cases for south africa at the national level (fig 2(a) ). we estimated an effective contact rate 1.30 (95% crl 1.21-1.39) per day, incubation period of 3.21 days (95% crl 3.04-3.44 days), infectious period of 2.27 days (95% crl 2.04-2.74 days) and r 0 of 2.95 (95% crl 2.83-3.33) before the lockdown. the result r 0 >1 clearly shows disease sustainability in the country. estimates of r 0 were used to conduct sensitivity analysis based on different covid-19 vaccines' efficacy assumptions to explore possible scenarios that may arise from mass vaccination campaigns, as scientists attempt to develop effective vaccines for covid-19 [43, 44] . the vaccine efficacy scenarios were assumed to vary in the range of 50-100% (fig 2(b) ). the results suggest that a vaccine with more than 70% efficacy could have the potential to contain the covid-19 outbreak in south africa but at extremely high vaccination coverage rates of 94.44% (95% crl 92.44-99.92%). as expected, vaccination coverage for epidemic control decreases with an increase in vaccine efficacy, with a vaccine of 100% efficacy requiring table 2 before lockdown [45] . we also quantified the percentage reduction in effective contacts as a result of the lockdown mandated by the government of south africa. fig 3 shows that the epidemic is slowing down after the implementation of a lockdown. the results showed that the lockdown resulted in 80.31% (95% crl 79.76-80.85%) reduction in effective contacts ( table 2 ) and consequently resulted in a reduction in the number of covid-19 cases reported in the first two weeks of implementation. this confirms results in china that demonstrated the importance of quarantine, social distancing, and isolation in containing the pandemic [46] . covid-19 has spread rapidly globally assisted by air travel in an increasingly connected world [47, 48] . globally most countries, including south africa, have adopted one form or another of the lockdown approaches in an attempt to curb disease transmission within their borders [11, 49, 50] . our model estimate of r 0 >1 confirms covid-19 persistence in south africa and indicate that the outbreak has the momentum to rapidly spread and spill over to other geographic regions of the country, in particular if the coming winter season (may to july) presents ideal environmental conditions for persistence of the virus. the estimate of r 0 for south africa is in a similar range published for covid-19 in other modelling studies (table 1) . hypothetical scenarios on vaccine efficacy demonstrated that, a vaccine of at least 70% efficacy would have been sufficient to contain the spread of covid-19 in south africa although at high vaccination coverage. however, it is important to note that expectations that the development of a highly effective vaccine for the novel-coronavirus will be achieved in the coming months are extremely optimistic, especially when considering that a vaccine has still not been successfully created for viruses like hiv, severe acute respiratory syndrome (sars) and mers, with the hiv vaccine being in development for many years [44, 51] . nevertheless, the huge global interest in quickly identifying an effective vaccine could increase the possibility that a successful vaccine candidate can be developed in the coming months [43] . even when a safe and effective vaccine becomes available, there are several logistical and operational challenges that need to be addressed for successful deployment and for the vaccine to achieve the desired coverage [52, 53] . the modelled lockdown demonstrated 80.31% reduction in effective contacts, showing that it is an effective measure to bring the disease under control. however, the reduction in the number of daily reported cases should be interpreted with caution as this could also have been a result of many other factors such as reduced international travel to high-risk regions and behaviour change. as the epidemic continues to unfold, it remains to be seen what trend the epidemic will follow if local transmissions are sustained within south africa. the implementation of this society shut down is not sustainable in the long run as it is unlikely to be tolerated for too long by the population. a vaccine would be an ideal preventative strategy for covid-19 but it appears that it should be complemented with prevention approaches such as isolation, quarantine, personal hygiene and limitations of public gatherings in order to achieve optimal protection of the population in south africa. the economic and social burden of the disease continues to be felt and this likely to be enhanced by an extension of the current lockdown of 21 days by a further 2 weeks [54] . however it is unclear whether a stringent lockdown could be maintained for a longer period given the socio-economic challenges of the country where a significant percent of adults are involved in informal employment and others have jobs that do not allow them to work from home. this could affect the effectiveness of the lockdown in many of the townships as individuals will have to ease lockdown conditions in order to be economically active and prevent financial woes on individuals in urban communities. while the epidemic seems to have slowed down as a results of the lockdown (fig 3) , there is need for continued scientific investigation including explorations through mathematical models to monitor the trend with the aim of informing public health policy in the short-term. the study has some limitations. the estimate of the reproductive number is based on available data and this estimate could possibly change depending on the quality of the data from the start of the epidemic (with possible under-reporting of cases in the initial phases of the epidemic). we note that spatial modelling mainly in the affected provinces would have been ideal but we did not have good data on a finer resolution to effectively parameterise a spatial model but as the epidemic evolves, nascent data on local covid-19 transmission in south africa is becoming available. we used a simple mathematical model without other population demographics as these were not important for short-term prediction [55] and such models are also important when epidemiological and clinical disease characteristics of the disease are not well established as is the case for covid-19 [56] . the simple model is only intended to give preliminary estimates for an epidemic that is evolving and whose trend has the potential to change dramatically overtime. however, it would be interesting to see how our results will change when a more complicated model is used. despite these shortfalls, findings in this study are important in understanding the transmissibility of the virus and informing the development of robust covid-19 prevention and control programmes in south africa and outlining mass vaccination expectations. the covid-19 pandemic has continued to spread and causing many deaths than any infectious disease we have seen in recent years and this calls for an urgent and well-coordinated timely and effective public health response. currently there is no proven treatment or vaccines for covid-19 and countries have embraced quarantine, social distancing, and isolation of infected individuals to contain the pandemic. thus, as more setting-specific data about the transmission dynamics of the virus become available, the building of suitable mathematical models to weight out the impact of current public health control measures and explore the potential utility of anticipated biomedical interventions such as vaccines is paramount. supporting information s1 fig. schematic covid-19 model diagram outlining infection progression. the arrows connecting compartments denote covid-19 infection at rate βs(t)i(t)/n, progression to infectiousness σe and recovery rate γi respectively. 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experts urge reality check logistical and structural challenges are the major obstacles for family medicine physicians' ability to administer adult vaccines operational challenges of vaccination, 10th annual african vaccinology course (aavc) nationwide lockdown extended by two weeks is modelling complexity always needed? insights from modelling prep introduction in south africa epidemiological and clinical aspects of covid-19; a narrative review key: cord-030421-8eu9zlba authors: shirley, dennis title: vectors of educational change: an introduction to the twentieth anniversary issue of the journal of educational change date: 2020-08-13 journal: j educ change doi: 10.1007/s10833-020-09399-8 sha: doc_id: 30421 cord_uid: 8eu9zlba this article introduces a special, 20th anniversary issue of the journal of educational change. the special issue edictoras have organized significant international contributions to theory-building into three areas. these concern diverse modalities of educators’ professionalism, debates around “getting to scale” with successful innovations, and conflicting views of social justice in schools and societies. each of these areas comprises an independent vector of disagreement and debate, with differing meaning and interpretations based upon the cultures and histories of the given systems under review. the article asks what kinds of new research, and what kinds of affiliated theories in these topic areas, can best help to move the field of educational change forward in the coming years. anyone had imagined when state-wide testing was introduced in the us in the 1980s. standards were promulgated with increasing force. exit options like charter schools in the us and academies in the uk spread like wild-fire. the traditional grammar of schooling (tyack and tobin 1994) , was back with a vengeance. such phenomena now have been documented in tens of thousands of schools in the us and beyond. accountability pressures provided new rationales for educators to return to forms of frontal instruction and curriculum delivery that innovators had sought to surpass with more active, student-initiated forms of learning. as evidence accumulated, many began to suspect that it was no longer a matter of tinkering here and there to upgrade the new reforms, some of which we had tacitly supported, but rather of critically interrogating them. it became important to determine what the purpose of education was in the first place, and then to assess whether the new reforms were attaining espoused goals or distracting from them. this became an increasingly moral imperative as surveys and teacher retention data showed that educators themselves were increasingly disenchanted with what was transpiring under the name of "reform," while the ratcheting up of pressure and sanctions produced at best modest results. at times, it began to feel that the entire enterprise of public education was under siege. still, those of us working away in the proverbial "trenches" knew that the problems in schools had predated recent reforms. many issues couldn't be pushed off on policy makers. some of the most tenacious problems-outdated teaching strategies, poorly designed curricula, tracking, and unfair assessments that discriminated against the poor, the learning disabled, and students of color-were squarely within the locus of control of the profession. these would have to be confronted and resolved by educators themselves. in this regard the journal of educational change, in its different iterations over two decades, has endeavored to stake out an independent position on contemporary educational issues while at the same time being open to all kinds of dissenting perspectives. in a retrospective review of the first 14 years of the journal published in 2017, juan cristobal garcía-huidobro and his colleagues identified 5 periods in the journal's history that reflected the major transformations in the field. in the first of these, "assumed universality in educational change," from 2000 to 2002, journal authors wrote with enthusiasm about learning across borders and its potential for improving the human condition. this was followed by a second phase from 2003 to 2005, emphasizing "equity and context" in diverse jurisdictions. from 2006 to 2008 the journal published numerous articles on international large-scale assessments. in the next phase, from 2009 to 2011, articles conveying predominantly "anglo-american skepticism" prevailed. finally, a fifth phase from 2012 to 2014 ensued of "emergent internationalization and empiricism." (garcía-huidobro et al. 2017, pp. 270) . there is real value in this type of literature review. the historical periodization rings true, and helps readers to understand where the field has been in order to ascertain where we might go next. still, there is a danger that subtle but important differences of opinion could be overlooked in the formulation of generalizations. mindful of tendencies towards groupthink that can inhibit even the best of journals, incoming editor corrie stone-johnson and i have wanted to do something different with this twentieth anniversary issue of the journal. we have sought out authors we believed could make significant contributions to theory-building and have clustered their topics into three areas. these are: in what does it reside, and how is it evolving over time? 2. getting to scale once a successful change model is identified, how we can ensure that it is accessible to each and every learner who could benefit from its approach. 3. justice given the striking inequalities evident in almost all school systems in almost all countries, what can educators do to contribute to teach and empower those students who are most needful of a quality education? consider each one of these topics-educators' professionalism, getting to scale, and justice-to constitute an independent vector of disagreement and debate. what kinds of new research, and what kinds of affiliated theories in these topic areas, can best help us to move the field of educational change forward? the first vector pertains to debates about the meaning and import of educators' professionalism. our opening article in this special issue is written by andy hargreaves, the editor-in-chief of the journal for its first 11 years. in it, hargreaves draws upon new data from ontario, canada, to argue that it isn't simply the case that high-stakes testing is damaging to pupil learning. this has been done many times. what is new here is that hargreaves argues that even mid-stakes testing has deleterious effects. ontario tests its students at grades 3, 6, and 9, and it is precisely at those grade levels where educators report the least innovation and the most traditional forms of instruction prevail. while students at other grade levels can flourish, and their teachers enjoy far-reaching professional discretion, students in those 3 grade levels are subjected to the most anachronistic forms of rote learning and memorization. this is done even though teachers themselves know that they could do better, which makes for an insidious form of compliance in one's own de-professionalization. if ontario wishes to maintain its position as a global leader of educational change, hargreaves argues, it is time to abolish its mid-stakes testing system and to restore the professional integrity of its educators across the system. what might come after testing? in her essay entitled "creating capacity for learning-are we there yet?," louise stoll invites us to reposition learning as the central purpose of schools. this might seem so obvious as to go without saying. still, the challenges of "low trust and punitive accountability" in schools often provokes defensive reactions among educators that counteract the deep and mindful teaching and learning of which we are capable (shirley and macdonald 2017) . "spirals of inquiry" (halbert and kaser 2013) provide one way of thinking collectively about learning, rather than public relations management, as the core moral purpose of schools. while open to engaging with the kinds of concerns espoused by hargreaves and stoll, amanda datnow, my predecessor as editor-in-chief of the journal of educational change, suggests that an intermediate strategy that draws upon data selectively but is not enslaved to it, could be explored by teachers in more schools. drawing upon her research with vicki park (2019), datnow argues that much potentially useful data often is not studied by teachers in any meaningful way, because they do know how to leverage it to improve their teaching. she finds that when teachers have adequate professional development, administrative support, and collaborative opportunities with colleagues, that data can take their rightful place in a broad portfolio of materials that teachers can use to improve their instruction and to lift their students' learning results. while scholars should be rightfully critical of an overemphasis upon testing and accountability systems, then, there is no inherent reason why teachers should fail to draw upon relevant findings, especially when these can help those students who need assistance most to get on with their learning. the heart of the matter is "professional collaboration with purpose" driven by a genuine "mindset of learning" rather than a soulless "bureaucratic task or an overly linear model of instructional improvement." like datnow, jenny weiner acknowledges problems with testing yet still wishes to preserve what she sees as some benefits of testing and accountability. her research supports the findings of incoming journal editor corrie stone-johnson that younger teachers as a generational cohort don't especially mind testing, and even find their older colleagues' preoccupation with its negative features rather quaint and eccentric. weiner calls these educators' approach a new form of "nuanced professionalism" that is superseding an older variant of "occupational professionalism." this new form of professionalism recognizes that teachers' autonomy has sometimes been abused in the past by those unwilling or unable to put in the long hard hours planning lessons, managing unruly students, and grading assignments. observing these problems, younger educators appear to be willing to trade off some kinds of discretion in favor of a more collective way of conducting work, even if this entails some top-down direction from time to time. as weiner points out, her perspective is similar to stone-johnson's description of a "parallel professionalism" (2014, p. 749) in which educators find standards and curriculum frameworks to be useful points of reference that relieve them of the burden of planning everything from scratch day-in and day-out. the differences between the findings of hargreaves and stoll on the one hand, and datnow and weiner on the other, indicate that a range of opinions on the essence of educators' professionalism can be found in the journal of educational change. while there is a shared concern for ongoing transformations in teachers' work, the findings point in different directions when it comes to how policy should be understood and negotiated in situ in the schools. the differences should not be overstated, but they should be noted and taken as points of departure for further research. it is perhaps not accidental that in addition to different perspectives, the lines of division here reflect different" generational interpretive frameworks" (stone-johnson 2016, p. 12). a second vector of disagreement can be found regarding the topic of spreading educational change. in 2016 santiago rincón-gallardo and brahm fleisch brought together a truly global ensemble of articles for a special issue of the journal on the topic of "bringing effective instructional practice to scale." the underlying concept of the special issue was to "bring together original articles and scholars who have developed and/or studied relatively successful approaches to large scale instructional change in a variety of contexts." (rincón-gallardo and fleisch 2016, p. 380). these included colbert and arboleda (2016) , writing on the escuela nueva movement in colombia; banerji and chavan (2016) writing about literacy reforms in india; and rincón-gallardo and fleisch themselves, reporting on their findings on education as a social movement in mexico and the teaching of reading in south africa respectively. it was a fascinating special issue, not the least because the author credited with the notion of "getting to scale," richard elmore, wrote a blistering critique of his own concept as marked by "unthinkable presumptuousness and naivete," in an afterward to the volume (elmore 2016, p. 529) . hang minh le would be likely to agree with elmore on the dangers of thinking in terms of "getting to scale," especially when it comes to the dissemination of reform models internationally. in her article on "where be the 'magic bullet' for educational change? vietnam and the quest of policy borrowing from abroad" in this issue, le criticizes the tendency of policy makers in the global south to seek solutions from other countries rather than on developing indigenous capacity to address educational challenges. she asserts that a "coloniality of knowledge production" influences policy makers, who are controlled in many ways by transnational funders such as the world bank. le finds that this influence of coloniality is so powerful that even highly successful grass-roots mobilizing efforts in the global south, such as the escuela nueva movement in colombia, that have been recognized for their achievements by the yidan prize in hong kong and the wise prize in qatar, are complicit in the oppressive legacy of colonialism. for vietnamese educational reformers, the attraction to escuela nueva appears to reside in its adaptation of western educational ideals such as student-centered classrooms, active learning, and parent and community engagement. for le, these are not universal features of good teaching and learning. they are manifestations of western values that should not be imposed on vietnam, however attractive they might appear to policy makers eager to make their mark as effective educational leaders. since vietnam already scores very highly on the oecd's pisa tests, she notes, it hardly needs to engage in the "fast policy making still rooted in coloniality" that is common in much of the global south. le's analysis of escuela nueva would appear to offer a critique of the enthusiasm expressed by rincón-gallardo for this model of educational change recently in his book (2019) entitled liberating learning. in his article in this special issue, rincón-gallardo draws upon his leadership and research with the "learning communities" approach developed by gabriel cámara and his colleagues in remote rural middle schools in mexico, which shares many affinities with escuela nueva. he asks that greater scholarly attention be devoted to reform efforts such as these two latin american examples as well as "activity based learning" in india and community schools in egypt. these diverse efforts, he argues, are "more similar in their genesis and development to social movements than to conventional education programs or policies." taken together, they present a "feasible alternative" to the default culture of schooling that has been exported by the global north and imposed upon the global south. brahm fleisch, for his part, expresses no particular concerns about strong stateled initiatives to improve education in the global south. he argues that western commentators generally have failed to acknowledge the contributions of vigorous, top-down leadership to "systems as diverse as hong kong, singapore, korea, japan, shanghai, and vietnam." fleisch might agree with le that the sensitivity of educators from the "anglosphere" of the global north for child-centered pedagogies, project-based learning, and teacher autonomy has little relevance for countries endeavoring to extricate themselves from the powerful legacies of colonialism. instead, fleisch sees value in "strong central control" by governments motivated by "strong egalitarian impulses." from this perspective, elmore's retraction of the concept of "getting to scale" is overstated. whether through the kinds of confidence-building, state-led leadership strategies favored by fleisch, or the bottom-up social movements described by rincón-gallardo, educators have moral obligations and professional responsibilities to engage with all kinds of diverse populations to promote learning to enhance the human condition. even le's criticism of policy borrowing from one nation of the global south to another could be seen as an admonition to practice "getting to scale" with indigenous philosophies and practices within vietnam. self-criticism is good. self-paralysis is not. finally, a third vector of disagreement may be found in conceptualizations of justice in educational change. helen janc malone argues for community schools as expressions of social justice that help schools to "engage in diverse intentional partnerships, authentic grassroots family and community engagement, and collaborative governance and leadership structures." while many have argued that we each now live in a "deterritorialized context" (appadurai 1996, p. 37 ) with a concomitant "decline of the local" (foster 2004, p. 476) , malone sees local communities as indispensable educational resources, especially for equity purposes, as "funds of knowledge" (moll et al. 1992 ) ordinarily bracketed out of schools are appropriated for learning. however much we have come to rely on our cell phones and the internet, in the end we are all embodied and need contact with other human beings unmediated by technological tools. given the unprecedented disruptive power of the coronavirus, many would agree that local communities and their schools have proven themselves to be more crucial than ever. alison skerrett, on the other hand, asks educators to consider how they are serving growing numbers of transnational students, who, "through a mixture of necessity and choice, live their lives across two or more countries." she calls for a "transnationally-inclusive approach to literacy education" as an expression of social justice, that could help students to understand their different languages and distinctive cultural blends as assets rather than deficits. since educational systems are bound up with concepts of nation-building, skerrett sees formidable obstacles for the future of transnational education. she cites research by hamann and zuñiga (2011) showing that it nonetheless is possible to blend transnational identity formation for youth with nations' legitimate concerns to educate students capable of thriving within their given geographical boundaries. can we find a way to combine the social justice concerns for community schools advanced by malone and the similar values upheld by skerrett for transnational students? one promising case is provided by franco-ontarian educators in canada who have found new ways to blend their traditional and endangered language minority culture with a new transnational population of french-speaking students from countries as diverse as haiti, senegal, cameroon, and france itself (shirley and hargreaves 2020) . by building strong interdisciplinary teams of educators, including staff with expertise in cultural diversity, linguistics, and curriculum development, these educators have shown that an inclusive and creative approach to all of our diverse students can indeed be forged which creates a new kind of community appropriate to our current circumstances. we need not make a forced choice between local community and transnational students, then. as educators, we have the collective intelligence and can marshal the willpower to forge new kinds of learning communities that are as diverse and culturally rich as the students we find before us. in its first 20 years, the journal of educational change has served as a fulcrum for fascinating debates on many more topics than the themes of professionalism, getting to scale, and social justice than are featured in this special issue. as of this writing (june 2020) the world is in the grip of a global pandemic that has killed more than 350,000 people and infected more than 5 million others. nine out of 10 children worldwide have been kept home from school. millions of these had no internet access at the time, depriving them of access to educational resources even as others, more fortunate, bounded ahead. unemployment leapt off the charts to its highest levels since the great depression in many countries, and food insecurity soared. at the same time as dark clouds loomed, silver linings could be detected. some students genuinely liked learning at home, free from the distractions of disruptive classmates and ill-timed interruptions to instruction. while many apps designed to promote learning were poorly designed, others were exciting and they connected students with new digital friends from around the world. nature rebounded as flights and commutes to and from work ground to a halt. random acts of kindness popped up in unlikely places. many agreed that they now were taking each other less for granted. now and then it was possible to glimpse a better future. modernity at large: cultural dimensions of globalization improving literacy and math instruction at scale in india's primary schools: the case of pratham's read india program bringing a student-centered participatory pedagogy to scale in colombia data-driven leadership getting to scale …" it seemed like a good idea at the time the decline of the local: a challenge to educational leadership spirals of inquiry for equity and quality schooling and the everyday ruptures transnational children encounter in the united sttes and mexico funds of knowledge for teaching: using a qualitative approach to connect homes and classrooms. theory into practice liberating learning: educational change as social movement bringing effective instructional practice to scale: an introduction community organizing for urban school reform valley interfaith and school reform: organizing for power in south texas student engagement: beyond relevance, technology, and fun parallel professionalism in an era of standardization generational identity, educational change, and school leadership the "grammar" of schooling: why is it so hard to change? the journal of educational change has a role to play in shaping that better future. in its 20 years, it has forged bold new spaces for debates on professionalism, "getting to scale," change, and social justice. the coronavirus pandemic is just one signal that the scope of these debates has ample new room for development in the years to come. in this, my final introductory essay for the journal, i ask that all of us affiliated with the journal-its board members, authors, and reviewers-provide our wholehearted support to incoming editor-in-chief corrie stone-johnson. key: cord-284652-7npya3yx authors: shim, eunha; tariq, amna; chowell, gerardo title: spatial variability in reproduction number and doubling time across two waves of the covid-19 pandemic in south korea, february to july 2020 date: 2020-10-08 journal: int j infect dis doi: 10.1016/j.ijid.2020.10.007 sha: doc_id: 284652 cord_uid: 7npya3yx objectives in south korea, 13,745 cases of coronavirus disease (covid-19) have been reported as of 19 july, 2020. to examine the spatiotemporal changes in the transmission potential, we present regional estimates of the doubling time and reproduction number (rt ) of covid-19 in the country. methods daily series of confirmed covid-19 cases in the most affected regions were extracted from publicly available sources. we employed established mathematical and statistical methods to investigate the time-varying reproduction numbers of the covid-19 in korea and its doubling time, respectively. results at the regional level, seoul and gyeonggi province have experienced the first peak of covid-19 in early march, followed by the second wave in early june, withrt exceeding 3.0 and mean doubling time ranging from 3.6 to 10.1 days. as of 19 july, 2020, gyeongbuk province and daegu are yet to experience a second wave of the disease, where the mean rt reached 3.5-4.4 and doubling time ranging from 2.8 to 4.6 days during the first wave. conclusions our findings support the effectiveness of control measures against covid-19 in korea. however, the easing of the restrictions imposed by the government in may 2020 facilitated a second wave in the greater seoul area. since the first covid-19 cases reported in wuhan, hubei province, china, in december 2019, more than 24.7 million cases of coronavirus disease , including more than 830,000 related deaths, have been reported worldwide (who) as of august 30, 2020. in south korea, the novel coronavirus was first diagnosed in a 36-year-old chinese woman who entered the country on 20 january 2020. south korea has since experienced two heterogenous waves of the disease with a total of 13,745 cases including 295 deaths as of 19 july 2020 (kcdc, 2020a) . during the early phase of the covid-19 outbreak in south korea, public health authorities primarily conducted strict contact tracing and isolation of confirmed cases as well as quarantined those suspected with the novel coronavirus (covid-19 national emergency response center et al., 2020) . as the number of covid-19 cases continued to increase, korean public health authorities set the alert to the highest level (level 4) on 23 february and mandated the population to report any symptoms related to for further screening and testing. in addition, the country rapidly adopted a "test, trace, isolate, and treat" strategy that has been deemed effective in stomping out localized outbreaks of the novel coronavirus (kcdc, 2020a) . however, the total number of confirmed cases in south korea spiked from 31 cases on 18 february to 433 on 22 february. according to the korea centers for disease control and prevention (kcdc), this sudden jump was mainly attributed to a super-spreader (the 31 st case) who had participated in a religious gathering of attendees of the shincheonji church of jesus in daegu (kcdc, 2020a) . these superspreading events occurred in the daegu and gyeongbuk provincial regions, leading to more than 5,210 secondary covid-19 cases in korea (kcdc, 2020a , ryall, 2020 . these events facilitated sustained transmission chains, with 38% of the cases in the country associated with the church cluster in daegu (shim et al., 2020b) . on 8 march, the kcdc announced that 79.4% of the total cases had epidemiological links, whereas the remaining 20.6% cases were either sporadic cases or under investigation (kcdc, 2020a) . case clusters started to accumulate from churches in the seoul capital area, and on 17 march, 79 church j o u r n a l p r e -p r o o f attendees developed covid-19 after attending a service at the river of grace community church. notwithstanding social distancing orders put forward by the government, some churches continued to conduct services, which led to new clusters of infections. for instance, the manmin central church in seoul was involved in one of the clusters, with 41 infections linked to a gathering in early march; saengmyeongsu church in gyeonggi province was another church cluster linked to 50 cases (park, 2020) . as sars-cov-2 infection spread rapidly outside korea, the number of imported cases started to increase, resulting in 476 imported (4.9%) cases out of 9,661 total cases as of 30 march. consequently, as of 1 april, the kcdc implemented self-quarantine measures for travellers from europe and the u.s.a (kcdc, 2020a) . in addition, incoming travellers with symptoms but negative test results for coronavirus, as well as asymptomatic short-term visitors were ordered to follow a 2-week quarantine in the government facilities (kcdc, 2020a). such control measures undertaken by south korea have been deemed successful in limiting the spread of the outbreak, without locking down entire cities (normile, 2020) . therefore, after a sustained period of low incidence with fewer than 20 cases per day (16 april -5 may), the government eased its strict nationwide social distancing guidelines on 6 may, with a phased reopening of schools starting mid-may, 2020. however, a new cluster linked to nightclubs in itaewon emerged in central seoul in early may, resulting in a resurgence of cases, that led to a second wave of covid-19 in the greater areas of seoul. as of 29 may, the number of cases that were linked to this cluster had reached 266 (kcdc, 2020a) . accordingly, the seoul city government ordered all clubs, bars, and other nightlife establishments in the city to close indefinitely (kcdc, 2020a). simultaneously, another cluster emerged from an ecommerce warehouse in the gyeonggi province, resulting in 108 cases as of 30 may. in the last week of may, ~40-80 daily new cases of covid-19 were being reported (kcdc, 2020a). following this spike in the number of new covid-19 infections in nearly 2 months, public health authorities reimplemented strict lockdown measures in seoul along with school closure, one more time across the nation. in june, it was announced that the strict social distancing campaign would be j o u r n a l p r e -p r o o f indefinitely extended as a preventive measure in seoul, incheon, and gyeonggi province; however, phased reopening of schools was initiated on may 20. it was reported by the kcdc that a holiday weekend in early may triggered a new wave of infections focused in the greater seoul area, the so-called second wave of covid-19 in south korea (2020) . in seoul, the average number of new daily cases reported from 4 june to 17 june was 43 (kcdc, 2020a). this was followed by sporadic clusters of infections across the country in july, most of them associated with religious facilities and door-to-door salespeople, especially in the densely populated seoul region and adjacent areas. therefore, since 10 july, the government banned churches from organizing small gatherings other than regular worship services (kcdc, 2020a to estimate the regional and temporal variability in the reproduction number of covid-19 in south korea, including the second wave concentrated in the greater seoul areas, we analysed the spatiotemporal progression of the epidemic in the country from mid-february to mid-july 2020. here our focus lies on estimating and interpreting the doubling time and effective reproduction number rt, a metric that quantifies the time-dependent transmission potential of the disease, incorporating the effect of control measures, susceptible depletion, and behavioural changes. this key epidemiological parameter, rt, represents the average number of secondary cases generated per case whenever conditions persist as they were at time t. epidemic doubling times describes the sequence of intervals at which the cumulative incidence doubles (lee et al., 2020 , muniz-rodriguez et al., 2020 . therefore, an increase in the doubling time implies a decline in disease transmission. in this report, we estimated the doubling time and the effective reproduction number involving two epidemic waves of the covid-19 epidemic in south korea by employing the time series of cases by date of symptoms onset for the four most affected korean regions: seoul, gyeonggi province, gyeongbuk province, and daegu. we also discuss the spatiotemporal variability of the reproduction number in terms of the public health policies that were put in place by the korean government. we collected the daily series of confirmed local covid-19 cases in south korea from 20 january to 19 july, which were published by national and local public health authorities, including city or provincial departments of public health in south korea (kcdc, 2020b). we focused our analysis on the regions with the highest caseloads including seoul, gyeonggi province, gyeongbuk province, and daegu ( figure 1 ). for a more accurate estimation of epidemic growth rates, the epidemic curve should be analyzed according to the date of symptom onset rather than the date of reporting because reporting delays can fluctuate substantially over the course of an epidemic. reporting delays distort the incidence pattern of epidemics, misrepresenting the outbreak trajectory, thus possibly affecting the estimation of the reproduction number (tariq et al., 2019) . a prior study suggested that obtaining knowledge about reporting parameters, such as delay patterns and structure improves the estimates of the reproduction numbers (azmon et al., 2014) . however, for the covid-19 data in korea, the date of symptom-onset is only available for 732 cases reported in gyeonggi province, which yielded a mean of 4.5 days and standard deviation of 4.4 days for the distribution of delays from symptoms onset to reporting of cases. therefore, we utilized the empirical distribution of these 732 reporting delays from the onset of symptoms to reporting to impute the missing dates of onset for the remaining cases (shim et al., 2020a) . specifically, we reconstructed 300 epidemic curves according to the date of symptom onset, from which we derived the mean incidence curve of local case incidence (shim et al., 2020a , tariq et al., 2019 . for the calculation of rt(t), the mean incidence curve estimated based on the date of symptom onset was used for the regions of interest (i.e., seoul, gyeonggi province, gyeongbuk province, and daegu) (figure 2 ). using the reconstructed mean incidence curve of local case incidence, we removed the first and last three data points to adjust for the reporting delays in our real-time analysis. we assumed that the first wave ends when the mean incidence becomes less than 0.2 individuals per day. similarly, we assumed that the second wave starts when the mean incidence of local cases becomes greater than 0.5 individuals per day. slight variations to these thresholds did not affect our results. we analyzed the number of times covid-19 cumulative incidence doubled and the evolution of the doubling times in the four most affected areas in korea (i.e., seoul, gyeonggi province, gyeongbuk province, and daegu) from from 20 january to 19 july. using regional-level daily cumulative incidence data, we calculated the times at which cumulative incidence doubles, denoted by . specifically, we assume that where 0 = 0, ( 0 )= 0 ( = 0, 1, 2, 3, … , ), and ( ) denotes the cumulative number of cases at time (muniz-rodriguez et al., 2020) . here, is defined as the total number of times cumulative incidence doubles. specifically, the sequence of doubling times are described as = ∆ = − −1 where = 1, 2, 3, … , . in addition, we used parametric bootstrapping with a poisson error structure around the harmonic mean of doubling times to obtain the 95% confidence interval (chowell et al., 2006a , chowell et al., 2006b . we assume that rt(t) can be estimated by the ratio of the number of new infections generated at time step t (it) to the total infectiousness of infected individuals at time t, given by ∑ − =1 (chong et al., 2018 , fraser, 2007a . here, ws denotes the infectivity profile of the infected individual, which is j o u r n a l p r e -p r o o f dependent on the time since infection (s) but independent of calendar time (t) (he et al., 2020, wallinga and teunis, 2004) . specifically, ws is defined as a probability distribution describing the average infectiousness profile after infection. individual biological factors such as pathogen shedding or symptom severity can affect the distribution ws. the infectivity profile, ws, can be approximated by the distribution of the generation time; however, times of infection are rarely observed, making it difficult to measure the distribution of the generation time (fraser, 2007b) . therefore, the timing of symptoms onset is often used to estimate the distribution of the serial interval (si) instead, which is defined as the time interval between symptom onset in two successive cases in a chain of transmission (cori et al., 2013) . specifically, the infectiousness of a patient is a function of the time since infection and is proportional to ws if we set the timing of infection in the primary case as the time zero of ws and assume that the generation interval equals the si. the si was assumed to follow a gamma distribution with a mean of 4.8 days and a standard deviation of 2.3 days (nishiura et al., 2020) . analytical estimates of rt were obtained within a bayesian framework using epiestim r package in r language version 3.6.3 (r foundation for statistical computing, vienna, austria) (cori et al., 2013) . rt was estimated at 7-day intervals, and we reported the median and 95% credible interval (cri). (figure 3 ). during the second wave, the doubling time in seoul decreased to 6.0 (95% ci: 5.4, 6.7) days, indicating faster transmission compared to that during the first wave ( table 1) . as of 15 july 2020, the rt in seoul was estimated at 0.9 (95% cri: 0.7-1.2), straddling the epidemic threshold of 1.0, and suggesting potential for further transmission of the virus. gyeonggi province (literally meaning the "province surrounding seoul") is located in the western central region of korea and is the most populous province in south korea with a population of 13.5 million people. in gyeonggi province, the daily number of new cases by date of symptoms onset during the last weeks of february was 6.3 on average (figure 4) . accordingly, the first peak of rt occurred on 22 february, reaching 8.9 (95% cri: 4.8-14.2), with an estimated doubling time of 4.6 (95% ci: 4.2, 5.5) days (table 1) (50), door-to-door sales in the seoul metropolitan region (32), and yangcheongu sports facility (28). as of 19 july, the number of local cases in gyeonggi province was 1,027 (10.4% of the total reported cases in south korea), including 29 deaths, with an rt estimated at 0.8 (figure 4) . the incidence rate in the province was estimated at 108 per million. the first case in the sincheonji cult cluster (the largest covid-19 cluster in south korea) appeared on 18 february, resulting in sustained transmission chains, with 39% of the cases associated with the church cluster in gyeongbuk province. therefore, the virus alert level was raised to "red" (the highest level) on 23 february, and health authorities focused on halting the spread of the virus in daegu and gyeongbuk provinces. figure 5 shows that the peak of the epidemic occurred in the first week of march (with a reproduction number greater than one until 9 march) ( figure 5 ). the doubling time in gyeongbuk province reached the values as short as 3.6 (96% ci: 3.5, 4.0) days ( table 1) (figure 6 ). the estimates of the transmission potential of covid-19 in korea displayed substantial spatiotemporal variation. indeed, several factors influence the value of the reproduction number, including the transmissibility of an infectious agent, individual susceptibility, individual contact rates, and control measures (anderson and may, 1991) . our results indicate that the effective reproduction number for covid-19 declined to low levels after the first wave and straddled around the epidemic threshold of 1.0 in march and april suggesting that social distancing measures had a significant effect on mitigating the spread of the novel coronavirus. estimates of early national rt for south korea retrieved from other studies, 2.9 (95% cri 2.0-3.9) in february (ryu et al., 2020) and 2.6 (95% ci: 2.3-2.9) in march, are in good agreement with our rt estimates (zhuang et al., 2020) . our results suggest that south korea has experienced two spatially heterogenous waves of the novel coronavirus. at the regional level, seoul and gyeonggi province have experienced two waves whereas daegu and gyeongbuk provinces are yet to experience the second wave of the disease. the highest epidemic peak occurred in daegu and gyeongbuk province in late february and early march, with rt estimated at 4.4 (95% cri: 2.6-6.6) and 3.5 (95% cri: 0.9-7.3), respectively. during their epidemic peak, the doubling time was estimated at 2.8 (95% ci 2.5, 4.0) days and 3.6 (95% ci 3.5, 4.0) days in daegu and gyeongbuk province, respectively, which is similar to prior estimates of doubling time, 3.8 (95% ci: 3.4-4.2) days (lee et al., 2020) . similarly, in gyeonggi province and seoul, the first wave was observed in late february and early march, respectively. however, sporadic clusters of infections appeared in seoul and near gyeonggi province, immediately after the government eased its strict nationwide social distancing guidelines on may 6. this resurgence of infections in seoul and gyeonggi province (i.e., the province surrounding seoul) after a sustained period with fewer than 5 cases per day in each region, led to j o u r n a l p r e -p r o o f the second epidemic wave with sub-exponential growth dynamics. in seoul, the mean doubling time decreased from 7.5 (95% ci: 7.0, 8.2) days during the first wave to 6.0 (95% ci: 5.4, 6.7) days during the second wave, indicating faster transmission during the case resurgences. accordingly, our findings revealed sustained local transmission in seoul and gyeonggi province, with the estimated reproduction number estimated above one until the end of may. in late may, the country implemented two weeks of strict social distancing measures incorporating stringent virus prevention guidelines for the metropolitan area. these measures included the shutting down of public facilities and regulating bars and karaoke rooms. in the second week of june, south korea decided to indefinitely extend a period of strict social distancing measures, as nearly all locally transmitted cases were in the metropolitan area. although korea has a relatively low number of reported cases compared to other countries including the u.s. and china, it is believed that south korea is currently experiencing yet another resurgence of the virus (who). originally, south korean authorities predicted a resurgence of the virus in the fall or winter; however, this possible second wave started in and around seoul, which, with 51.6 million inhabitants, accounts for about half of the entire population of the country. secondary waves of the disease can result from multiple factors, including easing of travel restrictions and resuming social activities especially in the high population density areas of seoul and gyeonggi province. furthermore, a substantial proportion of covid-19 cases are asymptomatic (mizumoto et al., 2020) ; thus, they are not detected by surveillance systems, resulting in the underestimation of the epidemic growth curve. it was also recently reported that individuals aged 20-39 years in south korea drove the covid-19 epidemic throughout society with multiple rebounds, and an increase in infection among the elderly was significantly associated with an elevated transmission risk among young adults (yu et al., 2020) . our study is not exempt of limitations including the lack of dates of symptoms onset for all of the cases, relying on a statistical reconstruction of the epidemic curve by dates of symptoms onset as in a previous study (shim et al., 2020a) . overall, using most up-to-date epidemiological data from south korea, our study highlights the effectiveness of strong control interventions in south korea and j o u r n a l p r e -p r o o f contributions: es conceptualized analysis, retrieved and managed the data. es, gc, and at analyzed the data. es and gc wrote the first draft of the paper. all authors contributed to the writing of the paper. coronavirus: south korea confirms second wave of infections infectious diseases of humans: dynamics and control on the 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severity of covid-19 in south korea assessing reporting delays and the effective reproduction number: the ebola epidemic in drc different epidemic curves for severe acute respiratory syndrome reveal similar impacts of control measures distinctive trajectories of the covid-19 epidemic by age and gender: a retrospective modeling of the epidemic in south korea preliminary estimates of the reproduction number of the coronavirus disease (covid-19) outbreak in republic of korea and italy by 5 table 1. regional variations in doubling times in days of covid-19 cumulative incidence and its 95% j o u r n a l p r e -p r o o f key: cord-032252-8usagw86 authors: muntingh, lukas m title: africa, prisons and covid-19 date: 2020-08-31 journal: j hum rights pract doi: 10.1093/jhuman/huaa031 sha: doc_id: 32252 cord_uid: 8usagw86 africa’s prisons are a long-standing concern for rights defenders given the prevalence of rights abuses, overcrowding, poor conditions of detention and the extent to which the criminal justice system is used to target the poor. the paper surveys 24 southern and east african countries within the context of covid-19. between 5 march and 15 april 2020 covid-19 had spread to 23 southern and east african countries, except lesotho. the overwhelming majority of these countries imposed general restrictions on their populations from march 2020 and nearly all restricted visits to prisons to prevent the spread of the coronavirus. the pandemic and government responses demonstrated the importance of reliable and up to date data on the prison population, and any confined population, as it became evident that such information is sorely lacking. the world health organization recommended the release of prisoners to ease congestion, a step supported by the un subcommittee on prevention of torture. however, the lack of data and the particular african context pose some questions about the desirability of such a move. the curtailment of prison visits by external persons also did away with independent oversight even in states parties to the optional protocol to the convention against torture (opcat). in the case of south africa, prison monitors were not listed in the ensuing legislation as part of essential services and thus were excluded from access to prisons. in the case of mozambique, it was funding being placed on hold by the donor community that prevented the human rights commission from visiting prisons. the covid-19 pandemic has highlighted long-standing systemic problems in africa’s prisons. yet african states have remained remarkably reluctant to engage in prison reform, despite the fact that poorly managed prisons pose a significant threat to general public health care. africa's prisons are a long-standing concern of human rights defenders. overcrowding, poor nutrition, illness, disease, and rights violations, to name a few concerns, characterize * the author is associate professor at the dullah omar institute, university of the western cape, south africa. he has been involved in criminal justice reform since 1992; his current focus is on the prevention and combating of torture and ill-treatment of prisoners and detainees. africa's prisons. the possibility that a highly infectious virus for which there is no vaccine becomes prevalent in africa's prisons is a scenario almost too disastrous to contemplate. many are familiar with the devastation that aids brought to africa's prisons and with underlying health conditions such as hiv/aids, tuberculosis (tb) and general poor nutrition, covid-19 does conjure up images of an unprecedented prisons health crisis, as both the infection rate (the proportion of people infected) and the infection fatality rate (the proportion of infected persons who die) may be higher in prisons than that which may occur among the general population outside prison. this essay reviews the situation regarding prisons and covid-19 in southern and east africa. there are many gaps in the information, which does point to long-standing issues on data reliability and accessibility. nonetheless an overview of prison numbers is provided, as well as some general comments on conditions of detention. this followed by a short description of covid-19 in africa and how different states have responded, imposing more or less severe restrictive measures. southern and east africa consist of 24 internationally recognized countries 1 and have a combined prison population of some 655,000 people. 2 the average national prison population size for these countries is some 30,000, with the average prison holding 533 prisoners. there are, however, significant outliers with island states like the comoros having 225 prisoners in three prisons and, at the other end of the spectrum, south africa with some 235 prisons holding close on 160,000 prisoners at an average size of 657 prisoners per facility. a further important variable is the proportion of prisoners who are awaiting trial. this is important for two main reasons. firstly, it indicates the efficiency and effectiveness of the criminal justice system, with a low percentage indicating that there is good reason for pretrial detention and that individuals do not remain in pretrial detention for an excessive time. secondly, a high percentage of pretrial detainees not only reflects inefficiency and ineffectiveness, but also results in more contact between the prison population and the outside world, because of remand prisoners' appearances in court and visits to them in prison, and this contact is relevant to the covid-19 discussion. in the 24 southern and east african states surveyed, the highest proportion of pretrial detainees is found in madagascar at 57 per cent and the lowest in rwanda at eight per cent. the average for all 24 countries is 31 per cent, meaning that nearly one-third of bed spaces in prisons are occupied by people presumed to be innocent. the last important variable to note is the level of occupancy. in uganda and zambia prisons are occupied at 319 per cent and 303 per cent respectively, meaning three people are using the space originally designed for one person. colonial-era laws as well as colonial-era modalities of policing have also shaped to some extent the profile of that segment of the population coming into (regular) contact with the criminal justice system. it is in particular in anglophone states of southern and east africa that a myriad of laws dating back to the previous century give the police wide discretion in arresting people for poorly defined offences such as loitering or being a rogue and vagabond (muntingh 2015; muntingh and petersen 2015) . these petty and outdated offences remain an affront to human dignity and perceptions of fairness, and need to be removed from statutes (achpr, principles on the decriminalisation of petty offences in africa). nonetheless, their continuous enforcement plays an important role in determining who is imprisoned. while there is much variation in the conditions of imprisonment in these countries, it can generally be concluded that there is significant room for improvement and, in some instances, prison systems are not able to meet even the most basic standards of humane detention with reference to accommodation, nutrition and health care. in some states prisoners are provided with only one meal per day of the most basic nature, resulting in malnutrition; illness and infectious diseases are common in the prison population; and prisoners are forced to sleep in cells filled to two or three times their capacity with the most rudimentary toilet facilities, and with limited capacity to maintain and keep ablution facilities sanitary. these conditions worsen health outcomes. poor conditions of detention and structural problems in african criminal justice systems are well documented and a number of efforts have been made at international and regional levels to enable, encourage and support prison and criminal justice reform. the african commission on human and peoples' rights (achpr) not only appointed two special mechanisms 3 on the issue, but also adopted four soft law instruments to support reform. 4 despite these efforts as well as general efforts to improve conditions of detention, the situation has not improved markedly. there are a few countries in east and southern africa that have been able to effectively maintain and replace (if not expand) prison infrastructure, such as south africa and botswana. but in most instances, the same infrastructure built by britain, portugal and france as colonial powers more than 50 years ago remains in use and it is simply not possible to meet the minimum standards of humane detention (un standard minimum rules for the treatment of prisoners 2015). in many instances sentenced and unsentenced prisoners are not segregated, as is required by rule 11(b) of the 2015 un standard minimum rules, and this has implications for controlling infectious diseases. not only have post-independence governments largely failed to invest in criminal justice and prison reform; they have also failed to see prisons from a public health perspective and give recognition to the inescapable fact that prisons are vectors for disease. the first covid-19 case in africa was reported from egypt (bbc news 2020) and the second from algeria (who africa 2020). in southern and east africa, the first case was reported in south africa on 5 march 2020 and the first prison system case (an official) was reported also in south africa on 6 april (groundup 2020; graaff-reinet advertiser 2020). covid-19 came to africa through various entry points and most likely travel hubs like johannesburg and nairobi, from where it moved quickly to even the island states of the region, such as seychelles (14 march the covid-19 pandemic and subsequent government responses again demonstrate the importance of reliable and up to date data on the prison population, and any confined population (such as police and immigration detainees). this not only concerns data on the health of prisoners, as well as more general data concerning the profile of prisoners, the reasons for their custody and so forth, but above all, if this information is available in the public domain those with an interest in prisoners' rights can make informed contributions to governments and other stakeholders. when the world health organization (who) recommended the release of prisoners to address overcrowding (who 2020) and this call was further supported by the un subcommittee on prevention of torture (spt) in its public advice to national preventive mechanisms (npms) (un spt 2020: para 9(b)), it seemed in principle like an admirable idea, but reality demanded a more cautious approach, in africa at least. firstly, cognizance should be had for public safety and that it cannot merely be a case of opening the prison gates indiscriminately, not least because the person concerned may currently be infected. this means that there need to be clear criteria for eligibility, a confirmed and contactable address, and presumably consent from the household in which the person is intending to reside. moreover, should only deserving pretrial detainees be released or are sentenced prisoners also eligible prior to the expiry of their sentence? following from this, it must also be asked: how many people need to be released in order to have a protective impact for those that remain behind? secondly, in some instances, especially when an infection has not been recorded at a particular prison, it may in fact be a better option not to release prisoners since their basic needs are at least met in prison (this is assuming that basic nutritional and health requirements are complied with). thirdly, assuming that the preceding requirements are satisfied, the question becomes: where do released prisoners go to? they may not be welcome at their normal place of residence, or they may indeed have no place to go to, or their return may place additional socioeconomic strain on an already marginal household. with large-scale loss of income in the formal and informal sectors, and the absence of state-provided socioeconomic support, the large-scale release of prisoners may require a re-think in the african context. regardless of this, a number of southern and east african countries announced the release of prisoners to 'ease congestion', but the intended impact would be symbolic rather than real. seven countries announced significant releases with the highest number in south africa (19,000), ethiopia (5,600) and mozambique (5,032) (republic of south africa, the presidency 2020; ethiopian monitor 2020a; daily nation 2020) and the lowest in botswana (149). in the case of south africa, the releases would constitute 12 per cent of the total prison population. however, in the case of ethiopia the prison system capacity is not known and the impact is thus uncertain, but the 5,600 releases constitute less than five per cent of the prison population. the 5,032 released in mozambique moved the occupancy level from 211 per cent to 186 per cent (world prison briefs 2020). with the exception of botswana, the releases effected did not move prison occupancy below the specified levels, and overcrowding remains present as ever. the releases should also be seen against the background of normal releases when prisoners are released conditionally (for example, parole) or on expiry of sentence. these figures are not in the public domain and it is therefore not known if the releases will have any meaningful and sustained impact on prison congestion. much as we would like to think that prisons are isolated from society, they are not. family and friends visiting prisoners are in many ways the lifeblood of the prison, bringing not only human interaction and contact with the outside world but also resources such as cash, food, bedding, toiletries and so forth. it is predominantly the poor who find themselves in prisons, but since the state cannot provide all the resources, prisoners are dependent on outside support (when they have such support) to make life in prison more bearable. in the end it is the poor who are subsidizing imprisonment in africa, picking up the tab where the state falls short in providing the basics to prisoners (muntingh and redpath 2018) . admittedly, visitors also bring contraband fuelling the carceral economy-which is often crucial for some prisoners to 'buy' their safety. contact with the outside world is vital for both physical and mental well-being. it is, however, not only prisoners' visitors who come to a prison. the staff working there as well as other officials also come to prisons on a daily basis. prisoners awaiting trial and sentenced prisoners with further charges also have to appear in court. in short, the gates of a prison are busy. this has obvious implications for virus transmission. of the 24 countries surveyed in southern and east africa, only two could be confirmed as not having declared a state of disaster or emergency or lockdown: malawi and tanzania (new frame 2020). in the case of malawi, the government did declare a lockdown, but this was blocked in the high court (news24 2020). eighteen of the 24 states surveyed declared some form of a national restriction, such as a state of disaster or a state of emergency. this was then to a greater or lesser degree supported by a lockdown or curfew (terminology differs from one state to another). in some instances, this was announced for a very limited duration (such as 21 days), but frequently extended. in ten states access to prisons by external visitors was prohibited (independent online 2020b; all africa 2020a; independent online 2020c; ethiopian monitor 2020b; icrc 2020a; léger 2020; all africa 2020b; icrc 2020b) and in a further 11 states this could not be confirmed. south sudan imposed light restrictions (that is, sign a register and wash hands) (undp south sudan 2020), and zambia prohibited visits but visitors could leave items for prisoners, such as food or clothing (global press journal 2020). while it must be appreciated that governments have an obligation to protect their citizens against public health threats, it must also be noted that the states surveyed have by and large shown a particular enthusiasm to restrict civil and political liberties and, further, to limit access to prisons. the guidelines from who made it clear that the 'covid-19 outbreak must not be used as a justification for objecting to external inspection of prisons and other places of detention by independent international or national bodies whose mandate is to prevent torture and other cruel, inhuman or degrading treatment or punishment' (who 2020). of the 24 countries surveyed, six have ratified the optional protocol to the convention against torture (opcat) 5 and two have signed it but not ratified. 6 in the case of south africa, the judicial inspectorate for correctional services (jics) provides regular visits to prisons through its inspectors as well as community-based independent correctional centre visitors (iccv). however, the state of disaster declared on 15 march and subsequent regulations (26 march) closed all prisons to civilian visits (disaster management act regulations) and did not include the jics inspectors and iccvs in the definition of essential services; thus they were not permitted to conduct prison visits. the net result was that not only were visits by friends and families to prisoners stopped, but so were the visits by iccvs mandated under the correctional services act. moreover, this also prevented visits under the opcat, to which south africa is a party, since the jics forms part of the national preventive mechanism (npm), the south african human rights commission (sahrc), as designated by south africa in june 2019. while officials of the department of correctional services (for example, prison warders) are exempted from the restrictions of the lockdown that commenced on 26 march, the jics inspectors and iccvs are appointed under a different provision of the correctional services act resulting in them not being exempted from the lockdown. it then appears that a major victim of covid-19 was transparency of the prison system. south africa's neighbour, mozambique, declared a state of emergency on 30 march (all africa 2020c), but technically also a state of disaster in terms of a threat to public health or a natural disaster, and so which should be distinguished from martial law. the impact of restrictions imposed is less severe, and essentially, gatherings of more than 20 people are prohibited, including in prisons. moreover, no restrictions, save for family members, are placed on who visits prisons and lawyers and the npm is free to conduct visits and even training programmes are continuing as long as groups remain under the 20-person ceiling (t. lorizzo, director: reformar, based in maputo, mozambique, interview with the author, 6 may 2020). visits by the npm are, however, not taking place since the donors 5 mozambique, south africa, madagascar, mauritius, rwanda and south sudan. 6 angola and zambia. that would have supported the npm's visits to places of detention (and planning was reportedly well under way) placed all funding on hold due to the covid-19 pandemic. covid-19 has again highlighted the long-standing problems in africa's prisons, and these were noted above. as unpopular as this may sound, africa needs new prisons, not necessarily more prisons, because the basic infrastructure is so old and dilapidated that it is simply no longer possible to meet the minimum requirements of humane detention, let alone to have the capacity to deal with a health crisis. it is necessary to look beyond covid-19 and pose questions about long-term solutions. people should also not find themselves unnecessarily in prison and that means that reforms in law, policy and practice are needed, as has been advocated by many, including the african commission on human and peoples' rights. pretrial detention is very often the default position without any real exploration of conditional release mechanisms such as warning and bail. monetary bail is frequently set at amounts that are simply not affordable (such as equivalent to a year's income) that can only be regarded as punishing people for being poor. the statutes of many african states still contain colonial-era offences (such as rogue and vagabond) and in a more recent development, the creation of new petty offences, frequently under municipal by-laws, for which people are arrested and end up in custody. placing people in custody for petty offences is not only disproportionate, it places their health at risk and holds significant adverse socioeconomic consequences. these offences need to be decriminalized and/or declassified. prison overcrowding can to a certain measure be addressed by using non-custodial sentencing options, such as community service, or releasing prisoners prior to the expiry of sentence (for example, on parole). there are only a few african states where these measures are used on any significant scale. public health threats such as covid-19 or tuberculosis (tb) will always have particular significance in the prison environment, but also pose a particular threat to public health when prisons are poorly managed and resourced. in the end, the old dictum stands: good prison health is good public health. this work was supported by the open society foundation (human rights initiative) and the sigrid rausing trust. ouagadougou declaration and plan of action on accelerating prisons and penal reforms in guidelines on the conditions of arrest, police custody and pre-trial detention in africa-luanda guidelines, adopted at the 55th ordinary session of the achpr all africa. 2020a. mozambique: visits to mozambican prisons suspended. 27 march coronavirus: beijing orders 14-day quarantine for returnees daily nation. 2020. virus fears: mozambique frees 5,000 inmates. 7 april 7(a) and (b), published in government notice no prison commission blocks personal, legal visits over coronavirus fear now coronavirus: keeping zambia's prisoners healthy gets even harder women's prison in east london records 26 positive cases of coronavirus covid-19: call for minister to release prisoners judge shocked at the high number of deaths in sa prisons lesotho extends lockdown by two weeks, rolls out mass testing for covid-19 sa prisons suspend visits for 30 days due to covid-19 outbreak eswatini suspends prison visits, restricts hospital visits as covid-19 fears mount kenya: red cross races to prevent spread of covid-19 to country's prisons. 31 march 2020b. sudan: helping prison authorities keep covid-19 at bay. 27 april overcrowding and the risk of unmitigated spread of covid-19 in madagascar's prisons. amnesty international arrested in africa: an exploration of the issues punished for being poor: evidence and arguments for the decriminalisation and declassification of petty offences the socio-economic impact of pre-trial detention in three african countries tanzania's state response to covid-19 under fire malawi court indefinitely bars virus lockdown optional protocol to the convention against torture and other cruel, inhuman or degrading treatment or punishment the presidency. 2020. placement on parole of selected categories of sentenced offenders un standard minimum rules for the treatment of prisoners (the nelson mandela rules), adopted by un general assembly resolution 70/175 undp supports prisons service of south sudan to protect inmates from covid-19 advice of the subcommittee on prevention of torture to states parties and national preventive mechanisms relating to the coronavirus pandemic frequently asked questions about prevention and control of covid-19 in prisons and other places of detention a second covid-19 case is confirmed in africa world prison briefs. 2020. mozambique acknowledgements i wish to express my appreciation to t. lorizzo, j. mangwanda and j. redpath for their comments on an earlier draft of this paper. key: cord-307610-tqvt5hzr authors: arora, amarpreet singh; rajput, himadri; changotra, rahil title: current perspective of covid-19 spread across south korea: exploratory data analysis and containment of the pandemic date: 2020-08-08 journal: environ dev sustain doi: 10.1007/s10668-020-00883-y sha: doc_id: 307610 cord_uid: tqvt5hzr the outbreak of severe acute respiratory syndrome coronavirus 2 is regarded as a highly contagious disease that has challenged the healthcare systems worldwide with confirmed cases approaching 12 million and more than 50,000 deaths. considering the worldwide cases of novel coronavirus disease (covid-19), it remains a pandemic and the vaccines and therapeutic agents have yet to be developed to stop the spread of this outbreak. due to the unavailability of specific treatment for the covid-19, it can be viewed that the risk of cluster infection will continue to be present within the intermittent and small-scale outbreaks. though the covid-19 has been identified as a communicable disease, the preventive measures and response policies in south korea are effectively serving the purpose and gained the confidence to overcome the covid-19 crisis. this paper includes the exploratory data analysis of covid-19 cases in south korea till july 8, 2020. south korea has reported the lowest death rate with the majority of the deaths, associated with persons with underlying health conditions or elderly infected individuals. currently the infected patients (total 989) remaining in south korea are mild cases owing to its robust health care system and quarantine inspection procedures followed by the ministry of health and welfare of south korea to flatten the covid-19 curve. although the covid-19 countermeasures taken by the south korean government may not be conclusive or universal for all, but its exemplary approach to tackle covid-19 can aid countries across the globe to strengthen their response system for the future outbreak of such an infectious disease. electronic supplementary material: the online version of this article (10.1007/s10668-020-00883-y) contains supplementary material, which is available to authorized users. in december 2019, the wuhan city of hubei province in china became the epicenter of an outbreak of local pneumonia in some patients with an unknown cause (bherwani et al. 2020; gautam 2020) . by january 7, 2020, the chinese research community isolated a novel virus, severe acute respiratory syndrome coronavirus 2 (sars-cov-2), from the virus-infected pneumonia patients (phelan et al. 2020; gorbalenya et al. 2020 ). on january 30, 2020, world health organization (who) declared the sars-cov-2 epidemic a public health emergency of international concern, which was later designated as a covid-19 in february 2020 (muhammad et al. 2020; gautam and hens 2020a, b; who 2020b) . although the outbreak is plausible to be associated with the large seafood market which has triggered a zoonotic transmission event, but soon it became clear that an efficient human-to-human transmission is also taking place (li et al. 2020; wu et al. 2020; sarkodie and owusu 2020) . due to the potential of covid-19 to generate widespread outbreaks in confined settings and cross border following the mobility of human patterns, it was regarded as a pandemic by the who on march 11, 2020 (cucinotta and vanelli 2020) . coronavirus is a current novel and highly infectious contagion disease that belongs to the family of "nidovirus" which includes "roiniviridae," "artieviridae" and "coronavirdae" family, causing respiratory illness in humans from the common cold to more severe diseases such as severe acute respiratory syndrome (sars) and middle east respiratory syndrome (mers) (de wit et al. 2016; gautam and hens 2020a) . coronavirus is enveloped positive-sense rna virus mainly comprising of almost 30,000 nucleotides in its genome, and its replication and transcription are dependent on the replicase gene which encodes two overlapping polyproteins, pp1a and pp1ab (zhou et al. 2020a, b) . the diameter of coronavirus ranges from 60 to 140 nm with club-shaped spikes on its surface and making a crown-like structure as evident from an electron microscopy, hence the name given coronavirus (richman et al. 2016) . coronavirus is a "communicable" disease and its spread all over the world is entirely associated with human-to-human transmission rather than transmission through the air (wang et al. 2020a, b) . the transmission of covid-19 through airborne spread has not been reported yet and it is not believed to be the source of major transmission as per the evidence (who, 2020a). due to its small size (about 0.1 micron), it can enter into the body via droplets from mouth or nose during close and unprotected contact between an infector and infectee. it has also been observed that coronavirus infected people generally develop symptoms and signs, including mild respiratory illness, fever, dry cough, and tiredness, with a mean incubation period of 5 to 6 days which can also range up to 1 to 14 days (who 2020b). predominantly, the presentation of disease can also range from asymptomatic (with no symptoms) to severe pneumonia, and even death (who 2020a) . recent studies showed that the number of infected individuals with the novel covod-19 may get double every 7 days and each person could spread this virus to 2.2 to 3.58 persons on an average (chan et al. 2020) . additionally, the individuals ≥ 60 years of age and individual with chronic underlying health conditions are in a greater risk of being infected with covid-19 in comparison to the children who might have less probability to get infected or, if so, these children may show mild symptoms or may have asymptomatic infection (li et al. 2020; sun et al. 2020) . besides, cleaning surfaces with an alcohol-based disinfectant is also important to practice to stop the spread as covid-19 can survive on surfaces such as copper (up to 4 h), plastic and stainless steel (up to 72 h), and cardboard (up to 24 h) (who 2020b). some of the countries have adopted the early isolation of infected patients and quarantine policies to prevent the transmission from the travelers who have returned from the covid-19 infected countries (hellewell et al. 2020) . practicing frequent hand hygiene (with alcohol-based gel or sanitizer), maintaining respiratory hygiene, and a physical distance of at least 1 m (3 feet) is the best possible way to protect yourself and others from the novel covid-19 (who 2020a). in addition, staying in home quarantine and seeking medical care early if person is allied with the acute symptoms fever, cough, or difficulty breathing, not going outside unnecessarily, avoid touching your eyes, nose or mouth, avoid eating raw meat and unnecessary contact with wild animals, etc. are some other precautionary measure for protection against the coronavirus disease. nevertheless, a clear representation of the epidemiology of this novel coronavirus and vaccination is still being elucidated (zhou et al. 2020c) . with the two months of the outbreak, the pandemic spread throughout the world at an alarming speed. as of march 1, 2020, a total of 87,137 confirmed cases and 2997 deaths had been reported globally by the who (who 2020a), and 58 countries were affected (who 2020a). while the cases continue to decline in china, the covid-19 cases have been reported in more than 100 countries outside of china, including south korea, iran, italy, japan, france, and germany by the end of march 2020 (who 2020c; shim et al. 2020; gautam and trivedi 2020) . the first case in south korea was reported on january 20, 2020, followed by a rapid increase in the number of cases in subsequent days (shim et al. 2020) . in particular, south korea quickly became the hardest-hit country affected by the covid-19 virus, with a steady increase in the number of cases over the month of february 2020. by the end of march 2020, south korea was successfully able to control the outbreak of the novel covid-19, and since its peak on march 11, 2020, the daily number of cases has been decreasing. this paper analyzes the trend and data of covid-19 on certain criteria using "exploratory data analysis." it is a revelatory step to any kind of analysis based on the date sets. in this paper, we reviewed the covid-19 spread in south korea with time by considering the different factors during the analysis. this will also enable us to know how south korea managed to flatten the curve of covid-19 cases with time. current and widespread outbreak of novel coronavirus motivates to perform exploratory data analysis (eda) on the datasets, which was collected from the different sources such as, korea centers for disease control and prevention (kcdc, south korea 2020), the ministry of health and welfare of south korea (mohw, south korea 2020), john hopkins github repository (jhgr, usa 2020) and coronavirus worldometer (worldometer 2020). the data was used to analyze the trend and spread pattern of covid-19 cases in south korea and compared with a pattern of cases in the most affected countries in the world. the data collected, organized, and processed in the form of graphical representation for the better visualization of results using originpro 2016 software (version 9.3.226, originlab corporation, usa). the total number of confirmed cases, active cases, deaths, and recovered cases as of july 8, 2020 (05:00 gmt), as well as the fatality rate distribution by province-wise was also presented. from the first detected patient on january 20, 2020, to march 1, 2020, when the third patient was reported, confirmed cases were mostly inbound travelers from overseas and their contacts. following february 18, an exponential surge with a short period was observed, starting with cluster infections mainly related to the shincheonji church and cheongdo daenam hospital in daegu city or south korea. at that time, south korea was on the verge of facing a continued surge in the covid-19 outbreak with new confirmed cases per day amounting to 909 and total cases under isolated treatment at 7470 (mohw, south korea). however, the situation has been successfully contained as of now with new confirmed cases per day reduced to a single digit. figure 1 shows the trend of confirmed, recovered, active and deceased cases of covid-19 in south korea till july 8, 2020 (gmt 05:00). as of july 8, 2020, the total number of confirmed cases in south korea reported to be 13,244, with the largest cluster of infected patients from daegu and gyeongsangbuk-do accounting for 62.8% of the total cases. according to the mohw, among the total cases of 10,806 as on may 5, 2020, females account for 40.5% and males for 59.5% (fig. 2a) . figure 2b shows the age distribution of infected persons. the number of deceased reaches 255 with 92.2% of the deaths from the age group of ≥ 60 and a fatality rate of 2.36%. the as of july 8, 2020, there were 1714 of total confirmed cases that had a travel history to different countries. among them, the usa and europe together contribute to more than 65.2% of the total confirmed cases in south korea as shown in fig. s2 (supplementary material) . out of the 1714 cases, 1286 (75.1%) cases were of korean nationality and 428 (24.9%) cases were of foreign nationality. when the covid-19 started spreading across the globe, the initial phase saw south korea becoming the second most affected country after china (the epicenter of the outbreak). but soon within a span of 2-3 weeks, south korea managed to control this virus from spreading through its rigorous and effective approach. as of now on july 8, 2020 as shown in fig. 3 , south korea has witnessed a total of 0.11% of the covid-19 cases being reported worldwide, with usa reporting one-fourth of the total number of cases. the number of causalities stands at 0.05%, attributing to the advanced health care system of south korea. the world is now witnessing the biggest pandemic, with the total death exceeding 550,000 till date. as of july 8, 2020, the total confirmed, deceased, recovered and active cases of 954, 944, 546, 720, 6, 846, 897, and 4, 206 ,920, respectively. table s1 (supplementary material) provides detailed information on the covid-19 cases around the world with usa and europe being affected the most in terms of causalities and the number of infected patients. compared to the worst hit countries with covdd-19, south korea has reported the lowest mortality rate of 2.2, when compared to usa, uk, spain, mexico, and italy with mortality rate of 4.4, 15.5, 11.3, 11.9, and 14.4, respectively (mohw, south korea). thus, the mortality per lakh population in india is 6 deaths per 1 million populations, which is owing to its early detection and testing capabilities which included extensive use of icts and drive-thru testing stations, south korea was able to contain the spread of this deadly contagion. south korea is capable of conducting 23,000 diagnostic tests per day, and almost a total of 1,359,735 tests have been conducted until july 8, 2020 (05:00 gmt). besides, the healthcare professionals in south korea were allowed to conduct a covid-19 diagnostic test on any suspected individual without any charge. the efforts made by the south korean government for carrying the extensive and free of charge diagnosis of covid-19 was key to minimize the outspread and damage of this virus at an early stage. as of april 27, there are 347 of national safe hospitals designed by the government to provide the services for non-respiratory patients and ensuring the safety of general patients. table s2 (supplementary information) provides the detail of the total numbers to tests conducted, in progress, and the concluded results. as of july 8, 2020 the total number of confirmed cases stands at 13,244, which is concentrated mainly in daegu and gyeongsangbuk-do province (62.8% of all confirmed cases) and the specific religious sector (shincheonji) as the major epidemiological link (47%). figure 4 provides the province wise data related to the spread of covid-19 in south korea. table s3 (supplementary information) provides the province wise detail on the total number of confirmed and active cases along with the recovered and deceased patients. the death toll in south korea stands at 285 to date with daegu having the largest share of causalities of 189 deceased. the world is facing an unprecedented economic, social, and political crisis with the spread of covid-19. global leaders and experts regard this pandemic as "the gravest challenge since world war ii." south korea too is no exception in this global pandemic. south korea had a surge of covid-19 outbreak and virus started spreading at the local and community level since the 31 st patient linked to shincheonji church was reported. the number of new coronavirus cases increased exponentially peaking at 909 new infections on february 29. but since then, new cases have dropped significantly. south korea is being applauded worldwide for being able to successfully flatten the curve on covid-19 in only 20 days without enforcing extreme draconian measures that restrict the freedom and movement of people. to begin with, south korea adopted its rigorous quarantine measures for incoming passengers from abroad (both symptomatic and asymptomatic). figure 5 and 6 provide details on the quarantine inspection procedures (qip) adopted by south korea for symptomatic and asymptomatic individuals, respectively. one of the key aspects which played a significant role in south korea's effective response was its use of icts and the state-of-art devices and applications including, self-isolation safety protection app, self-diagnosis app and epidemiological investigation support system which were able to tract the routes of confirmed individuals. mobile devices, cctv recordings and credit card usage data were used extensively for contact tracing to boost early testing. advanced icts were particularly useful in spreading key emergency information on the novel virus and help to maintain extensive "social distancing." the testing results and latest information on covid-19 was made available via national and local government websites. culturally and legally, south korea is more tolerant of personal data-sharing, and its success has been heavily dependent on its citizens that followed the government guidelines and took responsibility on themselves to self-quarantine in case of suspected illness. the government provided free smartphone apps indicating infection hotspots along with text alerts on testing. municipalities throughout south korea made every effort into curbing the contagion as they used the cellular broadcasting service (cbs) to inform the public of the movement paths taken by confirmed patients and other related information. residents who received covid-19 emergency texts can quickly check if they have been anywhere that overlaps with the movement of a confirmed patient, allowing them to get tested quickly if necessary. this formed a strong basis for south korea's early detection and testing capabilities. figure s2 (supplementary material) shows one such website providing the travel history of the confirmed cases. the image shows the track of covid-19 patient at a particular location in south korea using government data available online. besides, a walk-thru testing station named k-walk-thru testing facilities was adopted by south korea for the first time in the world to safely and quickly collect the samples of covid-19 with minimal contact. since the 2015 outbreak of the middle east respiratory syndrome (mers), south korea has learned key aspects, remained vigilant, and continued to refine its response system to better address potential outbreaks of large-scale epidemics, supporting hospitals to set up negative pressure rooms in 2018. the swift actions south korea has lately taken against covid-19, including its innovative "drive-thru" testing stations that help minimize the risk of cross infections at the testing centers while maximizing daily testing capacity amid fast rates of new cases, have received international attention and commendations. in addition, the government efficaciously explored various ways to balance the demand and supply of infection control supplies such as hand sanitizers and face masks from the early stage of the outbreak. south korea's success with widespread testing and its approach to slowing the spread of covid-19 offers a way out for most countries that are stuck in lockdown and it also acts as a model response to faces the future outbreak of such diseases as well. from the experience of the mers outbreak, the country learned the importance of diagnostic testing and basic infection prevention measures, which all came into play during the current pandemic. after the mers outbreak, when kcdc was not able to trace the movements of the virus, south korea changed the law allowing the government to collect a patient's data and security footage during an outbreak. all their steps are logged and then shared to alert people to stay away from the path of infection and if a confirmed case is found near a person's whereabouts, authorities send a text to let the person know if he or she has crossed paths with an infected person. while tracing people's every move can be controversial, many in south korea prioritize public health over privacy in an outbreak. as a result, south korea was able to test hundreds of thousands of people, more than any other country at the time, and this made it easier for authorities to track and contain the spread of the virus. this ability to find and treat infected people has allowed korea to avoid aggressive lockdowns and helped to bend the curve of the outbreak that started out dangerously steep. with just 30 cases reported, south korean health authorities had already started working with biotech companies to develop a test kit for the novel coronavirus, making available thousands of test kits. because the government had already equipped hospitals with coronavirus tests, doctors were able to test (patients right away), and contact tracing, in which all people an infected patient has had contact with are traced and tested, helped break the chain of infections and prevent mass outbreaks. at this time, when almost every country is fighting against the same enemy, an invisible micro-pathogen. the success or failure of this fight will naturally be a measure of the overall capacity of a country and will have great implications for the global community and history. through the key outcome reported in the study it is believed that a small but significant contribution could be made to the policy guidelines for the international community by sharing korea's experiences and countermeasures against covid-19 over the past six months. although covid-19 countermeasures taken by the south korean government may not be conclusive or universal for all but its exemplary approach to covid-19 can aid countries across the globe to strengthen their response system for the future outbreak of such contagious disease. for the successful resolution of covid-19 spread, there is a need for a robust response system powered by the combination of state-of-art techniques and the public's voluntary cooperation along with the sharing of information transparently and promptly in society. valuation of air pollution externalities: comparative assessment of economic damage and emission reduction under covid-19 lockdown a familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster who declares covid-19 a pandemic. acta bio-medica: atenei parmensis sars and mers: recent insights into emerging 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z. l.; chaturvedi, n.; tillin, t.; dale, c.; garfield, v. title: the association between sleep quality and type two diabetes at 20 year follow-up in the southall and brent revisited (sabre) cohort: a tri-ethnic analysis date: 2020-08-25 journal: nan doi: 10.1101/2020.08.23.20157073 sha: doc_id: 102218 cord_uid: jnigcguz objective: the risk of developing type 2 diabetes associated with poor sleep quality is comparable to that of traditional risk factors (e.g. overweight, physical inactivity). in the united kingdom, these traditional risk factors could not explain the two to three-fold excess risks in south asian and african caribbean men compared to europeans. this study investigates the (i)the association between mid-life sleep quality and later-life type 2 diabetes risk and (ii)a potential modifying effect of ethnicity. research design and methods: the southall and brent revisited (sabre) cohort comprised europeans, south asians, and african caribbeans (median follow-up = 19 years). complete case analysis was performed on 2190 participants without diabetes at baseline (age= 51.7 {+/-} 7sd). competing risks regressions were used to estimate the hazard ratios (hrs) of developing type 2 diabetes associated with four self-reported baseline sleep exposures (difficulty falling asleep, early morning waking, waking up tired and snoring) while adjusting for confounders. modifying effects of ethnicity were analysed by (i) testing for interactions and (ii) performing ethnicity-stratified analysis. results: snoring was strongly associated with increased type 2 diabetes risk but only among south asians in a fully-adjusted model (hr 1.42, 95%ci=1.08-1.85, p=0.011). our results revealed no elevated risk for any of the sleep exposures across all three ethnic groups. conclusions: the association between snoring and type 2 diabetes appeared to be modified by ethnicity, with south asians at greatest risk. there is growing evidence for an association between sleep duration or quality and type 2 diabetes. compared to sleep duration, fewer studies have explored the potential long-term effect of the equally important aspect of sleep quality on type 2 diabetes (1). while sleep duration refers to the number of hours asleep, sleep quality refers to difficulty initiating sleep, difficulty maintaining sleep (e.g. sleep-disordered breathing or uncontrollable limb movements), and the subjective feeling of being rested (2) (3) (4) . obstructive sleep apnoea (osa) is a severe but relatively common form of sleepdisordered breathing (5) , characterised by loud snoring, breathing cessation and repeated nocturnal awakenings. a recent meta-analysis of prospective cohort studies revealed that the adjusted pooled relative risks of developing type 2 diabetes associated with difficulty initiating sleep, difficulty maintaining sleep and osa were 1.55, 1.72 and 1.49 respectively. these effect sizes were comparable to wellestablished type 2 diabetes risk factors, and only marginally smaller than having a family history of diabetes or overweight, but greater than being physically inactive (6) . even fewer studies have included ethnic minorities (5, 7) , specifically south asians and african caribbeans, despite their two-to three-fold increased risk of type 2 diabetes compared to those of european origin (8) . these excess risks appear only partially due to traditional biological and environmental risk factors (8) . given the potential social patterning of sleep (9) and that osa may be more prevalent among ethnic minorities (10), we hypothesised that there would be (i) a deleterious association between specific sleep quality measures (difficulty falling asleep, early morning waking, waking up feeling tired, and snoring) and type 2 diabetes risk, and (ii) that these associations would be stronger in people of south asian or african caribbean origin. since sleep quality is potentially modifiable, understanding its role . cc-by-nc-nd 4.0 international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted august 25, 2020. . https://doi.org/10.1101/2020.08. 23.20157073 doi: medrxiv preprint in the development of type 2 diabetes may offer new opportunities for the prevention of type 2 diabetes. southall and brent revisited (sabre) (2008-12) is a multi-ethnic community-based prospective cohort composed of older europeans, south asians, and african caribbeans from london. median follow-up period was 19 (iqr=15, 20) years. the cohort was specifically set up to examine ethnic differences in cardiometabolic disorders. at baseline (1988) (1989) (1990) (1991) , there were more europeans (48.8%) than south asians (38.8%) and african caribbeans (12.4%) (11) . participants were aged between 40-69 years old and 75% were men (by initial study design) (8) . participants' ethnicity was initially determined by interviewers based on grand-parental origin and confirmed by participants (8) . all south asians and african caribbeans were first-generation migrants. the majority of african caribbeans originated from the caribbean (91.5%) and the rest from west africa (8) . south asian participants consisted of punjabi sikhs (52%), gujarati or punjabi hindus (20%), muslims (15%) and other south asians (15%). survivors at follow-up were between 57-90 years old. a detailed cohort profile (11) and information on follow-up (8) is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted august 25, 2020. . https://doi.org/10.1101/2020.08.23.20157073 doi: medrxiv preprint all indian asians and african caribbeans were first-generation migrants. ethnicity was interviewer-recorded based on parental origin and appearance and was subsequently confirmed by participants. indian asians originated from the indian subcontinent. african caribbeans originated from the caribbean (91.5%) or from west africa. exposure: sleep quality at baseline, participants answered four questions on sleep quality, including whether they (i) had difficulty falling asleep, (ii) woke up too early, (iii) felt tired upon waking up and (iv) snored in the past 30 days. the first three questions were adapted from the jenkin's sleep questionnaire (jsq) (12) , which is a brief, reliable and widely used sleep disturbance questionnaire validated among air traffic controllers and patients recovering from cardiac surgery. all responses were recoded as binary variables (yes=1 or no=0). the snoring variable was dichotomised at 'often' and 'almost always' as 'yes', whereas 'occasionally' and 'often' were coded as 'no'. snoring was used as a proxy marker for osa, which is a more severe form of sleep-disordered breathing. because sleep disturbances may be a symptom of type 2 diabetes, participants with diabetes at baseline were excluded to ensure that sleep quality exposures preceded any type 2 diabetes outcome. baseline type 2 diabetes was ascertained by (i) selfreport of doctor diagnosis or (ii) receipt of anti-diabetes medications (iii) fasting blood glucose ≥7.0 mmol/l or post load glucose after an oral glucose tolerance test (ogtt) ≥ 11mmol/l according to the world health organisation (13) criteria. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted august 25, 2020. . https://doi.org/10.1101/2020.08. 23.20157073 doi: medrxiv preprint for incident type 2 diabetes status, participants were directly followed-up using (i) primary-care medical record review of diagnosis or prescribed antidiabetic medication, (ii) self-completion questionnaires of physician diagnosis in addition to the year of diagnosis or named antidiabetic medication, and (iii) ogtt ≥ 11mmol/l at follow-up (11) . incident diabetes status of survivors obtained by direct follow-up was readily available as binary outcomes in the dataset owing to previous work done by tillin et al., 2013. participants who had died due to type 2 diabetes between baseline and followup (before 2011) but did not have a recorded year of diagnosis were excluded from the study sample, as this information was necessary for competing risks regression modelling. a range of baseline-measured covariates were adjusted for, grouped by (i) demographic factors (age, sex, ethnicity and socioeconomic position (sep) as measured by years of education), (ii) self-reported health behaviours (smoking status and total weekly leisure physical activity), and (iii) general adiposity (bmi). these covariates were established a priori risk factors for type 2 diabetes (8, 14) . our study controlled for general adiposity instead of central adiposity (using waist-to-hip ratio) as several studies suggest that general adiposity may be more important in impacting sleep quality, particularly for osa (15) (16) (17) . statistical analyses were carried out using rstudio version 1.1.456 and stata. this study used a complete case analysis (cca) to ensure comparability across different models. this study excluded participants with diabetes at baseline, those lost is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted august 25, 2020. . https://doi.org/10.1101/2020.08.23.20157073 doi: medrxiv preprint to follow-up for diabetes status (ltfu), and participants with missing data on any covariates specified in the models. the descriptive analyses were performed on n=2194 participants. however, the competing risks regression analysis was conducted on n= 2190 participants. the authors were unable to harmonise these figures as covid-19-related government regulations prevented access to restricted data held at the workplace. baseline characteristics of participants were presented for all covariates, grouped by incident type 2 diabetes status. results are expressed as geometric mean±sd for continuous variables and frequency with percentages for categorical variables. in this study, all formal tests of differences between groups were conducted using one-way analysis of variance (anova) for continuous variables and pearson's chi-squared (χ 2 ) tests for categorical variables. t-tests were not used in this study. the patterns of sleep quality exposures were also examined by ethnicity and incident type 2 diabetes status. competing risks hazard regression models were used to calculate (sub) hazard ratios (hrs) and 95% confidence intervals (ci) of developing type 2 diabetes for the four sleep quality exposures specified within the same model. for each sleep quality exposure, those who reported no sleep problems formed the reference group. the outcome for the survival model was time from baseline until the development of type 2 diabetes or censoring. death from other causes than type 2 diabetes was considered as a competing event. participants without death notification were censored at the end of the follow-up time (2011). is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted august 25, 2020. . https://doi.org/10.1101/2020.08.23.20157073 doi: medrxiv preprint three hierarchical competing risk models were specified. model 1 controlled for demographic factors (age, sex, ethnicity and education); model 2 additionally adjusted for health behaviours (smoking status and physical activity); model 3 additionally adjusted for general adiposity (bmi). the potential modifying effects of ethnicity on the association between poor sleep quality and incident type 2 diabetes were initially explored by adding an interaction term for ethnicity*sleep quality exposures in the fully adjusted model (model 3). however, these interaction effects were tested for each sleep variable one at a time. any interaction terms below the alpha threshold of 0.10 were taken forward by running the models within ethnicity-stratified samples, in which the conventional alpha of 0.05 was then applied. more than one-third of participants without diabetes at baseline were lost to follow-up (ltfu) on incident type 2 diabetes status despite extensive efforts for tracing and follow-up. missingness on all other variables of interest was negligible (<5%). baseline characteristics of those ltfu were compared to the cca sample. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted august 25, 2020. . https://doi.org/10.1101/2020.08.23.20157073 doi: medrxiv preprint of african caribbeans. type 2 diabetes incidence was also associated with nearly all model covariates, except for socioeconomic position. overall, early morning waking was the most commonly reported sleep problem (40%), followed by tiredness upon waking (38%), snoring (36%) and difficulty falling asleep (19%) . for all ethnicities combined, snoring prevalence was found to be different between type 2 diabetes cases and non-cases (43% and 36% respectively). this difference seemed to be driven by snoring patterns among south asians (figure 1 ). snoring was reported by 47% of south asians who developed type 2 diabetes, in contrast with 33% by non-cases. inter-ethnic differences were also found for difficulty sleeping and early morning waking; african caribbeans tended to have greater difficulty falling asleep; south asians tended to wake up too early. applying an alpha of 0.10 to the interaction effect models, results suggested a modifying effect of ethnicity on the association between snoring and incident type 2 diabetes risk only (p=0.056). for snoring, results show a modifying effect of being of south asian origin compared to europeans in the fully adjusted model (p=0.048). is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted august 25, 2020. in minimally-or fully-adjusted models. results show that snoring was strongly associated with incident type 2 diabetes, observed only in south asians but not in europeans and african caribbeans. difficulty falling asleep, early morning waking, and feeling tired upon waking up were not associated with elevated type 2 diabetes risk across all ethnic groups. our null findings for difficulty falling asleep and difficulty maintaining sleep (measured here as "early morning waking") were not comparable to results from a recent meta-analysis (6) . some study-specific characteristics may explain these results. studies included in the meta-analysis typically involved over 2000 ethnically homogenous groups from wealthy countries. although most studies included in recent meta-analyses employed similar self-reported sleep quality questions, biased interpretation due to cultural differences may exist. for instance, african americans is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted august 25, 2020. . https://doi.org/10.1101/2020.08.23.20157073 doi: medrxiv preprint were less likely to complain of a "sleep problem" but more likely to report taking over 30 minutes to fall asleep, which is the typical clinical cut-off (18, 19) . if a similar bias exists in other ethnic groups, then insomnia-symptoms may be underestimated, potentially explaining the lack of adverse effects in this study. moreover, the jenkin's sleep scale has not been cross-culturally validated. the questions may be more appropriate for western monophasic sleep cultures (one sleep session at night) but less suited for the siesta sleep culture (daytime napping and nocturnal sleep) common in caribbean communities (20) . future sleep research should use cross-culturally validated sleep questionnaires or multigroup analysis to ensure measurement invariance across ethnic groups. the strong association found for snoring among south asians is comparable to the pooled unadjusted relative risk for osa in the same meta-analysis (6). the twofold increased type 2 diabetes risk associated with snoring observed only in south asians represents a novel finding. in an attempt to extend previous work on ethnic differentials in type 2 diabetes risk (8), our findings suggest that snoring could play a more prominent role in type 2 diabetes pathogenesis in south asians. while this study did not adjust for an identical set of covariates as the study by tillin and colleagues (8) , uncovering the causes of the south asians' heightened type 2 diabetes vulnerability associated with snoring is an important research implication. our study could not measure objectively diagnosed osa and we did not capture the intensity of snoring, which might be informative in suggesting presence of osa (21) nevertheless, previous studies have found that the progression of increased apnoea/hypopnoea index (an indicator of the presence and severity of osa) among primary snorers and untreated patients with mild to moderate osa were significantly associated with length of time and increased weight (22) . furthermore, the prevalence is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted august 25, 2020. . https://doi.org/10.1101/2020.08.23.20157073 doi: medrxiv preprint and severity of osa among south asians are higher than europeans for the same level of bmi (23) , which could be partially attributed to a greater propensity among south asians to visceral adiposity at a lower bmi compared to white europeans (24). short-term laboratory studies have found several mechanisms linking poor sleep quality in general to impaired glucose metabolism, upregulation of appetite and similar-levels or reduced total energy expenditure due to daytime fatigue, predisposing individuals to weight gain and risk of type 2 diabetes (25, 26) . of note, three nights of laboratory-controlled sleep fragmentation (reducing slow-wave sleep, the deepest sleep stage) without changes in total sleep duration, showed a 25% decreased insulin sensitivity without a compensatory increase in insulin secretion among healthy volunteers (27) . this effect was comparable to a difference in type 2 diabetes risk associated with being eight to 13 kilograms heavier (28) . this suggests an adverse effect of poor sleep quality on the pathogenesis of type 2 diabetes independently of total sleep duration. for osa specifically, mechanistic explanations mainly involve (i) sleep fragmentation/ reduced slow wave sleep due to repeated night time awakening, (ii) intermittent hypoxia (periodic deoxygenation and reoxygenation of blood due to recurrent airway blockage), and (iii) reduced total sleep duration. these states may predispose individuals to glucose intolerance and insulin resistance through multiple pathways, including systemic inflammation and increased oxidative stress, ultimately increasing type 2 diabetes risk (25) . moreover, the association between snoring and type 2 diabetes risk independent of adiposity was consistent with findings from a metaanalysis of prospective cohorts which examined osa (29) . however, adjusting for adiposity contributed to the greatest attenuation in type 2 diabetes odds in this study, which suggested a partial mediation or confounding effect. obesity is a prominent shared risk factor for osa and type 2 diabetes. fat deposition surrounding the neck, is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted august 25, 2020. . https://doi.org/10.1101/2020.08.23.20157073 doi: medrxiv preprint chest, and abdomen (30) may compromise airway space and collapsibility, predisposing individuals to osa. yet, frequent snoring has also been found to be independently associated with glucose intolerance in lean adults (31) . without information regarding the temporality of adiposity and osa onset, it was unclear from this study whether adiposity acted as a confounder or a mediator. future research to disentangle the pathogenesis of type 2 diabetes due to obesity and/or osa may benefit from a life-course perspective. we also acknowledge that our study had several limitations. we only used sleep quality data at one time point in 20-years and as such could not capture the cumulative exposures of sleep problems and changes over time. ageing is associated with decreased sleep quantity and quality (32, 33) , and more daytime napping (34) . as insomnia were work-related (e.g. shift-work, work-related stressors). more free time post-retirement may also allow for longer sleep or napping to compensate for poor sleep quality. indeed, laboratory experiments have found that recovery sleep following a time of restricted sleep could partially reverse disruption in glucose metabolism over the short term (35) but long-term impacts of improved sleep require further investigation. for migrant groups, poor sleep quality caused by acculturative stress might also improve over time upon successful integration to the host society (36) . another limitation common to observational studies includes residual confounding, particularly for family history of diabetes, dietary patterns (e.g. hypercaloric diets, caffeine intake) (37) and depression (38) . other unmeasured aspects of socioeconomic position (e.g. wealth), migration-related health determinants and adverse childhood exposures may also contribute to observed ethnic differences (39) . furthermore, attrition may introduce bias. compared to the cca sample, participants is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted august 25, 2020. . https://doi.org/10.1101/2020.08.23.20157073 doi: medrxiv preprint lost to follow-up had slightly greater age, bmi, as well as slightly fewer years of education, but were otherwise nearly identical in observable baseline characteristics (esm 1). sleep disorders might be undertreated and underdiagnosed in the uk (40) . given the comparable effect size of poor sleep quality with traditional type 2 diabetes risk factors (6), identifying cost-effective and scalable early interventions to optimise sleep quality and duration show potential for type 2 diabetes prevention and for promoting population health. in conclusion, our findings suggested that sleep quality, particularly snoring (a proxy for osa) in middle-age is associated with the development of type 2 diabetes in later life, even after adjusting for traditional type 2 diabetes risk factors. this association was only found in south asians but not among the europeans and african caribbeans. findings do not suggest significant associations for difficulty falling asleep, early morning waking and waking up tired. this warrants further investigation into the apparent ethnic inequality and any sources of resilience due to changes in sleep pattern post-retirement. this study may inform strategies for type 2 diabetes prevention among south asians through screening for snoring or osa as risk factors for type 2 diabetes. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted august 25, 2020. the authors declare that there is no conflict of interest. the dataset analysed are available from the sabre study group but restrictions apply to the availability of these data, which were used with permission for the current study, and so are not publicly available. data are however available from the . cc-by-nc-nd 4.0 international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted august 25, 2020. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted august 25, 2020. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted august 25, 2020. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted august 25, 2020. . https://doi.org/10.1101/2020.08.23.20157073 doi: medrxiv preprint figure 2 . is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted august 25, 2020. . https://doi.org/10.1101/2020.08.23.20157073 doi: medrxiv preprint is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted august 25, 2020. . https://doi.org/10.1101/2020.08.23.20157073 doi: medrxiv preprint recommended amount of sleep for a healthy adult: a national sleep foundation's sleep quality recommendations: first report sleep health: can we define it? does it matter? measuring sleep quality sleep duration and quality: 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prevalence of diabetes depression and type 2 diabetes over the lifespan: a meta-analysis diabetes in migrants and ethnic minorities in a changing world sleep and health-postnote 585. london the authors are grateful to the participants for their continued support and to the sabre study group who contributed to the study design, study management and primary data collection. key: cord-024078-d34e31zd authors: baldwin-ragaven, laurel title: social dimensions of covid-19 in south africa: a neglected element of the treatment plan date: 2020-04-17 journal: nan doi: 10.18772/26180197.2020.v2nsia6 sha: doc_id: 24078 cord_uid: d34e31zd nan mandela's triumphant release from prison 30 years ago, those halcyon weeks in 2010 when we were hosts to the soccer world cup, or more recently siya kolisi's diverse team of players overcoming enormous odds to achieve a global rugby victory -the unity and transcendence of the rainbow nation largely have eluded us. while a pandemic is not the occasion to point fingers, it does expose the structural fault lines that undermine social cohesion. in "normal" times, these fissures are mostly tucked away safely in the recesses of our national collective consciousness. it is as if the virus, anthropomorphised, has pulled back the veil, baring the naked truth of our imperfect realities. there is no place to hide; and, to be totally honest, we are afraid. in south africa, with over 2000 total covid-19 cases and 25 deaths at the time of writing, it is important to reflect on the intersections between the biomedicine of the novel coronavirus and its sociopolitical manifestations. while sars-cov-2 is clearly a biological phenomenon that clinicians and researchers are learning more and more about each day, we also observe that the disease plays out differently in different bodies and in different social-political realities. no two people, and no two countries, are living and dying from covid-19 in exactly the same way. while there are common threads of pathophysiology and constraints of health-care systems, the illness experiences of individuals, families, communities and countries are unique, based on underlying contextual factors that are embedded in culture, economics, politics and philosophy. as clinicians, what can we learn from such observations? how can south africa benefit from analysing what has happened in countries that are ahead of us in viral spread? is it possible to avert a future imperfect in our context that is already fraught with social upheavals and inequity? what will a post-covid-19 health-care workforce look like? these questions, and others, probably keep many of us up at night with good reason. as we struggle to plan for meaningful interventions, what social considerations need to be kept in mind? in the past month, vast amounts have been written capturing the south african experience of the sars-cov-2 adenovirus that causes covid-19 disease. from the social distancing necessary to reduce the speed of transmission and flatten the curve, to buying essential goods for the duration of a communal lockdown, to the suffering endured by not consuming alcohol and tobacco, to reports about the personal and collective economic costs, to the nightly release of case statistics by geographical region, to the biographies of those who have died, we have amassed a hefty repository of pandemic stories that are intended to reveal a shared humanity and promote common cause. yet, there is something that should niggle at us, a discomfort as we begin to realise that apart from the similarities, there are also major divergences in our narratives. while transmission is the same for everyone (droplet spread vs aerosolisation which only occurs during invasive medical procedures), we are told that the expression of symptoms can range from completely sub-clinical to severe respiratory failure and death. biomedically, these differences are accounted for by age and/or other comorbidities. in his daily broadcasts, minister of health dr zweli mkhize reassuringly informs the public that those who have died so far would have died anyway from their co-morbid conditions: those with hypertension, diabetes, obesity, chronic obstructive lung disease, end-stage cancer, underlying immunosuppression and the elderly (with the exception of two people under age 50).(1) by implying that covid-19 was simply an added insult to an already-compromised human, he attempts to avoid panic by explaining that these people were already sick. he acknowledges that while the loss to each family is significant, the loss to the collective should be mitigated by this understanding. how true is this, however? it is certainly a more palatable explanation for the mounting death toll: weakened constitutions, people battling to stay alive anyway, a necessary culling of the herd. individual bodies live in communities with histories. these reveal the complex and less visible web of a person's or a community's inherent sociopolitical vulnerabilities that emerge as risk factors for poorer health outcomes. increasingly, it appears that someone's positionality on the uneven playing field of life will determine her prognosis in addition to biological factors for covid-19.(2,3) although there are well-established links between social positionality and the body's ability to mount an effective immunological response, the exact mechanism of these interactions remains elusive. (4, 5) in the united states, we observe relationships between zip code, race and death from covid-19, such as in new york city, where latinx people (those with latin american cultural or ethnic identity in the united states) make up 29% of the population but account for 34% of the death rate, a difference also seen with black new yorkers (24% of the population and 28% of the deaths). (6) there is speculation that poorer access to the advanced technologies for heroic life-saving interventions was the reason; however, there is a growing body of evidence pointing to the intersectional stressors of living with inequality, racism, classism, marginalisation or being "othered" that act at a cellular level even in the presence of adequate medical care. (2) this interplay between inherited and acquired vulnerability works its way into an embodied expression of disease at a granular level. however, there are ways to conceptualise some of the social and structural forces that increase risk (such as power and privilege) and simultaneously silence the expression and visibility of such suffering.(7) paul farmer points out, "structural violence is one way of describing social arrangements that put individuals and populations in harm's way. […] the arrangements are structural because they are embedded in the political and economic organization of our social world; they are violent because they cause injury to people … neither culture nor pure individual will is at fault; rather, historically given (and often economically driven) processes and forces conspire to constrain individual agency".(8) unlike the direct police violence resulting in the marikana massacre or the brutal rape and murder of uct student uyinene mrwetyana, structural violence is often invisible and has been likened to the unseen mass that lies beneath the tip of every iceberg exerting its influence by creating unequal life chances. structural violence is viewed as simply the way the world works, the natural order of things: entrenched power has become so normalised that it is often difficult to fathom where and how the injury came about. reflecting a recent episode of structural violence in our own health-care context, the life esidimeni tragedy comes to mind. as well intentioned as psychiatric deinstitutionalisation is in theory, economic expediency and a callous disregard for human life trumped professional ethics and the right to dignity. at least 144 people died from hunger, starvation, hypothermia and neglect following the ill-conceived transfer of long-term mental health patients to community-based non-governmental organisations that were not equipped to care for them. what is striking about this disaster, however, is the role of those in the gauteng department of health who foresaw nothing unusual, or turned a blind eye to possible pitfalls, while executing the deinstitutionalisation plan. when reading out the findings from evidence presented to the arbitration commission he chaired, retired deputy chief justice dikgang moseneke commented about the sheer lack of official accountability for the life esidimeni tragedy: "senior provincial heath officials had lied‚ played the victim‚ abused their power and knowingly violated the rights of mentally ill patients and their families because the instruction had come from above". (9) given that those who were directly responsible for the plan have not yet faced criminal prosecution, it remains whether this incident will be seen as a catastrophe of inordinate proportions or as a massive injustice perpetrated by particular individuals who benefitted. the late political theorist and legal philosopher judith shklar in her book the faces of injustice posits how accountability is apportioned according to how an incident is framed. if one interprets what has occurred as a "misfortune" or rather as an "injustice", there is an important distinction between whether and how accountability can be attributed. although people suffer either way, the depersonification of responsibility for that suffering in the case of a misfortune -a tsunami, landslide, tornado or other natural disaster -assumes that it is the invisible hand of fate at fault. according to shklar, however, a calamity is rarely neutral: scratch deeply enough and there will be an injustice where someone or something has behaved with culpability.(10) returning to our current crisis of covid-19, we actually have a choice in how our own responses will be judged by history. like famine, pandemics can either be mitigated or exacerbated by the political leadership and the decisions they make. (11) in fact, as many have argued, the root causes of mass starvation are wholly human-made. (12) although extreme weather events such as drought or flooding or a scourge of locusts or other blight may destroy food crops, theorists of the politics of famine argue that it is human beings who first determine their degree of responsiveness to climate change that actually results in such "natural" disasters and after, the nature and extent of food distribution that has been banked for emergencies, often privileging one group over another as food becomes weaponised. the national department of health in its covid-19 infection prevention and control guidelines for south africa states an obvious truth about combatting the spread of the virus in our particular situation: "south africa has a unique challenge of a large vulnerable immunocompromised population living in overcrowded conditions".(13) over the past 26 years, prior to being hit by the sars-cov-2 virus, this is a frank admission that we have been sluggish in our duty to address the needs of the masses. despite constitutionally enshrined guarantees to housing, sanitation, nutrition, education, recreation, gender equity and protection of those most vulnerable, progress on these fronts has been achingly slow. while pandemics are the ultimate litmus test of a nation's health system, the social determinants of health have never been more meaningful in our context. the minister of health, dr zweli mkhize, made it clear, "at this point … this is collaborative work. we did say [that] to defeat covid-19, it's no longer an issue of a nurse and a doctor. it's actually about society…about going into a combat zone to fight this infection". (14) attention to the social determinants of health, those underlying predictors of life and death, should give us pause to realise that no amount of ventilators and hospital beds can in fact stem the ravages of a virus that only knows a single pathway, that of vulnerability. we have ignored engaging with them at our peril. stats sa data from 2014/2015 indicate that almost half of the adult population (men and women over age 18) were living below the upper bound poverty line, the cut-off point at which there is just enough money for basic nutrition and other essential non-food items such as soap, clothing and sanitary pads. (15) in 2019, that amount was r1227 per person per month, with women experiencing 6% higher rates of poverty (52%) than men. (16) as regards changes in housing value over a 10 year period, the statistics are also grim: "more than half of south african households headed by black africans lived in dwellings that were valued at less than r50 000 […] [in contrast], most households headed by indians/asians and whites lived in properties valued at r400 000 or more". (17) in terms of both the number of rooms in these dwellings -and by implication size -"there has been a shift between 2002 and 2014 towards more rooms in formal dwellings and changes from multiple rooms in informal housing to one to two rooms" (italics added for emphasis). (17) in another report released by stats sa in february 2020 explaining income inequality, there is the stark finding that the poorest 60% of south african households are now relying more on social grants than paid employment to attain overall household income. this intervention prevents an even greater "income inequality gap between the bottom and top deciles". (18) despite this attempt at economic stabilisation, the divide between rich and poor is so wide that south africa carries the dubious honour of being the longest running most unequal country on the planet from 2006. (19) now it seems we must pay the price as the virus threatens to run its course along the fault lines of poverty and inequity. therefore, adherence to world health organisation directives like social distancing is impossible for large swaths of south africans who, through no fault of their own, lack the necessary infrastructure for such adherence. in an ironic twist, a resident of a rural community in mpumalanga expressed his "thanks" to the coronavirus for water. commenting on the installation of "six boreholes [with running taps] and six 10,000 litre water tanks" in the space of a week after years of waiting for access to fresh water, another resident pointed out that, "[al]though they (government) had promised us water a long time ago, […] now that we have this virus, we see fast delivery". (20) ongoing service delivery protests bear testament that in other parts of the country, after decades of neglect, improving access to water and sanitation has not been as successful. similarly, sheltering in place takes on new meaning across the inequality divide. given the challenge highlighted by stat sa (2014) in that 14% of the country's population live in informal dwellings, corresponding to 8 million people, (21) physical distancing in such conditions becomes next to impossible. there are substantive differences in self-isolating with a fridge and freezer full of food, opportunities for recreation on one's own lawn or swimming pool or tennis court versus the informality and overcrowding that are daily realities for much of the population. in the early days of the lockdown, we recall the images of law enforcement officials acting with zealousness to confine people to their shacks. as the bbc reported, "the police and army have, at times, acted with thuggish abandon in their attempts to enforce the […] lockdown, humiliating, beating, and even shooting civilians on the streets of the commercial capital, johannesburg, and elsewhere". (22) similar reports from front-line colleagues providing primary medical care in the townships expressed exasperation that the mall in ebony park remained open, or that it was "business as usual" with informal traders and food vendors in daveyton.(23) despite application of the siracusa principles (see table 1 ) during the declaration of a national disaster to ensure that any limitations of human rights are the least restrictive possible and affect all members of the population without discrimination, is it really possible to apply these principles equally if we live in such an inequitable society? these principles are not explicitly discriminatory against the poor. yet, the lockdown disproportionately affects low-wage workers in precarious employment. during and after the 5-week lockdown, the consequences of staying home are substantively different on the one hand, for a person with no guarantee of sustainable income or paid sick leave and on the other, for a person with job security or a stable business. can we blame the population for wanting to leave their overcrowded homes and travel to the local clinics during the lockdown to consult on previously neglected health matters? can we blame a parent who, because of lockdown, is not working at her usual three jobs and sees it as an opportunity to catch up on delayed immunisations for children, to extract a tooth that has been bothersome for months or to pass by for a social visit with the staff or other patients? the experiences of confinement and boredom are psychological for those of us with adequate housing. in the townships and informal settlements, these experiences are spatial and material. davis and others have described such toxic urban environments as "… a dumping ground for a surplus population working in unskilled, unprotected and low-wage informal service industries and trade". (26) in such contexts, does the restriction of rights to freedom of movement and employment carry the same meaning or intention? the current national debates about whether to extend the lockdown, and for how long, reveal the tensions between competing agendas. although few people are explicit about the trade-offs in terms of lives worth sacrificing as opposed to lives worth preserving, experts speak as if we inherently share the same belief that some lives are more precious, or at least worth saving, than others. further signalling the contingencies that will sway the balance between human life, and the survival of the economy is the personification of corporations and businesses: how long can the engines of industry remain moribund without suffering terminal complications? the flip side of this, however, is that there have been some very brave public health-motivated decisions taken by president cyril ramaphosa and his cabinet to regulate industry and repurpose manufacturing to address the pandemic. although the "combat zone" war metaphor may be problematic, it invokes powers for the executive to act in ways that place health at the centre of a societal agenda, something that we have not seen during peacetime. it opens up certain possibilities that are at odds with "getting back to normal", such as the mining industry is keen to do. (27) embedded in this calculus is what number of human beings can be forfeited to get the stock exchange up and running again -so that the poor can get back to work and not starve; because without employment and in the absence of a meaningful social safety net they will die anyway. we are told that actuarial scientists are key to resolving these equations, presumably relying on a common understanding of what utilitarianism means in our context. while it is acknowledged that we will all take a hit, certain among us must pay with our lives as well as our purse. so, what will be our levels of complicity with managing these "surplus people", those who in the best of times die from falling into a pit latrine, or a delayed cancer diagnosis, or at the hands of a violent partner or from a gang rape for being queer? in conversations with gauteng colleagues regarding their role in the covid-19 pandemic, they recall the trauma of working or training in apartheid-era segregated hospitals or wards with woefully inadequate resources and security police monitoring, or the overwhelming helplessness in the pre-antiretroviral days when aids patients lay dying on stretchers everywhere. other colleagues are more in tune with the fluidity of this crisis: "well, we are rationing all the time", which is probably a more honest appraisal of the resource constraints (structural violence) we have come to accept as a normal condition of practising in south africa's public health sector in the 21st century. whether we support national health insurance as the realisation of universal health coverage or not, we are now confronted with a number of questions that will determine our post-pandemic future. what is our appetite as clinicians to tackle these underlying sociopolitical issues, recognising their inexorable links to the current best medical and scientific management of covid-19? it is not a one or another choice. traditionally, clinicians have been averse to engaging in such issues because they are not regarded as purely "medical", but rather political, something that i have written extensively about in the past. yet, these are exceptional and truly ominous times. a set of agreed-upon foundational principles when human rights are temporarily restricted and subject to ongoing review and appeal in so far as • the restriction is provided for and carried out in accordance with the law; • the restriction is in the interest of a legitimate objective of general interest; • the restriction is strictly necessary in a democratic society to achieve the objective; • there are no less intrusive and restrictive means available to reach the same objective; • the restriction is based on scientific evidence and not drafted or imposed arbitrarily i.e. in an unreasonable or otherwise discriminatory manner. (25) in thinking about what instructs and informs physician advocacy, we can turn to various guidelines. first, the world medical association statement on patient advocacy and confidentiality advises, "medical practitioners have an ethical duty and a professional responsibility to act in the best interests of their patients. this duty includes advocating for patients, both as a group (such as advocating on public health issues) and as individuals".(28) (italics added for emphasis) the canmeds health advocate role, adopted by the health professions council of south africa, states, "as health advocates, physicians contribute their expertise and influence as they work with communities or patient populations to improve health. they work with those they serve to determine and understand needs, speak on behalf of others when required, and support the mobilization of resources to effect change". (29) (italics added for emphasis) inherent in these professional statements is a divide between the doctor and the patient or community, which recognises both the power differential and a need for therapeutic distancing that is purported to allow objectivity and reason to prevail. this divide also confers an element of safety, a recognition that doctor and patient are not in the same boat, at least not in that exact moment. covid-19 has changed that equation. now, it is not safe to be caring for patients with sars-cov-2, especially in an environment where access to appropriate personal protective equipment may be restricted. st augustine's hospital in durban is closed indefinitely due to an outbreak of covid-19 at the facility, where 48 nurses and 16 patients who tested positive are being kept in quarantine. (30) the media coverage of both famous and ordinary doctors from around the world who have died in the line of duty caring for covid-19 patients makes us question our own mortality and realise that, in this instance, nothing separates us from our patients really, except if fortunate, a medical or n95 mask. even the retreat to the sanctuary of our own homes is fraught with the risk of unwittingly bringing the virus, trojan horse-like, into our most sacred of spaces. patients are us. we are them. yet, not really. the repercussions of the pandemic will exact a high toll on our collective psyche and on the public's trust in medicine, nursing and the health-care system. clinicians can choose to exhibit leadership in opening up difficult conversations that frame a set of questions about the value of life in principle and about the underlying and obvious value chains of who deserves human rights. we can advise on how to "get people to stay home" by giving them the resources to make that possible. or, we can usher in a police state that will further violently punish poor people for existing while we do nothing to help stop the spread of the virus. community engagement, public education, housing and financial support are required to help people practise physical distancing. our treatment armamentarium for covid-19 needs to expand if we have a hope of coming through this alive. coronavirus deaths in south africa rise to being a person of color isn't a risk factor for coronavirus. living in a racist country is -the boston globe vulnerable groups. world health organization world health organization perceived discrimination, race and health in south africa racism and health: evidence and needed research new york city's latinx residents hit hardest by coronavirus deaths on suffering and structural violence: a view from below pathologies of power: structural violence and the assault on human rights full: life esidimeni arbitration handed down by moseneke the faces of injustice from cholera to corona: the politics of plagues in africa africa is a country the political economy of famine. a preliminary report of the literature, bibliographic resources, research activities and needs in the uk. institute for research in the social sciences covid-19 infection prevention and control guidelines for south africa -draft v1. department of health covid-19 recovery patients quadruple: report. sabc news -breaking news, special reports, world, business, sport coverage of all south african current events africa's news leader statistics sa. men, women and children: findings of the living conditions survey national poverty lines. pretoria, gp: isibalo house ghs series volume vii: housing from a human settlement perspective in-depth analysis of general household survey (2002-2014) and census (1996-2011) media statement inequality trends in south africa: a multidimensional diagnostic of inequality world bank we thank virus for water', say grateful mpumalanga community we thank virus for water', say grateful mpumalanga community. sowetanlive [internet]. sowetanlive; 2020 south africa's ruthlessly efficient fight against coronavirus personal oral communications with clinical colleagues siracusa principles on the limitation and derogation world health organization. who guidance on human rights and involuntary detention for xdr-tb control world health organization planet of slums amcu rules out mines returning to limited operations business day world medical association-wma statement on patient advocacy and confidentiality [internet]. the world medical association royal college of physicians and surgeons of canada. canmeds role: health advocate the royal college of physicians and surgeons of canada durban hospital closed indefinitely due to covid-19 outbreak i am thankful to antje schuhmann, sanele sibanda, zimitri erasmus and sarala naicker for rich conversations that have assisted in converting my thoughts and ideas around the covid-19 pandemic into something coherent. i am grateful to my daughter shanthi samara ragaven for a careful read of the text as well as her assistance with putting the references into vancouver citation style. finally, many clinician colleagues from south africa and internationally have generously shared their own frontline experiences which have broadened my own understanding of the challenges we are facing. key: cord-269362-pne9qolr authors: yassi, annalee; bryce, elizabeth a; breilh, jaime; lavoie, marie-claude; ndelu, lindiwe; lockhart, karen; spiegel, jerry title: collaboration between infection control and occupational health in three continents: a success story with international impact date: 2011-11-08 journal: bmc int health hum rights doi: 10.1186/1472-698x-11-s2-s8 sha: doc_id: 269362 cord_uid: pne9qolr globalization has been accompanied by the rapid spread of infectious diseases, and further strain on working conditions for health workers globally. post-sars, canadian occupational health and infection control researchers got together to study how to better protect health workers, and found that training was indeed perceived as key to a positive safety culture. this led to developing information and communication technology (ict) tools. the research conducted also showed the need for better workplace inspections, so a workplace audit tool was also developed to supplement worker questionnaires and the ict. when invited to join ecuadorean colleagues to promote occupational health and infection control, these tools were collectively adapted and improved, including face-to-face as well as on-line problem-based learning scenarios. the south african government then invited the team to work with local colleagues to improve occupational health and infection control, resulting in an improved web-based health information system to track incidents, exposures, and occupational injury and diseases. as the h1n1 pandemic struck, the online infection control course was adapted and translated into spanish, as was a novel skill-building learning tool that permits health workers to practice selecting personal protective equipment. this tool was originally developed in collaboration with the countries from the caribbean region and the pan american health organization (paho). research from these experiences led to strengthened focus on building capacity of health and safety committees, and new modules are thus being created, informed by that work. the products developed have been widely heralded as innovative and interactive, leading to their inclusion into “toolkits” used internationally. the tools used in canada were substantially improved from the collaborative adaptation process for south and central america and south africa. this international collaboration between occupational health and infection control researchers led to the improvement of the research framework and development of tools, guidelines and information systems. furthermore, the research and knowledge-transfer experience highlighted the value of partnership amongst northern and southern researchers in terms of sharing resources, experiences and knowledge. working conditions for health workers are undergoing rapid change [1] . new methods for diagnosis and treatment of diseases, combined with rapid communication technology, makes the world's ability to communicate and disseminate new knowledge remarkably effective; the speed with which the sars outbreak was controlled [2] and pandemic h1n1 information transmitted are clear illustrations [3] . on the other hand, economic globalization is severely straining healthcare resources, preferentially benefiting richer countries [4, 5] . the changes in labour flow [5] and trends to deregulation [4, 6] also impact the health and well-being of the labour force. international travel, representing 684 million passengers in 2009 [7] , adds complexity in preventing and reducing rapid transmission of infectious diseases across borders. rapid travel has intensified the global need for consistent application of infection control principles to ensure the safety of patients, hospital visitors and health workers. healthcare acquired infections (hais) are often linked to invasive devices, longer hospital stays and more time spent in intensive care [8] . these infections make up a substantial proportion of the infectious disease burden in high income as well as in low and middle-income countries (lmics) [9] . the risk of a hai is 2-20 times higher in lmics than in high income countries, and this may be an underestimate, due to differences in the intensity of surveillance [9, 10] . an estimated 20% of patients could suffer from preventable hais [11] . along with patients, healthcare workers are also at high risk of exposure to biological agents in healthcare settings [12, 13] . almost half the cases of sars were in health workers [2] , 40% of the hepatitis b and c that occurs in health workers is estimated to be due to occupational exposures [11, 14, 15] , and health workers have a high risk of multiple drug-resistant tuberculosis [16] . to protect the health and safety of patients and health workers in all countries, infection control and occupational health professionals must work closely together. our interdisciplinary international collaboration has contributed to produce practical tools such as guidelines, online and face-to-face training products, checklists, research materials, frameworks and a health information system. this innovative participatory paradigm that has been widely embraced by collaborators and front line health workers. post-sars epidemic, the canadian-based team (led by co-authors ay, an occupational health researcher, and eab, an infection control specialist) conducted research to ascertain the determinants of sustainable adherence to appropriate infection control practices, refining a framework on individual, organizational and environmental factors [17] . in a survey of 1,290 workers across sixteen hospitals in british columbia the team found that health workers who rated the environmental protective measures highly at their institutions were 12 times more likely to report a high level of compliance with appropriate personal protective practices compared to those who did not rate this factor highly at their institutions. similarly, those who perceived organizational factors in the workplace to be consistent with safe practices were 10 times more likely to report good compliance. interestingly, though, there was no association with the individual factors previously thought to be pivotal in affecting compliance [17] . next, a survey of infection control and occupational health resources and a questionnaire completed by healthcare workers were compared with on-site observational audits in facilities in british columbia and ontario. health workers believed that plans were available to protect against future sars-like events but audits revealed that these did not exist in many facilities. both occupational health and infection control were underresourced post-sars, with occupational health professionals particularly lacking in british columbia. there was a discrepancy between health workers' perception of what was available and what is actually accessible in facilities [18] , highlighting the need for better communication. the findings from our initial research in canada led to our developing an evidence-based workplace assessment tool. our initial research in canada also showed that training health workers was significantly associated with health worker perception of a positive safety culture in their healthcare workplace [17, 19] . one of the identified constraints was the limited quantity of information that could be presented at group sessions due to the time restrictions. these sessions were insufficient to build knowledge and good practices on the selection and use of personal protective equipment [20] . these research observations were the impetus for our developing online infection control courses that were self-directed, flexible, interactive, and relevant to day-to-day work activities [21, 22] . in the region of the americas, our team collaborated with the pan american health organization (paho) on a project related to the prevention of occupational transmission of infectious diseases among health workers. in collaboration with the ministry of health from ecuador, the team members collectively adapted the canadian workplace assessment tool and questionnaire to assess knowledge, attitudes and practices in three hospitals in ecuador (two in quito and one in the amazon) [23] [24] [25] . the workplace assessment tool comprises a list of occupational hazards, including physical, chemical, biological, ergonomic, safety, and psychological hazards. under each hazard classification, the evaluator completes the workplace assessment form by indicating whether the environment and practices are satisfactory, require correction but are not an immediate hazard, or require immediate correction. using the results of the questionnaire and needs assessment, local colleagues identified strengths and challenges at each healthcare facility and initiated projects to address the issues unearthed. for example, campaigns were begun to improve hand hygiene and reduce needlestick injuries, as well as implement muchneeded renovations in the emergency department of one of the hospitals [25] all priorities identified by using the tools developed. following the success of this initial work in canada and ecuador, the government of the republic of south africa (through co-author ln) invited our team to lead a healthy hospital initiative in that country. again, working closely with local colleagues, we revised the assessment tools, then invited 76 participants to a three-day workshop on occupational health and infection control to complete the initial survey. invited participants included all the 54 representatives elected from the workforce to serve as health and safety representatives as well as the 16 occupational health and infection control staff members from pelonomi hospital, the health facility selected for our pilot study [26] . the participants were then divided into ten groups to conduct workplace audits, covering five domains; physical environment, specific occupational health practices and hazards, specific infection control practices, equipment and procedures, and ergonomics. training sessions were also conducted specifically for medical practitioners, a usually hard-to-reach population, as the canadian-based research also confirmed [17, 19] . having identified the need for better data collection instruments, we developed the occupational health and safety information system (ohasis), a web-based health information system, to track incidents, exposures, risk factors, immunizations and occupational injury and diseases. based on experience in canada [27] , we ensured that this system particularly focused on preventing hais in health workers. we then began the process of implementation and evaluation [26, 28] . meanwhile, paho invited our team to assist in preparing health workers for the global summit and the pan american games in trinidad and tobago. the workplace audit tool, developed originally in canada by the team (comprised of experts in program evaluation, infection control, occupational health, information technology, public health and medicine), and refined from use in ecuador and south africa, was again adapted and workshops held to train occupational health and infection control practitioners from 7 countries across the caribbean. the audit tool is a structured form, which enables healthcare workers to evaluate their working environment in a systematic manner. health and safety professionals have noted that the tool has enabled them to set priorities and act upon identified needs. a novel animated skill-building tool that permits health workers to practice selecting and wearing personal protective equipment was also developed for the caribbean training (http://www.ghrpinnovation.com/protectpatti/eng/index. html). in collaboration with paho, the basic infection control course originally developed in canada post sars was then translated into spanish (http://www.ghrpinnovation.com/ infectioncontrol), with input from colleagues in ecuador (led by co-author jb). we collaborated with member countries to pilot the online course in several countries to ensure its relevance to the local context. during the pilot phase, the participants expressed high levels of satisfaction towards the training specifically the interactive format and comprehensive content. the online course and tools, such as the workplace assessment, have been presented at various regional and national trainings such as the paho train-the-trainer workshops which were held in venezuela, colombia, ecuador, trinidad and tobago and belize. the latin american and south african work also included development of evidence-based training programs to specifically build capacity of health and safety committees, as our previous research indicated was important [29] . the tools developed have since been revised and are now being used to train health and safety committees in canada as well. advances in worker health and safety have been historically tied to workers' struggles, led usually by trade unions, to obtain better working conditions. the well-being of the workforce, particularly when the economy is strained, as is occurring ever more forcefully in this era of deregulated globalization [4, 30] , is often treated as expendable by decision-makers. ironically, perhaps, worker health and safety has not received greater attention in the healthcare sector than in other economic sectors [4] , despite the fact that health workers constitute the largest workforce in the world, with an estimated 59 million worldwide [31] . while the tools we produced are limited in conveying an indepth understanding of the complex global forces that weaken public health systems, hindering the allocation of resources to infection control and worker health, they do help mitigate the impact of resource strains in countries such as ecuador and south africa, where strong government commitment has been expressed towards health system improvement and worker well-being. our collaboration has produced a better understanding of the social, cultural, environmental, occupational and economic processes that determine the health of health workers locally [17, 18, 20, 21, [32] [33] [34] and globally [4, 25, 26, 35] . our conceptual framework has been since used by other research groups [36] ; our findings were used by hospital decision-makers and government planners; and these research findings were taken into account by our own team in the development of the tools described above. as noted above, the research we conducted first confirmed that providing health workers with training to properly protect themselves from infectious diseases is significantly associated with better perception of a positive safety climate. after we created training tools to address the organizational, environmental and individual factors we identified as important determinants of infection control compliance, we conducted further research followingup on the use of these online tools. we then found that providing time to take the course on work time was significantly associated with higher intention to comply with safety precautions compared to promoting the course on a voluntary basis (logistic regression model showed a statistically significant difference between supervisor-required and voluntary groups with respect to perceived importance of infection control in the workplace, the extent to which the facility ensures patient safety, and the extent to which the facility ensures staff safety) [19] . this led to the course becoming mandatory in british columbia [22] . building on the findings of our research in canada, initial work in ecuador, and our pilot study in south africa (for example, poor staff knowledge on recapping of needles as well as the finding that more than half the respondents felt that they were not given guidance as to how to perform their jobs safely [26] ), we collaborated with government officials in ecuador, south africa and the caribbean to develop guidelines, policies and programmes. we also worked with international agencies to develop new policy guidelines [15] . acting on our own research findings, we created further training materials, addressing not only basic infection control and how to don and doff personal protective equipment, but how to establish health and safety committees, inspect workplaces, investigate incidents, and establish policies and health and safety programs based on solid evidence. our work has squarely addressed north-south power relations and the digital divide, always building on local capabilities to transfer knowledge south-south, north-south and vice versa in a respectful manner that benefits both northern as well as southern partners [37] . the products developed have been widely heralded as innovative and important components of "toolkits" used internationally. the tools now used in canada have, in turn, been improved from the collaborative adaptation process for south and central america and south africa. thus this research has resulted in health service approaches, products and policies that are being embraced nationally (e.g. in ecuador, trinidad-tobago and south africa) and internationally (e.g. through international organizations including paho) as well as having canadian impact [19, 21, 22] . the guidelines, research and needs assessment instruments, web-based health information system, and on-line learning modules will continue to have widespread impact well into the future. more importantly, by elucidating the links between worker health and the health of patients, we have begun to show that attending to the health of the healthcare workforce is not only the right thing to do to protect this vulnerable population, but also produces safer healthcare for all. this case thus illustrates the benefits of infection control and occupational health researchers working together and also how canadians and southern partners alike benefit from international collaboration. this case study is really about a partnership of partnerships. first, there was the partnership between canadian occupational health and infection control [17] [18] [19] [20] [21] 32, 34] researchers, and simultaneously, a partnership between an inter-disciplinary ecuadorean occupational and environmental health team and canadian counterparts who shared an appreciation of an ecosystem approach to human health [38] , including its applicability to emerging infectious diseases [39] . meanwhile, a new partnership was being forged between the combined canadian occupational health and infection control team and their south african counterparts [26] , brought together by the world health organization (who). finally, with the assistance of paho and later also the who, the various partnerships were brought together, informing each other in what became an integrated international approach to promoting healthy healthcare. knowledge translation experts emphasize the importance of good quality evidence [38] as well as involving users of the research findings at the earliest stage. thus it was essential that we involved the local healthcare leadership, already established occupational health services as well as health and safety committee members and governmental-based expertise at the outset. in ecuador, the project built on a strong partnership between the university of andina simon bolivar, the university of cuenca, and various other universities and healthcare facilities on one hand, and the various centres at the university of british columbia on the other. having a strong local champion is key to success, and ecuadorean co-author (jb) fulfilled that role. similarly, we chose pelonomi regional hospital in the free state as a research pilot site to support knowledge translation and capacity building, in large part due to the local champion. a major impact of our work to date has been the demonstration of the benefits of close collaboration between infection control and occupational health, which, in most jurisdictions, was weak. the director of the national institute for occupational health in south africa cited our collaboration as a model that should be embraced in south africa. linkages are now being fostered between infection control and occupational health personnel, modeled on the canadian-initiated collaboration; ohasis, or at least some modules from ohasis, is being used by occupational health and infection control professionals and by health and safety committee members in latin america, the caribbean and south africa, as are the interactive online training modules. the full benefits of these innovations will increasingly manifest over time, but the impact on knowledge, attitudes and practices has already begun to be demonstrated [25] . collaboration requires mutual respect and trust, as well as a shared vision and sense of common mission. we were fortunate that the various partnerships within this partnership-of-partnerships all agreed to an open source, creative commons philosophy, in which none of the products of our work would be commercialized. this viewpoint also maintains that all derivatives must be approved by all members of the collective, which ensures on-going quality improvement and a flexible, yet standardized, and more easily communicated approach. with this sense of common mission, we are confident that the fruits of our collaboration will continue to provide high quality knowledge transfer of best available evidence. our first real challenge was in sustaining engagement of politically active workplace stakeholders, specifically the trade unions. we have had decades of successful experience in this regard [29, 39, 40] , but may have taken for granted that labour union trust would be there. while this was not problematic in our latin american work, a communications breakdown occurred in the south african work, creating a setback. the lesson learned was that trust can never be assumed, and it is well worth taking the time to ensure that all key stakeholders are indeed engaged before the project moves ahead too far. getting process issues right is paramount to success. a second challenge, also stemming from politicallycharged labour relations, was the advent of a major strike in south africa just as we were beginning what was supposed to have been an intensive two-week capacitybuilding effort. the team therefore had to come up with training innovations (including role-play, drawn scenarios, and interactive on-line learning modules [19, 21, 22, 41] ); with necessity being the mother of invention, the products created were very well-received and will serve the crosscontinental partnerships well for years to come. another important lesson to note is the importance of thinking about scale-up and sustainability from the start. while the ecuadorean pilots were successful, resources are not in place to continue the efforts at the desired intensity. learning from this, before launching the full pilot in south africa, decision-makers (including coauthor ln) started planning for scale-up early, should the pilot prove successful. this required thinking through complexities beyond the pilot, such as who will continue to implement and monitor the model after the pilot has ended, and how should the model be altered in the pilot with such questions in mind. by working closely with the who, the international labour office, the international commission on occupational health, and a world-expert on scaling up [42] , we are now optimistic that the tools produced will be successfully used not only in local pockets, but on national and international scale. from a funding perspective, the increasingly embraced philosophy of open source [43] and creative commons licensing [44] assures that these tools are available without charge. key however, will be the extent to which local (and national) colleagues are indeed comfortable in using the tools and promoting their use locally. also, in the case of information technology that requires maintenance and periodic updating, commitment from authorities (either government or external funders/partners) is needed. the "business model" of using revenue from distribution in high-income countries to fund maintenance and updates globally, is one way that lmics can have their systems maintained and updated without strain on their resources, and assist high income countries to assume their global responsibilities [35] . finally, it should be stressed that the success of this work has been, and will continue to be, based on frontline support and active engagement of the decisionmakers. this can never be taken for granted. severe acute respiratory syndrome (sars) and health care workers public health communication with frontline clinicians during the first wave of the 2009 influenza pandemic understanding "globalization" as a determinant of health determinants: a critical perspective taming the 'brain drain': a challenge for public health systems in southern africa assessing the health implications for healthcare workers of regulatory changes eliminating locally developed occupational exposure limits in favor of tlvs: an evidence-based bipartite approach international air transportation association: fact sheet: iata-international air transport association the efficacy of infection surveillance and control programs in preventing nosocomial infection is us hospitals healthcare-associated infection in developing countries: simple solutions to meet complex challenges making hospitals safer: the need for a global strategy for infection control in health care settings the preventable proportion of nosocomial infections: an overview of published reports death of a health care worker with nosocomial extensively drug-resistant tuberculosis in india nosocomial transmission of invasive group a streptococcus from patient to health care worker sharps injuries: global burden of disease from sharps injuries to health-care workers provision of workplace programs for hiv and tb for healthcare workers -a systematic review to support development of guidelines for the implementation of policies to improve health worker access to prevention, diagnosis, treatment, and care services for hiv and tb. vancouver: prepared for the world health organization high incidence of hospital admissions with multidrug-resistant and extensively drugresistant tuberculosis among south african health care workers determinants of healthcare workers' compliance with infection control procedures staff perception and institutional reporting: two views of infection control compliance in british columbia and ontario three years after an outbreak of severe acute respiratory syndrome the impact of requiring completion of an on-line infection control course on health professionals' intentions to comply with infection control guidelines: a comparative study occupational health and infection control practices related to severe acute respiratory syndrome: health care worker perceptions personal protective equipment in healthcare: can online infection control courses transfer knowledge and improve proper selection and use? using online delivery for workplace training in healthcare healthy hospitals project part i (audit and survey): collaboration between canada and ecuador. carwh conference -occupational health and safety research in action: method, results and applications montreal healthy hospitals project part ii (workshop): collaboration between canada and ecuador. carwh conference -occupational health and safety research in action: method, results and applications international collaboration to protect health workers from infectious diseases building capacity to secure healthier and safer working conditions for healthcare workers: a south african-canadian collaboration workplace and workforce health information systems in healthcare: acknowledging the role of university researchers and highlighting the importance of health and safety committee capacity-building tool, weapon or white elephant? a canadian-south african collaboration to explore how information systems can be harnessed to help make health care a healthier place to work joint health and safety committee education and the value of bipartite cooperation in the healthcare sector in british columbia globalization and social determinants of health: the role of the global marketplace (part 2 of 3). globalization and health working together for health protecting health care workers from sars and other respiratory pathogens: a review of the infection control literature protecting health care workers from sars and other respiratory pathogens: organizational and individual factors that affect adherence to infection control guidelines research gaps in protecting healthcare workers from sars and other respiratory pathogens: an interdisciplinary, multi-stakeholder, evidence-based approach assuming our global responsibility: improving working conditions for healthcare workers globally the individual, environmental, and organizational factors that influence nurses' use of facial protection to prevent occupational transmission of communicable respiratory illness in acute care hospitals international adaptation and sharing of an infection control and occupational health inspection tool for healthcare facilities: bringing lessons back home. international commission on occupational knowledge for knowledge translation: the role of the cochrane collaboration the development of worker-controlled occupational health centers in canada a collaborative evidence-based approach to making healthcare a healthier place to work innovative training for occupational health and infection control workplace assessment in healthcare: necessity as the mother of invention implementing best practices in reproductive health: a guide for fostering change to scale up effective health services global access creative commons licensing submit your next manuscript to biomed central and take full advantage of: • convenient online submission • thorough peer review • no space constraints or color figure charges • immediate publication on acceptance • inclusion in pubmed, cas, scopus and google scholar • research which is freely available for redistribution authors' contributions ay and eab conceived these projects and created the first draft of this manuscript. jb was responsible for the coordination of the projects in ecuador. nl was responsible for the projects in south africa. mcl aided in the coordination of the projects in venezuela and in trinidad and tobago. all authors (ay, eab, jb, nl, mcl, kl and js) helped to write and revise this manuscript. no competing interests to declare. key: cord-033759-cjxzenld authors: kang, jaeho title: the media spectacle of a techno-city: covid-19 and the south korean experience of the state of emergency date: 2020-08-17 journal: nan doi: 10.1017/s0021911820002302 sha: doc_id: 33759 cord_uid: cjxzenld this essay provides a critical observation of the south korean government's distinctive management of covid-19 with particular reference to the state of emergency. it reveals that the success of south korea's handling of the pandemic is largely attributed by a majority of western media to the efficient deployment of both information and communication technologies and confucian collectivism, two components that seem contradictory yet not incompatible under the rubric of techno-orientalism. analyzing the intensification of surveillance and the rapid datafication of society, this essay argues that the current state of emergency is not a breakdown of normality but a continuation of the state of crisis and disaster that rules a developing country like south korea. in doing so, the essay seeks to facilitate a critical discussion about a new mode of democracy in the era of pandemic that increasingly grapples with tensions between individual freedom and public health. and the early hours of may 2. that the spike of nearly 100 new infections was directly linked to gay nightclubs sparked widespread blame of the "promiscuous gay lifestyle." the marked increase in homophobic backlash against the lgbtq community via internet trolling exemplifies a typical cultural response of asian countries depicted by the western mainstream media. south korea's handling of covid-19 has been hailed by the majority of western media. national public radio touted south korea's approach, grounded in conducting rapid, extensive testing for the coronavirus, as a model for other countries. 1 an article in the new yorker illustrated that the south korean government's approach to combating the coronavirus made the american response look "absurd." 2 echoing highly positive accounts, the new york times identified a few lessons from the south korean model to contain the coronavirus without shutting down the economy and asked whether these could work abroad, particularly in the united states. 3 south korea may deserve some credit for its handling of the coronavirus. among numerous indications, it is striking that the nation has had a significantly lower mortality rate from covid-19 than other countries. as of may 26, south korea's rate was 2.40 percent (269 deaths out of 11,225 cases), whereas most organisation for economic co-operation and development (oecd) countries, particularly in western europe, were higher than 10 percent. 4 it is noteworthy that this was achieved without draconian restrictions on speech and movement, as imposed in china, or drastic measures such as locking down entire cities or regions, as deployed in european countries and the united states. highlighting that the first confirmed cases of covid-19 were reported in both the united states and south korea on january 20, 2020, the guardian reported that in the two months that followed, the responses by the two countries were polar opposites. 5 in a similar vein, the nation gave an account of south korea's success in "testing, national health care, and transparency," while contrasting it with the struggle of the united states, where the death toll exceeded 112,000 as of june 8, 2020. 6 1 anthony kuhn, "experts credit south korea's extensive testing for curbing coronavirus spread," national public radio, march 12, 2020, https://www.npr.org/2020/03/12/815097813/ experts-credit-south-koreas-extensive-testing-for-curbing-coronavirus-spread (accessed june 6, 2020). 2 colin marshal, "the comports of south korea's coronavirus response," the new yorker, april 14, 2020, https://www.newyorker.com/news/dispatch/the-comforts-of-south-koreas-coronavirusresponse?fbclid=iwar2k5eouhmuwlziab6mgwjjayrckb8-penpvlijloh7xud0d848pr-lanhqw (accessed june 6, 2020). 3 max fisher and choe sang-hun, "how south korea flattened the curve," new york times, march 23, 2020, https://www.nytimes.com/2020/03/23/world/asia/coronavirus-south-korea-flattencurve.html?fbclid=iwar3gm6g9qrqrqytjjebbhihr0sml6nelfvdsj12cu6avz65i9vycsy-juogq (accessed june 6, 2020). 4 center for evidence-based medicine, "global covid-19 case fatality rates," https://www.cebm. net/covid-19/global-covid-19-case-fatality-rates/ (accessed may 31, 2020). 5 ed pilkington and tom mccarthy, "the missing six weeks: how trump failed the biggest test of his life," the guardian, march 28, 2020, https://www.theguardian.com/us-news/2020/mar/28/ trump-coronavirus-politics-us-health-disaster (accessed june 6, 2020). 6 tim shorrock, "how south korea triumphed, and the us floundered, over the pandemic," the nation, march 20, 2020, https://www.thenation.com/article/world/coronavirus-south-koreaamerica/ (accessed june 6, 2020). analyses of south korea's management commonly attribute its success to both the efficient deployment of information and communication technologies (icts) and the confucian collectivism of obedience and conformity. for instance, comparing the application of different policies in south korea and italy as the divergent strategies of "east vs. west," the wall street journal underscored that, unlike individualistic societies, south korea's confucian cultural tradition enables a "paternalistic state" to intrude into people's lives freely during a period of emergency. 7 les echos, the oldest french financial newspaper, featured an opinion column arguing that the french government should not sacrifice individual freedoms by adopting the tracking measures deployed by south korea, a totalitarian country with "a culture of hyper-surveillance and denunciation." 8 the asia times, a hong kong-based news platform, stressed that confucian asian countries were winning the war against covid-19 while western countries were losing the battle with "fear, panic and hysteria." 9 the portrayal of korea as a confucian patriarchal country-that is, a hierarchical, homogeneous, monolithic, traditional, and collectivist society in asia-is not only found in media outlets but also resonates in a more sophisticated and philosophical way among prominent intellectuals. for instance, in the fight against the pandemic, han byung chul, the korean german philosopher, contended that asian countries such as south korea, japan, china, taiwan, and hong kong have a systematic advantage in dealing with the pandemic in comparison with their european counterparts because they are culturally "confucian, authoritarian and more obedient than in europe." 10 views on south korea's handling of the coronavirus that stress either the cultural traits of confucian collectivism or the technological aspects of governmentality might seem contradictory, but they are not totally incompatible. in view of "techno-orientalism," asia and asians are stereotypically imagined as technologically advanced but morally and intellectually primitive. 11 in fact, the image of the confucian techno-nation has been increasingly present within the media spectacle of south korea. the patriarchal, obedient, and collectivist image has long served notable filmic representations of south korea. since east seoul (1972), the first hollywood film that illustrated 1960s seoul, south korea has largely been portrayed as a struggling industrial country that remains in shambolic order since the korean war yet maintains its indigenous and local mores and traditions. in some films, north korea plays a crucial role as a reminder that there is a more totalitarian regime on the peninsula. the hollywood film industry has occasionally chosen korea as a host (at least an intermediate host, if not the final one) to infectious viruses. in the 1995 medical disaster film outbreak, one of the early movies on the dangers of epidemics, a reckless korean ship crew smuggled a whiteheaded capuchin monkey, the host of a fatal zoonotic pathogen, into us territory. in a more recent apocalyptic film, world war z (2013), camp humphreys, a us military base in pyungtaek, south korea, is where the outbreak of a zombie virus is first reported. a former united nations investigator is dispatched to south korea to develop a vaccine to save the world. there, he is told how the north korean dictatorship successfully prevented the spread of the virus: "they pulled the teeth of all 23 million in less than 24 hours. no teeth, no bites." quite coincidentally, there have been no reported cases of covid-19 in north korea so far. in contrast to the dreadful and dictatorial measure deployed in film by north korea, the extensive utilization of advanced icts has been highlighted as a crucial reason for south korea's success. a tech-savvy big-brother-like society is not incompatible with confucian collectivist culture. they are likely quite congruent. south korea, in particular seoul, has been increasingly portrayed as a futuristic high-tech city in more recent hollywood films such as avengers: endgame the glittery imaginary of the city reflects the changing location of seoul in global urban networks as well as the changing perception of the city and country in global media industries. south korea is projected as the most media-saturated and wired nation on earth, articulating its cultural identity with icts. this sort of technomythological perception of korea is exemplarily depicted in the german american sci-fi film cloud atlas, an adaptation of the 2004 novel of the same title. one of six stories, "an orison of sonmi-451," is set in neo seoul ("nea so copros" in the book), in an apocalyptic future dated to 2144. in the united korea, neo seoul appears to be a "totally administered society" (in herbert marcuse's terminology) termed a "corpocracy," an orwellian totalitarian regime that is governed by the juche ideology-north korea's governing national ideology-and by hyperconsumerism: the worst combination of north and south korea. as such, in filmic representations, the confucian collectivist regime and hyper-techno capitalism consolidate the image of south korea. but what about in real life, especially during the pandemic crisis? in the twenty-first century, is it still feasible to identify south korea as a confucian society? or do high-tech measures alone handle the coronavirus? whereas korea's icts are positively appraised, its asian traits are blamed. south korea's it-based epidemic containment strategies are conceived as a transgression of privacy that would not fit in individual-freedom-based liberal societies such as western europe and north america. herein lies a crucial limitation embodied in the conventional view of binaries: individual versus society, private versus public, nature versus culture, human versus machine, and so on. it oscillates between the two components by simplifying the complex dimensions of korean society as a choice between civic liberty as an individual freedom and public health driven by technological operation. the view based on this conventional dichotomy hardly grasps the south korean experience of covid-19. south korea as the mediasaturated society would be less the orwellian society in nineteen eighty-four, based on a monitoring system of hyper-surveillance, than aldous huxley's world state in brave new world, in which, by their own free will, individual citizens accept an intelligence and merit-based social mechanism engineered by the state-of-art technologies. during the outbreak of covid-19, the south korean government quickly identified key health and quarantine measures as the "three ts" of testing, tracing, and treating: testing as measures to prevent the entry of the virus; tracing as conducting rigorous epidemiological investigations; and treating as the establishment of a patient management system. 12 the nationwide crisis management system has been reinforced through the experiences of recent disasters. the sinking of the sewol ferry in 2014, which cost 304 lives, including 250 high school students, sparked grave criticisms about the ineffective -and indifferent-response and continuous political coverups by the government. it ignited nationwide protests with several million participating in 2016, eventually leading to the impeachment and imprisonment of the then-president park geun-hey in march 2017. as the current south korean foreign minister, kang kyung-hwa, emphatically stressed, south korea's quick and preemptive response to the coronavirus outbreak derived from the traumatic experience and memory of the sewol disaster. 13 the 2015 outbreak of mers (middle east respiratory syndrome) in south korea, which resulted in 38 deaths out of 186 confirmed cases, also induced the government to reassess and reorganize its disease control system for outbreaks of large-scale epidemics and to support hospitals to set up more negative pressure rooms. these rooms served as-not sufficient yet-essential locations for isolating and treating coronavirus patients during the outbreak this year. south korea is a society with a history of disasters and various forms of crisis, ranging from politics to economics to health. the disasters have penetrated every corner of ordinary lives. this time, the country is more prepared. in december 2019, the center-right government conducted a large-scale drill to prepare a response to a fictional outbreak of a disease imported by a south korean family after a trip to china. 14 less than two months after the exercise, korea's first confirmed case was reported when a person who had visited wuhan, china, tested positive. measures exercised during the drill were quickly deployed. the initial response of the government signified that a "developing" country like south korea is more prone to cope with disasters that require fast processes of decision and practice. "developed" postindustrial countries seemed to believe they had graduated from this sort of "asian" epidemic, at least in the initial stage of the outbreak. south korea, the twelfth-largest economy in the world yet always classified as a "developing" country, has not yet outsourced major manufacturing and production lines abroad, such that it is still able to produce and supply essential personal protective equipment not only to medical staff but to the majority of citizens. the previous crisis was also used by the government to relax some legal restrictions. no sooner had mers diminished than the government revised the personal information protection act (pipa), korea's strict data privacy law. in principle, pipa prohibits the collection, use, and disclosure of personal data without prior informed consent of the individual. under the amended contagious disease prevention and control act, which overrides pipa, data can be collected and profiled by public agencies such as the kcdc. 15 in doing so, the government led the private sector to collect, process, and use large-scale data, facilitating the development of various tracing applications. in particular, partnering with the kt corporation, korea's largest telecommunications company, the government provided researchers and app developers with data on levels of foot traffic and international roaming since april 1, 2020, for free. 16 one of applications that actively employs information provided by the kcdc is coronavirus map. created by a college student during the initial stage of the outbreak, the app informs users of the moment of a confirmed case. now and here is an app that calculates a mix of risk factors in surrounding areas when users enter their commuting route. if the user has been in the same place as an infected individual at a similar time, the app suggests when and where a test for infection is available. another app, cobaek, sends an alert when users are within 100 meters of a place that an infected individual visited. the app was upgraded to the cobaek plus version with the addition of alerts for the availability of publicly provided masks at pharmacies. the app serves to refrain from panic buying or long queues for purchase. the korean government went on to develop a mobile app, self-quarantine safety, to monitor the symptoms of inbound travelers. the app allows users to monitor their conditions and conduct self-diagnosis, and it ensures that self-quarantine orders are kept by setting off an alarm when a user ventures outside the designated quarantine area. the app had been installed by approximately 170,000 travelers as of april 9. 17 a great deal of controversy regarding information privacy arose when installation of the app became mandatory for all inbound travelers, including korean nationals, on april 1. as of april 13, 91.4 percent of those under self-quarantine had installed the app. inbound travelers who do not install the mobile application or fail to submit their daily health conditions are tracked down by immigration services using visa information and airline and passenger data. travelers who fail to use the app as advised receive a notification and warning text messages on the first and second days, respectively. travelers who show no indication of using the app properly on the third day are contacted by phone. if they still do not comply on the fourth day, they are reported to the police to be tracked down and fined for violations, up to $2,500. the south korean government justifies the employment of technological contact tracing as it curtails the limitations of interview-based investigations that rely on human memory and the honesty of the interviewees. in april 2017, the government introduced the advancement of smart quarantine information system, a quarantine information project that utilizes overseas roaming data to identify those coming into the country from high-risk regions and monitor them during the incubation period of the infection. now legally supported, the quarantine authorities of korea are empowered to acquire not only patient statements but also personal information through location tracking, card transactions, and cctv recordings to trace transmission. the success of contact tracing reveals how deeply south korea is a data society. the wide use of credit and debit cards made south korea a forerunner of a demonetized economy with high proportions of cashless transactions (52 percent of all transactions in 2019). the younger generation is already habituated to virtual payment. more than 60 percent of the 1,280 stores operated by starbucks coffee korea only accept credit cards and mobile payments. the rapid growth of the cashless economy has been expedited by the wide use of smartphones. in 2019, south korea had one of the world's highest phone ownership rates. phone locations are automatically recorded with nearperfect accuracy because devices are connected to one to three transceivers at any time. there are approximately 860,000 4g and 5g transceivers densely covering the whole country. phone companies require all customers to provide their real names and national registry numbers so that they can track nearly everyone by following the location of their phones. cctv cameras also enable authorities to identify people who have been in contact with infected individuals. in 2016, south korean cities contained 739,232 public cctv and 1.5 million private cctv cameras. the datafication of epidemiological investigation has been enhanced by the covid-19 epidemiological investigation support system, a data platform that is designed to support epidemiological surveyors in identifying the transmission routes and places that infected individuals have visited. through the application of city data hub, operating under the national strategic smart city r&d program, the cloud-based open data hub works to collect, store, process, analyze, and publish the cross-functional data. since 2018, the kcdc has run the platform in close coordination with the national police agency, credit finance association of korea, three telecommunications companies, and 22 credit card companies. conducting big data analysis, the platform provides real-time data on infected individuals, including their locations and the time spent there. in this vein, it is no wonder that the level of surveillance has been considerably heightened. since covid-19 has been classified as a new infectious disease syndrome in group 1 of infectious diseases, reporting a patient with an infectious disease to a health center is required under the mandatory surveillance system. the disclosed data are categorized by time and region, stored in the web-statistics on surveillance of infectious diseases, and shared and publicized by local authorities. 18 meticulous logs of the travel and contacts of infected individuals are compiled based on the data. consider, for example, the level of detail in the logs of patient 64, a 49-year-old female in gwan-ak gu, the southwestern district of seoul. on june 6, 2020, the district office sent me an alert text message stating that patient 64's logs had been uploaded to its blog following a positive test on june 5 after the patient visited a discount store, richway, where a collective infection took place on may 31: the log reconstructed here may seem overly meticulous, but in fact, it is far less detailed than the information gathered. on march 9, korea's national human rights commission issued a recommendation to ameliorate privacy concerns, suggesting that revealing exceedingly detailed information was unwarranted. 20 the high level of data sharing about infected individuals raised serious concerns about data privacy. the locations of infected individuals were exhaustively covered by district offices as well as mass media. the granular personal details about infected individuals have been profiled by the general public on various social media networks. reidentification of individuals prompted widespread internet trolling, in which individuals were blamed and criticized for their reckless, selfish, and negligent behaviors that harmed communities. tensions between civil society and the state increasingly grew to protect individuals from the centralization of data and the abuse of information power. it is a crucial point that the covid-19 crisis has not merely prompted "the intensification of surveillance" in korea but the "datafication" of society, involving "the transformation of human life into data through processes of quantification, and the generation of different kinds of value from data." 21 the "datafied" tracing system in south korea has consolidated icts and tech companies as institutions essential to the basic functioning of the quarantine society. as nick couldry warns, the emergence of a new social order 19 is centered on "data colonialism." 22 yet it is still debatable to what extent the south korean government's data policy during the pandemic prioritized public health over individual privacy and to what degree south korean citizens accepted the loss of privacy as a necessary trade-off. 23 as shown earlier, while critically questioning korea's deployment of surveillance technologies, individual privacy and public health are starkly contrasted as incompatible and an either/or scenario. 24 this sort of binary discourse on korean society pays little attention to the operation of the health care system while discussing the issue of "public" health. with a universal health care system, south korea ranked first in the oecd for health care access and was rated as the fourth most efficient health care system in 2015. according to the health care index by country in 2020, south korea ranked second after taiwan. 25 anyone with a fever can request a covid-19 test, which is free to the public. when doctors initially believe that a person is at risk based on where they have been or whom they have contacted, they collect samples from their nose and throat for analysis. the test takes 10 minutes or less. the person receives a text message with the result the next day. it is less likely that an individual would go for a test and treatment if an enormous medical bill would be expected. a tracing app can track down people, but it cannot enable them to visit a test center. the health care system does. south korean citizens willingly accept the experiment of testing and tracing while appreciating and securing public and communal systems of treating. in this distinctive way, the south korean experiment grapples with the relationship between individual freedom and public health, showing that the two key elements are not incompatible but complementary. despite its noticeably flattened curve, the covid-19 crisis in korea is ongoing. in fact, the kcdc is highly concerned about the possibility of the second wave in the fall. it is thus far too early to say whether the south korean approach was ultimately successful. my observations are equally tentative. yet i wonder whether the success that south korea has achieved so far stems from the fact that the state of emergency has been embodied in key social dimensions in a particular way. in his essay "on the concept of history," written in 1940 just before his death, walter benjamin, the jewish german cultural critic, noted that "the tradition of the oppressed teaches us that the 'state of emergency' in which we live is not the exception but the rule. we must attain to a conception of history that accords with this insight. then we will clearly see that it is our task to bring about a real state of emergency, and this will improve our position in the struggle against fascism." 26 clearly, the implications of this cannot be taken directly without careful consideration of its political context involving the height of the calamitous self-destruction of fascism. viewed from benjamin's critical perspective, south korea is a never-ending developing, progressing, and advancing country that has been and will be going through more crises. it is in a permanent state of emergency: the establishment of the republic-in-exile in 1919, the decolonization from japanese imperialism, the brutal three-year civil war between the north and south that cost millions of lives, the remaining hostile cold war relations with north korea, several military coups and dictatorships, the financial crisis, recurring largescale accidents costing hundreds of lives, and so on. in the permanent state of emergency, the crisis is "the rule," especially for the oppressed. on april 29, 2020, there were no domestic confirmed cases of covid-19, but 38 workers were killed in a fire that broke out at a construction site for a logistics warehouse in icheon, gyeonggi province, 50 miles southeast of seoul. in the very same city, an almost identical accident took place a few years ago. on june 6, 2008, forty workers were killed in a fire at a refrigeration warehouse. 27 in 2018, 971 south korean workers died in workplace accidents, and every day, 2.7 workers died in industrial accidents. in 2015, the occupational fatality was 10.1 per 100,000 employees, among the highest in the oecd. 28 for workers, south korea is a state of emergency. in 2018, the poverty rate of senior citizens was the highest in the oecd. for older people, south korea is a state of emergency. in the same year, the total fertility rate was 0.98, the lowest in the world. according to the world economic forum, south korea ranks 124th out of 149 countries in terms of economic participation and opportunity for women. given this gender inequality, south korea is a state of emergency for women. migrant workers in south korea are largely excluded from the government's handling of the coronavirus. in mask rationing and monetary coronavirus relief handouts, the majority of foreigners are left out of consideration. for migrant workers, south korea is a state of emergency. the current crisis of the covid-19 pandemic is not a breakdown of normality but a continuation of the state of emergency that rules a developing country like south korea. all of the social problems are legitimized as inevitable within the process of development and progress. this ideology serves to normalize the state of emergency and perpetuate the crisis for the marginalized, vulnerable and unprotected citizens. we cannot go back to normal because normal is a state of emergency. a "real" state of emergency is required to stop the "normal" state of emergency in which south korea exists. maybe we are passing through a long tunnel during this pandemic. no one is sure whether it will be another pandemonium or the less fatal, painful, degenerate state of emergency. it may depend on how we pass through it. log of patient 64 information technology-based tracing strategy tech giants are using this crisis to colonize the welfare system the costs of connection: how data is colonizing human life and appropriating it for capitalism how surveillance technology powered south korea's covid-19 response south korea's experiment in pandemic surveillance health care index by country 2020 mid-year on the concept of history this study was financially supported in part by the institute of communication research, seoul national university. key: cord-318252-vv3qsq74 authors: stuart, r. m.; abeysuriya, r. g.; kerr, c. c.; mistry, d.; klein, d. j.; gray, r.; hellard, m.; scott, n. title: the role of masks in reducing the risk of new waves of covid-19 in low transmission settings: a modeling study date: 2020-09-03 journal: nan doi: 10.1101/2020.09.02.20186742 sha: doc_id: 318252 cord_uid: vv3qsq74 objectives: to evaluate the risk of a new wave of coronavirus disease 2019 (covid-19) in a setting with ongoing low transmission, high mobility, and an effective test-and-trace system, under different assumptions about mask uptake. design: we used a stochastic agent-based microsimulation model to create multiple simulations of possible epidemic trajectories that could eventuate over a five-week period following prolonged low levels of community transmission. setting: we calibrated the model to the epidemiological and policy environment in new south wales, australia, at the end of august 2020. participants: none intervention: from september 1, 2020, we ran the stochastic model with the same initial conditions (i.e., those prevailing at august 31, 2020), and analyzed the outputs of the model to determine the probability of exceeding a given number of new diagnoses and active cases within five weeks, under three assumptions about future mask usage: a baseline scenario of 30% uptake, a scenario assuming no mask usage, and a scenario assuming mandatory mask usage with near-universal uptake (95%). main outcome measure: probability of exceeding a given number of new diagnoses and active cases within five weeks. results: the policy environment at the end of august is sufficient to slow the rate of epidemic growth, but may not stop the epidemic from growing: we estimate a 20% chance that nsw will be diagnosing at least 50 new cases per day within five weeks from the date of this analysis. mandatory mask usage would reduce this to 6-9%. conclusions: mandating the use of masks in community settings would significantly reduce the risk of epidemic resurgence. there is increasing evidence that localized suppression or even elimination of covid-19 is possible with interventions such as physical distancing, lockdowns, travel restrictions, testing, tracing, and quarantine. this outcome was very likely achieved in several countries, including new zealand, iceland, taiwan, thailand, and vietnam, among others [1] . however, even if the epidemic has been locally controlled, new outbreaks can emerge if community transmission has not been eliminated and cases escape detection or quarantine, or if infected people arrive from abroad or interstate and interact with the local community (as recently seen in cities such as melbourne and auckland). in settings with low numbers of active covid-19 infections, minimizing the risk of epidemic resurgence is essential for sustainability. therefore, it is crucial to identify and quantify strategies to reduce this risk. in this paper we focus on new south wales, australia's most populous state with 7.5 million residents, as an example of a setting with low transmission, high mobility, and a well-functioning test-and-trace system. after an initial wave of covid-19 infections in march and subsequent lockdown in april, new south wales began relaxing physical lockdown measures over may and was experiencing near-zero case counts by the start of june, with students back at school, businesses reopening and social/community activities resuming. in late june several clusters of new infections were detected, which subsequently led to a two-month long period of low but steady case counts (between 5-20 newly detected cases per day). this experience contrasts sharply with that of the neighboring state of victoria, which had also achieved near-zero case counts by early june but which then experienced a large second wave, with 14,434 new cases detected between 14 june and 14 august, 90% of which have been traced back to just four index cases [2] . the dynamics of covid-19 transmission are complex, and in low-transmission settings the probability of maintaining epidemic control depends on numerous factors outside of policy control, including the characteristics of people who get infected: the size of their households, the type of work that they do, and a number of other socio-economic factors that may influence their contact networks, access to testing and capacity to self-isolate. several studies have pointed to the role of superspreading events and overdispersion of infections in covid-19 transmission [3] [4] , including work by our group examining the seattle epidemic found that infections are overdispersed, with ~60% of infected people not transmitting at all, while 9% cause half of all onward transmission [5] , study on the role of superspreading events. as a result, even with physical distancing, high levels of testing, and rapid contact tracing, there is still a non-zero probability that a sustained outbreak could occur depending on who gets infected and where. there are numerous non-pharmaceutical interventions (npis) that jurisdictions can adopt to improve their resilience to renewed epidemic waves whilst still allowing social and economic activity to continue. such npis include physical distancing regulations, hygiene protocols, and the use of face masks, all of which have been recommended by the world health organization (who) [6] . these npis are supported by a growing body of evidence regarding their efficacy in preventing individuallevel covid-19 transmission [7] [8] [9] [10] [11] . however, australia's response through to the end of august focused on the first two measures, with only victoria having mandated the use of face masks -and even then only after the second wave of infections was well underway and lockdown measures were in place -while other jurisdictions have only encouraged mask use in particular settings. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september 3, 2020. . in this work, we assess the likelihood of epidemic rebound following a prolonged period of low, stable transmission and relatively high community mobility, using a stochastic agent-based mathematical model of covid-19. because the model is stochastic, we can run it multiple times and evaluate the probability of observing a given outcome among all possible outcomes. we use this feature to evaluate the probability that new south wales will experience an epidemic resurgence under different assumptions about the adoption of masks/face coverings. we began by simulating a population representative of new south wales by taking data on the age and sex composition of the population from the 2016 census (the latest available), and using it to create a model population of agents with similar characteristics. the simulations consist of 100,000 individual agents, who are dynamically scaled based on prevalence to represent the total new south wales population of 7.5 million. the dynamical scaling means that whenever the proportion of susceptible agents falls below a threshold of 5%, the number of agents in the model is increased; further implementation details can be found in section 2.3.6 of kerr et al [12] . next, we created contact networks for these agents. the governmental response to covid-19 in new south wales consisted of a set of highly context-specific policies covering individuals, businesses, schools, and other types of organizations. to model these policies, we allow agents in the model to interact over five types of contact network: households, schools, workplaces, and static and dynamic community networks. the static community network consists of interactions with friends, colleagues, or other known associates who come together on a regular and predictable basis, and contains four sub-networks: professional sports, community sports/fitness/leisure clubs, places of worship, and socializing with friends. the dynamic community network consists of interactions in which people interact with strangers or random groups of people, and contains seven separate subnetworks, representing: (1) arts venues such as museums, galleries, theatres, and cinemas, (2) large events such as concerts, festivals, sports games, (3) pubs and bars, (4) cafes and restaurants, (5) public parks and other outdoor settings, (6) public transport, (7) all other community settings. the method for constructing these networks is described in our previous study of the victorian epidemic [13] and is based on the methodology of the synthpops python package [14] . we used an agent-based microsimulation model, covasim [12] , developed by the institute for disease modeling and previously adapted by our group to model the victorian epidemic [13] . covasim contains detailed descriptions of age-dependent disease acquisition and progression probabilities, duration of disease by acuity, and the effects of interventions including symptomatic and asymptomatic testing, isolation, contact tracing, and quarantine, as well as other npis such as physical distancing, hygiene measures, and protective equipment such as masks. importantly, it also captures individual variability, with viral loads varying both between individuals and over time. throughout march, the policy response to covid-19 in new south wales progressed from guidelines encouraging precautionary handwashing and distancing to a much more restrictive "lockdown" phase, in which people were only allowed to leave their houses for a limited number of reasons. this phase was maintained throughout april and then gradually eased over may-july. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september 3, 2020. . figure 1 presents a summary of how contact networks and the relative risk of covid-19 transmission in different settings changed as policies evolved. some of these changes in transmission risk are derived from available data [15] , while others are taken from a similar modeling exercise conducted in victoria, in which a panel of australia-based experts reviewed the likely effect of policies on transmission risks [13] . further details of all policies and how we model their effects on transmission risk are contained in supplementary table 1 . most relevantly for our subsequent analyses, we assume that the proportion of new south wales residents who wore masks in dynamic community settings increased over august to reach 30% by the end of the month. figure 1 . relative changes in network structure and transmission risk across different settings in new south wales over march-august. the absolute transmission risk varies by setting and is highest in household and lowest in outdoor settings (see [13] for details). we initialized the model on march 1, 2020 by seeding 100 infections in the model population, with the number of seed infections chosen as part of the calibration process. the model was calibrated to data on (1) the number of tests conducted and (2) the daily number of cases diagnosed in nsw, excluding cases acquired overseas, by performing an automated search for the values of the percontact transmission risk and the number of seed infections that minimized the absolute differences between the model projections and the data. we repeated the initialization 100 times, each time with a different set of 100 people infected at the beginning of the simulation. figure 2 displays the outcome of this, with the model capturing the initial outbreak, the decline in cases following the april lockdown, and then the gradual increase in june/july as policies eased, new cases arrived from interstate, and new clusters began to form. by the end of august, we estimate just over 500 active infections in new south wales. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september 3, 2020. . we use the model to investigate the probability of a setting with low transmission and high mobility experiencing a resurgence in cases, grounding the analysis based on the policy settings and epidemic state of new south wales at the end of august. to calculate this probability, we reinitialize the model on august 31, 2020 and project forward by five weeks using the parameter values obtained via the calibration process, and beginning with the estimated epidemic state on august 31, 2020. we repeat this 100 times, with each iteration representing a different realization of the possible future transmission dynamics. we then calculate the proportion of simulations in which the number of cases being diagnosed per day exceeds different thresholds within five weeks. as a baseline, we assume that the policy and behavioral settings in place at the end of august continue, including the assumption that 30% of adults wear masks while at work and when participating in community-based activities along with strangers or random groups of people. we then model two alternative scenarios: 1. no mask scenario: assuming negligible mask use; 2. near-universal mask uptake: assuming that 95% of the adult population wear masks while at work and when participating in community-based activities along with strangers or random groups of people. the individual-level effectiveness of masks at reducing covid-19 transmission is difficult to determine, and will be influenced by the level of restrictions or npis already in place. a comprehensive meta-analysis covering 41 studies of mask effectiveness concluded that masks are associated with a reduction in infection for mask-wearers by at least one-third compared to control groups [16] . we assume that masks will reduce the per-contact probability of transmission by an additional 20% relative to a baseline in which other npis are in place. we also conduct a sensitivity analysis in which the individual-level effectiveness of masks is assumed to be 30%. beginning from a point with ongoing low levels of community transmission, high mobility, and with 30% of adults wearing masks at work and in settings with unknown groups of people, we estimate that there is a 20% chance that transmission will increase to at least 50 new cases per day within five weeks ( figure 3 ). if masks were not worn, the probability would increase to 25%, indicating that the . cc-by-nc-nd 4.0 international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september 3, 2020. . https://doi.org/10.1101/2020.09.02.20186742 doi: medrxiv preprint current level of mask usage does not have a great impact on containing the probability of a resurgent epidemic. however, we find that under the near-universal mask uptake scenario, the probability of diagnosing more than 50 cases per day within five weeks would fall to 8% ( figure 3a) . furthermore, we estimate that the total number of infections over the next five weeks would be 20% lower than under a scenario in which masks are not used, largely driven by a 37% reduction in infections transmitted in dynamic community settings ( figure 3c ). under all scenarios, we estimate that the median number of daily infections is likely to continue to gradually increase ( figure 3d) . we also conducted a sensitivity analysis in which individual-level mask effectiveness was assumed to be 30%. under this scenario, we estimate an 18% probability of diagnosing more than 50 new cases per day within five weeks if mask uptake does not change, or 6% under the high mask scenario. overall infections over the next five weeks would be 30% lower if masks were adopted with high uptake ( figure s1 ). evidence from numerous other settings has shown that as long as the population remains susceptible to covid-19 infection, reopening society is likely to lead to new epidemic waves unless a welloperating test-and-trace strategy is in place [5] , [17] [19] . in this work, we examined a lowtransmission, high mobility setting with limited mask usage, and found that high levels of testing and contact tracing have thus far succeeded in controlling the epidemic, but do not eliminate the risk of an epidemic resurgence. at the time of writing, case numbers in new south wales had is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september 3, 2020. . decreased from ~15/day over july to <5/day by the end of august, which may indicate that test-andtrace efforts in this instance were sufficient to curtail the risk of epidemic resurgence. however, our main finding does not depend on the exact date of the analysis; as long as viral transmission remains in the community, the probability of epidemic resurgence (e.g., an untraceable cluster, a failure of quarantine, or a superspreading event) remains. we found that the use of masks would reduce the probability of epidemic resurgence in new south wales: if the use of masks was mandated in new south wales, we estimate that the probability of diagnosing at least 50 new cases per day within five weeks would reduce from 20% to 9%. given that masks are an intervention with low social and economic costs, and containing an epidemic resurgence is extremely disruptive and costly (with treasury estimates suggesting that victoria's stage 4 restrictions will result in an au$7-9 billion reduction to national gdp in the september quarter [20] ), this reduction in risk is of major significance and suggests that a policy of mandatory mask use is likely to have an extremely high benefit-to-cost ratio. this study adds to a sizable body of evidence supporting the adoption of face masks as a low-cost means of protecting individuals from acquiring covid-19 [7] , [8] , [10] , [21] . modeling studies have shown that the population-level effects of masks depend on the state of the epidemic. a study from israel showed that masks are particularly effective when the effective r is close to 1, and can determine whether a low-level epidemic tips into an outbreak or not [22] . in higher transmission settings where the effective r is greater than 1, two studies found that masks are most effective when used in conjunction with a collection of other npis [9] , [23] . to our knowledge, no studies to date have examined the extent to which face masks can prevent a resurgent outbreak in low-transmission settings. furthermore, by using a model that already incorporated the numerous other covid-19 control measures in place in new south wales, we illustrate that face masks have benefit even in the context of a well-functioning test-and-trace system. there are several limitations to this study. firstly, the mathematical model that we use is subject to the usual limitations of mathematical models, including uncertainty around the parameters that characterize covid-19 transmission and disease progression, uncertainty around the impact of interventions and behavioral changes, and reliance on data sources (such as the number of covid-19 cases by likely source) that may be incomplete and/or subject to revision. to the extent possible, we managed these issues by sampling parameters from probability distributions and conducting sensitivity analyses around the efficacy of masks. secondly, we made assumptions about the proportion of contacts of diagnosed cases that can be traced within a certain number of days; further data on these proportions would greatly improve model estimates. thirdly, our analyses assume that the policy environment in new south wales would be relatively slow to react to an increase in case numbers; we focused on the question of quantifying the likelihood of diagnosing more than 50 cases/day on the assumption that this would equate to a high likelihood that new south wales would enter a more restrictive phase of lockdown, but a faster policy reaction, as recently seen in auckland, would change the nature of the results seen here. our work suggests that adoption of face masks by the general public could substantially reduce the risk of new epidemic waves. given that individuals are already requested to isolate if they have been diagnosed with covid-19 or are displaying symptoms, a major benefit of masks is in controlling asymptomatic transmission, which is estimated to make up approximately one third of all transmissions. the use of masks also has a role in reinforcing the importance of other npis. not only does this have positive health outcomes in terms of reducing the number of covid-19 infections is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september 3, 2020. . and associated mortality, but it also has clear social and economic benefits by mitigating the need for more extreme lockdown measures that are required to curtail epidemic resurgences once they have begun. table s1 . effects of policies on transmission risk in new south wales description of policy changes and their effects schools school attendance rates in nsw had already dropped by 25% by 15 march 2020 [1] , and on 23 march 2020 the nsw premier advised that although schools remained open, parents were encouraged to keep their children at home for online learning [2] . school attendance rates subsequently dropped to 5% of their pre-covid levels [3] . however, attendance quickly returned to pre-covid levels shortly after schools reopened in mid-may [4] . to model this, we removed 95% of contacts between school children and then restored them again as schools opened, but with the relative transmission risk set to 80% of its pre-march levels to account for additional safety measures in place for school activities [5] (figure 1 ). according to survey data from the australian bureau of statistics, almost half of working australians were working from home in late april/early may [6] , which is roughly consistent with google movement data indicating that 40% fewer people were at work over that period compared to baseline. workplace-based activities increased as covid restrictions eased, but remained 15% lower over june-july compared to baseline. in the model, we removed 50% of workplace contacts and then restored them so that the workplace network was back to 85% of its pre-covid size by the beginning of july ( figure 1 ). as with schools, we set the relative transmission risk set to 80% of its pre-march levels to account for the presence of npis. we assume that almost no contacts occurred over these networks from march 23 to may 1 with the exception of the limited contacts arising from permitted single-person visits., these networks were gradually restored over the period from may 1 to july 9 as restrictions eased ( figure 1 ). dynamic community networks over may-july (negligible mask usage) within new south wales, arts venues such as museums, galleries, theatres, and cinemas, large events such as concerts, festivals, sports games, and pubs/bars were all closed over the period from march 23 to may 15, after which the networks were gradually restored (figure 1 ). cafes and restaurants, public parks and other outdoor settings, public transport, and all other community settings including essential retail remained open in some capacity throughout the year but with decreased demand and operational restrictions to reduce the likelihood of transmission (e.g., takeaway service only, closure of playgrounds, capacity limits on transport, and physical distancing/hygiene). from august 3, 2020, the use of masks was mandated in victoria, which led to a marked increase in mask usage across the country. only 13% of australians wore a mask at least once over the month of june, but 58% . cc-by-nc-nd 4.0 international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september 3, 2020. reported wearing one at least once over august 7-17, 2020 (99% of victorian residents compared to 44% of residents of other states) [7] . within new south wales, media sources reported that 30% of people were wearing face masks on public transport in central sydney in mid-august [8] . to reflect the gradual increase in mask uptake in the model, we adjust the relative transmission risk assuming that the proportion of adults who wore masks while at work and in dynamic community settings increased over august to reach 30% by the end of the month. test, trace, and isolate strategies testing, tracing, and isolation strategies have formed a crucial part of the nsw response to covid-19, with health authorities encouraging anyone with symptoms (however mild) to get tested. levels of testing increased steadily from ~5,000 tests/day in april to ~20,000+/day by july. in keeping with the increased testing levels, we assume that the daily testing probability for those with symptoms increased from 5% in april to 15% by the beginning of june. assuming a symptomatic period of roughly 10 days, this implies that the proportion of symptomatic people who get tested increased from 40% to 80%. weekly surveillance reports published by nsw health detail comprehensive contact tracing efforts for all newly identified cases [9] . reflecting this, we assume that household contacts of confirmed cases can be traced within 1 day of diagnosis, as well as 95% of school-based contacts, 80% of work-based contacts, and 80% of contacts from static community networks (e.g., people met in social gatherings) within 2 days. tracing of dynamic community contacts encountered in locations that require customer registration is also included: we assume that 25% of contacts from restaurants, cafes, bars, pubs, sports/leisure/fitness centres, arts venues, places of worship, and large events can be traced with a 2 week delay, but only 1% of contacts from other community settings, including public transport, parks, and retail. in addition to symptom-based testing, we also assume that ~1% of people who are not symptomatic but have been told to quarantine as a result of having been in contact with a confirmed case will get tested. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted september 3, 2020. . https://doi.org/10.1101/2020.09.02.20186742 doi: medrxiv preprint figure s1 . the likelihood of epidemic resurgence in new south wales, assuming individual-level mask effectiveness of 30% countries beating covid-19 family of four staying at rydges seeded 90% of second-wave covid cases estimating the overdispersion in covid-19 transmission using outbreak sizes outside china stochasticity and heterogeneity in the transmission dynamics of sars-cov-2 controlling covid-19 via test-trace-quarantine advice on the use of masks in the context of covid-19 physical distancing, face masks, and eye protection to prevent person-toperson transmission of sars-cov-2 and covid-19: a systematic review and meta-analysis respiratory virus shedding in exhaled breath and efficacy of face masks to mask or not to mask: modeling the potential for face mask use by the general public to curtail the covid-19 pandemic low-cost measurement of facemask efficacy for filtering expelled droplets during speech estimating the effects of non-pharmaceutical interventions on covid-19 in europe covasim: an agent-based model of covid-19 dynamics and interventions modelling the impact of reducing control measures on the covid-19 pandemic in a low transmission setting institute for disease modeling recovering from coronavirus: data shows how australia is rebuilding as covid-19 restrictions ease covid-19: what's new for effectiveness of isolation, testing, contact tracing and physical distancing on reducing transmission of sars-cov-2 in different settings feasibility of controlling covid-19 outbreaks by isolation of cases and contacts impact of delays on effectiveness of contact tracing strategies for covid-19: a modelling study pm suggests $9 billion cost of stage 4 restrictions in melbourne efficacy of face mask in preventing respiratory virus transmission: a systematic review and meta-analysis impact of population mask wearing on covid-19 post lockdown estimation of effects of contact tracing and mask adoption on covid-19 transmission in san francisco: a modeling study coronavirus: nsw school attendance falls 25 per cent as soap, toilet paper shortage hit covid-19 in schools -the experience in nsw students are being sent back to school in nsw soon -here's what you need to know there were bubbles and balloons': high attendance on first day back at school a guide to nsw school students for term 3 media release -loneliness most common stressor during covid-19 (media release) media release -covid-19 anxiety in victoria felt australia-wide (media release) cctv monitors how many are wearing masks on trains covid-19 weekly surveillance reports -covid-19 (coronavirus) key: cord-273318-82ptu8fi authors: prats-uribe, a.; g. sena, a.; yin hui lai, l.; ahmed, w.-u.-r.; alghoul, h.; alser, o.; alshammari, t. m.; areia, c.; carter, w.; casajust, p.; dawoud, d.; golozar, a.; jonnagaddala, j.; mehta, p.; menchung, g.; morales, d. r.; nyberg, f.; posada, j. d.; recalde, m.; roel, e.; shah, k.; shah, n.; schilling, l. m.; subbian, v.; vizcaya, d.; zhang, l.; zhang, y.; zhu, h.; liu, l.; rijnbeek, p.; hripcsak, g.; lane, j. c. e.; burn, e.; reich, c.; suchard, m. a.; duarte-salles, t.; kosta, k.; ryan, p. b.; prieto-alhambra, d. title: heterogeneity and temporal variation in the management of covid-19: a multinational drug utilization study including 71,921 hospitalized patients from china, south korea, spain, and the united states of america date: 2020-09-18 journal: nan doi: 10.1101/2020.09.15.20195545 sha: doc_id: 273318 cord_uid: 82ptu8fi objectives: a plethora of medicines have been repurposed or used as adjunctive therapies for covid-19. we characterized the utilization of medicines as prescribed in routine practice amongst patients hospitalized for covid-19 in south korea, china, spain, and the usa. design: international network cohort setting: hospital electronic health records from columbia university irving medical centre (nyc, usa), stanford (ca, usa), tufts (ma, usa), premier (usa), optum ehr (usa), department of veterans affairs (usa), nfhcrd (honghu, china) and hm hospitals (spain); and nationwide claims from hira (south korea) participants: patients hospitalized for covid-19 from january to june 2020 main outcome measures: prescription/dispensation of any medicine on or 30 days after hospital admission date analyses: number and percentage of users overall and over time results: 71,921 people were included: 304 from china, 2,089 from spain, 7,599 from south korea, and 61,929 from the usa. a total of 3,455 medicines were identified. common repurposed medicines included hydroxychloroquine (<2% in nfhcrd to 85.4% in hm), azithromycin (4.9% in nfhcrd to 56.5% in hm), lopinavir/ritonavir (<3% in all us but 34.9% in hira and 56.5% in hm), and umifenovir (0% in all except 78.3% in nfhcrd). adjunctive medicines were used with great variability, with the ten most used treatments being (in descending order): bemiparin, enoxaparin, heparin, ceftriaxone, aspirin, vitamin d, famotidine, vitamin c, dexamethasone, and metformin. hydroxychloroquine and azithromycin increased rapidly in use in march-april but declined steeply in may-june. conclusions: multiple medicines were used in the first months of covid-19 pandemic, with substantial geographic and temporal variation. hydroxychloroquine, azithromycin, lopinavir-ritonavir, and umifenovir (in china only) were the most prescribed repurposed medicines. antithrombotics, antibiotics, h2 receptor antagonists and corticosteroids were often used as adjunctive treatments. research is needed on the comparative risk and benefit of these treatments in the management of covid-19. • drug repurposing is a common approach in the clinical management of novel diseases and conditions for which there are no available pharmacotherapies • hydroxychloroquine was widely used in the management of covid-19 patients during the early phases of the pandemic • recent nih (and other) guidelines recommend the use of concomitant therapies including immune-based, antithrombotic, antibiotic and other treatments what this study adds • this study demonstrates great variability and extensive drug repurposing and utilization in the management of covid-19 patients. • a wide range of adjunctive treatments has been used, including antithrombotics, antibiotics, h2 receptor antagonists, and systemic corticosteroids. • emerging clinical data on the safety and efficacy of hydroxychloroquine and azithromycin impacted their rise and rapid decline in use internationally • conversely, the use of corticosteroids grew only in more recent months, with little use in the early stages of the pandemic (january to april) . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september 18, 2020. . as of september 01, 2020, there were more than 25 million confirmed cases of coronavirus disease 2019 and more than 850,000 related deaths worldwide 1 . despite a lack of evidence, several medicines were repurposed in the first months of the pandemic based on in vitro anti-viral activity. as an illustrative example, hydroxychloroquine obtained emergency approval by the us food and drug administration on march 28, 2020 which was later revoked on june 15, 2020 th 2 . more recently, a few investigational drugs have been tested, with remdesivir being the frontrunner antiviral after an international placebo-controlled randomized controlled trial (rct) showed promising results 3 . in the absence of approved antivirals, the cornerstone of management has been supportive care, where adjunctive therapies play a major role. three recognized adjunctive therapies in covid-19 are corticosteroids, anti-cytokines (e.g., tocilizumab), and immunoglobulins (e.g. convalescent plasma) 4 . of these, dexamethasone, and corticosteroids, have recently been shown to reduce mortality among patients receiving mechanical ventilation or oxygen therapy in a large rct 5, 6 . additional adjunctive therapies are recognised in recent guidelines, including antithrombotics, statins, antihypertensives and other concomitant treatments. clinical guidelines have varied in their recommendations on covid-19 treatment geographically and over time 7 . in these circumstances, it is crucial to understand the use of treatments, identify trends of prescribing and determine rational medication use in different health care settings. we aimed to characterize the use of repurposed and adjunctive medicines among patients hospitalized for covid-19, and amongst those receiving intensive care in actual practice settings across europe, asia, and north america. multinational network cohort study based on hospital electronic health records (ehrs), and claims data. data from different sites were mapped to the observational medical outcomes partnership (omop) common data model (cdm) 8 . this approach allowed contributing centers to execute analytical code in a distributed/federated fashion without sharing patient-level data. data were obtained from usa, south korea, china and spain. ehr data from the usa came from columbia university irving medical center (cuimc), stanford medicine research data repository (starr-omop) 9 , premier, optum© de-identified electronic health record dataset (optum), tufts claret (trdw), and the department of veterans affairs (va). data from south korea came from nation-wide claims recorded in the health insurance review & assessment (hira). inpatient ehr data from spain was obtained from hm hospitals (hm). data from china was extracted from nine hospitals in honghu, supported by nanfang hospital, southern medical university, and contained full emr data (nfhcrd). intensive care drug use data was available from premier, optum, and va-omop. a detailed description of the databases can be found in appendix table 1 . patients hospitalized with a recorded diagnosis of covid-19 or a positive test result for sars-cov-2 between january and june 2020 were included. a second cohort of patients receiving intensive services was identified as a subset of the former, defined by the initiation of mechanical ventilation, extracorporeal membrane oxygenation/ecmo, and/or tracheostomy. index dates were the date of admission to hospital and the date of start of intensive services respectively. all medicines prescribed/dispensed during hospital admission and in the month prior were ascertained for characterization. for the study of medicines used for covid-19 we assessed all medicines included in at least two rcts according to the covid-19 clinical trial tracker 10 . the resulting list was circulated to stakeholders with a role in drug development and research (e.g., key opinion leaders, pharma industry) and drug regulatory agencies, with all suggestions added to the list. drugs were classified into two groups: i) repurposed medicines -those with alternative indications but believed to be efficacious as antivirals, ii) adjuvant therapies -drugs used for the treatment of pneumonia or preventing or treating covid-19 complications 4 . age, sex, and history of medical conditions were summarized as proportions, as calculated by the number of persons within a given category, divided by the total number of persons. . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september 18, 2020. . medication use was calculated over two time periods: (1) from 1 to 30 days before index date; and (2) from index date to 30 days after. episodes of drug/s use were defined as starting on the date of first drug exposure and ending on the observed end date (if available), or inferred (for example, based on the number of days of supply), with a persistence window of <=30 days permitted between two prescriptions 11 . we computed prevalence of use for each drug and major drug classes in both time periods. prevalence of medication use for each time window was determined by the proportion of subjects who had >=1 day during the time window overlapping with a drug use period for each medication or drug class of interest. all drugs and additional time windows (a year prior and on index date) are reported in full and will be updated over time as more data become available in a dedicated interactive website (https://data.ohdsi.org/covid19characterizationcharybdis/). all (aggregated) data can be downloaded from this same website. as an initial approach to characterize all use of medicines, rainbow plots were generated for each database. these display the proportion of users of each medicine in the days 0 to 30 from index, using anatomical therapeutic chemical (atc) groupings to curtail the long list of adjuvant treatments, we compared the prevalence of use of adjuvant therapies on -30 to -1 days before diagnosis and 0 to 30 days after (for all databases in which pre-index data was available). for this, we computed standardized mean differences (smd), a widely used method to detect differences, and selected those with smd>0.1; or those without use before diagnosis, for display in the main figures. we created lollipop plots of cumulative incidence of drug use 0 to 30 days after diagnosis and after hospitalization for repurposed and for adjuvant drugs. graphs with the whole list of adjuvants drugs can be found in the supplementary material. we calculated cumulative incidence of drug use 0 to 30 days after diagnosis for the selected drugs by month of index date. to ensure enough time points, we selected databases with 3 or more months of data available. we plotted cumulative incidence of use per calendar month in the study period. . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september 18, 2020. . a total of 10 databases were analyzed, including 71,921 participants: 2,089 from spain, 7,599 from south korea, 304 from china, 744 from california, 326 from massachusetts, 3,493 from new york, 8,118 from us-wide va, and the remaining 49,302 from us-wide databases (premier and optumehr). of these, 11,512 participants (from va, premier, and optumehr) were included in the intensive care cohorts. all the results from this study are available as an interactive website (https://data.ohdsi.org/covid19characterizationcharybdis/). this website contains both the summary results presented here, and further details including all medications and comorbidities recorded for the cohorts of interest. baseline characteristics are detailed in table 1 . age varied slightly across data sources, but most cases clustered around the ages of 50 to 74 years old. there was a majority of men amongst those admitted in china (51%), spain (60%) and the us (50% to 94%), but not in south korea (41%). a total of 3,455 different medicines were administered to the study participants in the month after hospitalization, as depicted in figure 1 . the atc groups anti-infectives for systemic use, treatments for 'blood and blood forming organs', 'cardiovascular system' therapies, and drugs for the 'musculoskeletal system' were consistently seen amongst the most commonly prescribed. among the targeted drugs, the top 10 most common in each of the contributing databases are reported in table 2 . in addition to hydroxychloroquine, ritonavir, lopinavir, oseltamivir, remdesivir and umifenovir were the most popular antivirals, with the latter used exclusively in china. commonly used adjunctive therapies included antibiotics, antithrombotics, corticosteroids, metformin, vitamin (c and d) supplements, antihypertensives, h2 receptor antagonists, and interleukin inhibitors. figure 2 shows the proportion of users of each of the targeted repurposed therapies in the month after hospital admission (circle) and after initiation of intensive services (triangle, where available) per database. hydroxychloroquine was the most used therapy, but with great variability in use ranging from < 2% in china to 85.4% in spain. chloroquine was used in china (11.5%). umifenovir was the most common treatment in china, dispensed to 78.3% of patients. azithromycin was the second in frequency of use, at a highest of 56.5% in spain. lopinavir/ritonavir were the third most popular treatments, with great heterogeneity in use, ranging from lowest in usa (2.8% in optum ehr), higher in south korea (34.9% in hira) and highest in spain (56.8% in hm). oseltamivir was variably used from 0.4% in hira (south korea) to 13.2% in nfhcrd (china). other treatments under study (interferon, itraconazole, and ivermectin) were rarely used (<1%) in any of the databases. . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september 18, 2020. . is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. preprint the copyright holder for this this version posted september 18, 2020. . the smd in the proportion of use for each of the listed adjunctive treatments in the month before vs after admission is depicted in supplementary figure 1 , and the proportion of users in the month after hospital admission for all in supplementary figure 2 . the list of 'shortlisted' therapies with an smd>0.1 and their respective proportion of users per database is plotted in figure 3 . the ten most used medicines (ingredient level) included, in descending order: bemiparin, enoxaparin, heparin, ceftriaxone, aspirin, vitamin d, famotidine, vitamin c, dexamethasone, and metformin. there was great variability in the use of all these medicines internationally across the participating databases. the use of adjunctive therapies (but not of repurposed treatments) increased substantially in intensive care, with the greatest augmentation seen for systemic corticosteroids, famotidine, heparin, and tocilizumab. the management of covid-19 has changed substantially over time as shown in supplementary figure 3 . the time trends in use of hydroxychloroquine are striking, with rapidly increasing use in february and march, a plateau in april, and a similarly rapid decline in may that continued in june (figure 4 ). azithromycin followed a similar trend. corticosteroids increased in some but not all databases in apr-may-june. . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted september 18, 2020. . this is the first study to describe the management of covid-19 patients in routine hospital care across three continents. we report on the use of adjunctive and repurposed therapies as recorded in electronic medical records and claims data covering a total of 71,921 hospitalized, and 11,512 patients receiving intensive care for covid-19 in south korea, spain, china and usa. we observed great heterogeneity in the use of repurposed therapies, with great variability in the use of hydroxychloroquine internationally and over time. similar trends were observed in the use of azithromycin. great heterogeneity was also seen in the use of anti-retrovirals, with use of lopinavir/ritonavir ranging from <1% in va (usa), almost 37% in south korea, and highest at >50% in spain. adjunctive treatments have been extensively used for the prevention or treatment of complications in the management of covid19, including antibiotics, anticoagulants, corticosteroids, vitamin d supplements, and to a lesser degree, antihypertensives, antacids, statins and metformin. unsurprisingly, the use of adjunctive therapies increased amongst patients receiving intensive care services. hydroxychloroquine has been in the public limelight since the start of the pandemic. its use has been supported/endorsed by misleading evidence due to flawed but heavily publicized studies [12] [13] [14] . despite all the hope and hype, numerous rcts have shown no benefit. the recovery rct of 1542 hospitalized participants treated with hydroxychloroquine showed no effects on 28-day mortality when compared to usual care 15 . another rct studied the efficacy of hydroxychloroquine as post-exposure prophylaxis in 821 asymptomatic participants, for whom the drug was not shown to prevent any covid-19 illness after high or moderate-risk exposure to covid-19 11 . azithromycin, a macrolide antibiotic with alleged antiviral efficacy against covid-19, was also widely prescribed in our data. while several guidelines recommend the use of empirical antimicrobial treatment, not all advocate its use 7 . currently, there are 47 rcts ongoing worldwide, which will hopefully shed some light on the efficacy of azithromycin to treat covid-19. use of protease inhibitors (pis) lopinavir-ritonavir was high in south korea and spain, with a much lower use in all other databases. this is consistent with korean and spanish guidelines, which recommended pis as antiviral treatments 16, 17 , probably based on in-vitro studies 18 . the world health organization has recently decided to discontinue hydroxychloroquine and lopinavir/ritonavir arms in its solidarity trial, due to interim results demonstrating little or no reduction in mortality of hospitalized patients 19 . the recovery trial has recently confirmed the lack of efficacy of lopinavir/ritonavir compared to usual care 20 . umifenovir in china was the most prescribed repurposed medicine, consistent with chinese guidelines and research. 21, 22 adjunctive therapy/ies to prevent or treat complications were strikingly different across the globe. heparin use was widely prescribed across the usa and spain, but not in china and south korea. corticosteroids use ranged from about 10% of admitted participants in hira (south korea) to more than 66% of patients in stanford (ca, usa). antibiotics use also varied widely, as did statins. . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september 18, 2020. . use of anticoagulants in our study was higher than expected. severe covid-19 has been associated with a coagulopathy that, when untreated, leads to poor clinical outcomes 23 . while a number of rcts are ongoing to evaluate the value of anticoagulation in patients with covid-19, interim guidelines recommend the use of anticoagulants for the prophylaxis of thromboembolism 17, 24 . prior to the results from the recovery trial, there was a wide debate on whether corticosteroids have a role in the mitigation of inflammatory organ injury 25, 26 . most clinical guidelines did not recommend the use of corticosteroids in covid-19 7 , with notable exceptions 12, 27 . our results show wide use of corticosteroids internationally. our description of patterns in hydroxychloroquine use before and after the publication of negative rct results indicated a reversal of pre-existing trends. the drastic decline in prescribing pattern is an indication of how rapidly the landscape of medication use changes with the emergence of new evidences. the reverse is also possible, -use of dexamethasone in patients receiving invasive mechanical ventilation or oxygen therapy would likely increase exponentially in-line with recent results from the recovery trial 5 . in an attempt to add context to our findings, we conducted a literature review of articles that reported medication use in patients with covid-19, of which 45% (n=595) reported at least one type of treatment for hospitalized patients. the most reported repurposed therapies were antivirals (25%), antibiotics (19%) and steroids (15%). it is worth noting though that 52% of the studies were from china, whereas our data sources were mainly from usa, spain and south korea. in addition, medication use has changed rapidly with the emergence of new evidences, thus findings from china may no longer be relevant for comparison as the studies were older. our study was based on routinely collected real world (ehr and claims) data, where misclassification of disease and therapies may be present. we only included patients who had a clinical covid-19 diagnosis or a positive pcr test at the time of hospitalization; therefore, patients without a coded diagnosis would have been excluded even if they were suspected of having the disease. there may also be an underreporting of covid-19 cases in clinical settings where testing resources were scarce, especially during the peak of the outbreak. in addition, medical conditions may be underreported as the absence of a medical code for the disease is interpreted as an absence of the disease itself. exposure misclassification is also possible; participating data sources varied in their capture of drugs, from hospital billing records, prescription orders, or dispensing data. medication use estimates on the date of hospitalization is particularly sensitive to misclassification and may conflate baseline concomitant drug history with immediate treatment upon admission. another limitation was the inability to assess the prescribing pattern of remdesivir as data was not available in our study. the lack of information on the dose and duration of medications was another limitation as these are important information that would have added value to the understanding of prescribing trends, especially among those in high-risk groups or those who are more susceptible to medication-related adverse events. while our study adds valuable information to the understanding of prescribing patterns at the peak of the outbreak, it only provides a . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september 18, 2020. . snapshot of medication use in clinical practice, and with the constant emergence of new evidences over time, medication use in covid-19 is likely to evolve rapidly. this is the largest and most diverse study characterizing the management of patients hospitalized with covid-19, covering the first 6 months of the pandemic and spanning across north america, europe, and asia. there has been great interest in the safety and efficacy of medications used for covid-19 treatment, but little evidence on the prescribing patterns in routine clinical practice. this study provides an overview of drug utilization in routine practice and highlights the need for future research on the safety and efficacy of the more commonly used treatments. . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september 18, 2020. . study; ms is a full-time employee of janssen r&d, and a shareholder of johnson & johnson; as is a full time employee of janssen and shareholder of johnson & johnson; mas reports grants from us national science foundation, grants from us national institutes of health, grants from iqvia, personal fees from janssen research and development, during the conduct of the study; js was a full-time employees of johnson & johnson, or a subsidiary, at the time the study was conducted, and owns stock, stock options, and pension rights from the company; dv reports personal fees from bayer, outside the submitted work, and full-time employment at bayer; dpa reports grants and other from amgen, grants, non-financial support and other from ucb biopharma, grants from les laboratoires servier, outside the submitted work; and janssen, on behalf of imi-funded ehden and emif consortiums, and synapse management lead authors affirm that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained. all the data partners received institutional review board (irb) approval or exemption. starr-omop had approval from irb panel #8 (rb-53248) registered to leland stanford junior university under the stanford human research protection program (hrpp). the use of va data was reviewed by the department of veterans affairs central institutional review board (irb) and was determined to meet the criteria for exemption under exemption category 4(3) and approved the request for waiver of hipaa authorization. the research was approved by the columbia university institutional review board as an ohdsi network study. the irb number for use of hira data was ajib-med-exp-20-065). the use of hm hospitals was approved by the clinical research ethics committee of the idiapjgol (project code: 20/070-pcv). the collection and usage of the data for clinical research in nfhcrd was approved by the irb of nanfang hospital. . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september 18, 2020. . . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september 18, 2020. . . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september 18, 2020. . . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september 18, 2020. . coronavirus (covid-19) update: fda evokes emergency use authorization for chloroquine and hydroxychloroquine. us food & drug administration remdesivir for the treatment of covid-19 -preliminary report pharmacologic treatments for coronavirus disease 2019 (covid-19): a review effect of dexamethasone in hospitalized patients with covid-19: preliminary report. medrxiv association between administration of systemic corticosteroids and mortality among critically ill patients with covid-19: a meta-analysis scope, quality, and inclusivity of clinical guidelines produced early in the covid-19 pandemic: rapid review feasibility and utility of applications of the common data model to multiple, disparate observational health databases a new paradigm for accelerating clinical data science at stanford medicine a real-time dashboard of clinical trials for covid-19. lancet digit health 2020. 2(6); e286-e287 commondatamodel -drug era (omop common data model v6.0) retraction-hydroxychloroquine or chloroquine with or without a macrolide for treatment of covid-19: a multinational registry analysis [retraction of: lancet hydroxychloroquine and azithromycin as a treatment of covid-19: results of an open-label non-randomized clinical trial treatment with hydroxychloroquine, azithromycin, and combination in patients hospitalized with covid-19 effect of hydroxychloroquine in hospitalized patients with covid-19: preliminary results from a multi-centre, randomized, controlled trial. medrxiv korea covid-19 central clinical task force 2020. antimicrobial therapy recommendation ministerio de sanitarias (madrid) 2020. technical document on the clinical management of patients with novel coronavirus (covid-19) crystal structure of sars-cov-2 main protease provides a basis for design of improved alpha ketoamide inhibitors solidarity" clinical trial for covid-19 treatments. world health organization how pharmacoepidemiology networks can manage distributed analyses to improve replicability and transparency and minimize bias the characteristics and outcomes of 681 severe cases with covid-19 in china arbidol/ifn-alpha2b therapy for patients with corona virus disease 2019: a retrospective multicenter cohort study thromboembolism and anticoagulant therapy during the covid-19 pandemic: interim clinical guidance from the anticoagulation forum isth interim guidance on recognition and management of coagulopathy in covid-19 on the use of corticosteroids for 2019-ncov pneumonia clinical evidence does not support corticosteroid treatment for 2019-ncov lung injury therapeutic and supportive care guidelines for patients with covid-19 coronavirus the authors appreciate the korean health insurance review and assessment service for providing the data and hm hospitals for making their data publicly available as part of the covid data save lives project. all authors have completed the icmje uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare analyses were performed locally, and the data is not readily available to be shared. however, all analytic code is available at: https://github.com/ohdsistudies/covid19characterizationcharybdis and results are available at https://data.ohdsi.org/covid19characterizationcharybdis/ key: cord-031316-yvid6qps authors: bisimwa, patrick n.; ongus, juliette r.; tiambo, christian k.; machuka, eunice m.; bisimwa, espoir b.; steinaa, lucilla; pelle, roger title: first detection of african swine fever (asf) virus genotype x and serogroup 7 in symptomatic pigs in the democratic republic of congo date: 2020-09-03 journal: virol j doi: 10.1186/s12985-020-01398-8 sha: doc_id: 31316 cord_uid: yvid6qps background: african swine fever (asf) is a highly contagious and severe hemorrhagic viral disease of domestic pigs. the analysis of variable regions of african swine fever virus (asfv) genome led to more genotypic and serotypic information about circulating strains. the present study aimed at investigating the genetic diversity of asfv strains in symptomatic pigs in south kivu province of the democratic republic of congo (drc). materials and methods: blood samples collected from 391 asf symptomatic domestic pigs in 6 of 8 districts in south kivu were screened for the presence of asfv, using a vp73 gene-specific polymerase chain reaction (pcr) with the universal primer set ppa1-ppa2. to genotype the strains, we sequenced and compared the nucleotide sequences of ppa-positive samples at three loci: the c-terminus of b646l gene encoding the p72 protein, the e183l gene encoding the p54 protein, and the central hypervariable region (cvr) of the b602l gene encoding the j9l protein. in addition, to serotype and discriminate between closely related strains, the ep402l (cd2v) gene and the intergenic region between the i73r and i329l genes were analyzed. results: asfv was confirmed in 26 of 391 pigs tested. however, only 19 and 15 ppa-positive samples, respectively, were successfully sequenced and phylogenetically analyzed for p72 (b646l) and p54 (e183l). all the asfv studied were of genotype x. the cvr tetrameric repeat clustered the asfv strains in two subgroups: the uvira subgroup (10 trs repeats, aaaabnaaba) and another subgroup from all other strains (8 trs repeats, aabnaaba). the phylogenetic analysis of the ep402l gene clustered all the strains into cd2v serogroup 7. analyzing the intergenic region between i73r and i329l genes revealed that the strains were identical but contained a deletion of a 33-nucleotide internal repeat sequence compared to asfv strain kenya 1950. conclusion: asfv genotype x and serogroup 7 was identified in the asf disease outbreaks in south kivu province of drc in 2018–2019. this represents the first report of asfv genotype x in drc. cvr tetrameric repeat sequences clustered the asfv strains studied in two subgroups. our finding emphasizes the need for improved coordination of the control of asf. pigs are increasingly contributing to improved nutrition and household incomes in regions of africa where pork consumption and pig keeping are culturally acceptable [1] . despite the importance of pig farming, this sector is facing several constraints, with infectious disease burden being the major problem [2] . african swine fever virus (asfv) causes an acute, highly contagious, and fatal disease in domestic pigs, with clinical signs such as fever and haemorrhagic lesions [3] . there are currently no vaccines available to combat african swine fever (asf). the first recorded asf outbreaks were reported in pigs belonging to european settlers in kenya in 1914 [4] . the disease continues to spread throughout eastern europe since 2007 [5] and was reported in belgium and china in 2018 [6] [7] [8] . asfv is a large, enveloped, doublestranded dna arbovirus belonging to the genus asfivirus, and the only member of the family asfarviridae [2, 9, 10] . warthogs, bush pigs and the soft tick of the genus ornithodoros are the major reservoirs of asfv [3] . the contagious nature and the ability to spread rapidly in pig populations over long distances makes it the most feared disease of domestic pigs [11, 12] . the genome size varies from 170 to 193 kbp and encodes between 150 and 167 open reading frames, depending on the virus strains [13] . to date, 24 asfv genotypes have been reported worldwide based on the b646l gene, which encodes the capsid protein p72, and all of them are known to circulate in africa [14] [15] [16] . using the serotype-identification approach [17] , an additional 8 asfv serotypes have been reported based on the ep402r gene encoding the cd2v protein [17] [18] [19] . distinct antigenic types of asfv were identified based on haemadsorption inhibition (hai) serological typing, where asf protective immunity was shown to be serotype-specific, and viruses belonging to identical serogroups cross-protected against each other [20] . this has significant importance for vaccine development. the cd2v protein, encoded by the asfv ep402r gene, is a transmembrane glycoprotein located in the viroplasm (around viral factories) and in the plasma membrane of infected cells. it is among the most variable genes in the asfv genome [21, 22] . haemadsorption involves adhesion of pig erythrocytes to the surface of asfv infected cells, a key requirement is expression of cd2v in asfv-infected cells [20] . control of the disease is relying on surveillance, restriction of pigs and pork products movement, and rapid diagnosis and culling of asfv infected animals. the implementation of these measures is particularly difficult for african pig farmers of which many can be characterized as smallholders, due to limited capacity and appropriate policy. in 2011, asf outbreaks were reported in more than 25 african countries with the highest number of outbreaks (84) registered in the democratic republic of congo (drc) causing a loss of 105,614 pigs [23, 24] . previous studies have reported circulation of genotype i, ix and xiv in drc, encouraging the need for continued characterization of asfv strains responsible for outbreaks to better understand the spread of this economical important disease in drc. several variable regions of the asfv genome have been extensively used as targets for molecular epidemiology studies of asfv strains [25] [26] [27] . however, previous studies achieved high resolution for discrimination between different virus strains when combining p72, p54 and b602l (central variable region or cvr) proteins [28, 29] . moreover, the ep402r gene encoding the cd2v protein and the intergenic region between the i73r and i329l have also been used to characterize asfv from various locations and to track virus spread [25, 26] . the first report of the presence of asf in drc was in 1939 [30] . south kivu province is an area in the eastern drc where suspected cases of asf appear regular. reports from the provincial ministry of agriculture livestock and fishery (pmalf) and the local veterinary body indicated the death of 1600 pigs out of 1608 that presented clinical signs of asf in 2015 (report of the pmalf, unpublished data). more recently, we have used a combination of p72 and p54 proteins to characterize asfv genotype ix in apparently healthy pigs in south kivu province sampled in 2016 [31] . it was the first study of asfv in the south kivu province. however, despite report of frequent incidences of asf in the south kivu province by the pmalf, information about asfv strains in circulation in suspected infected animals is lacking. therefore, the present study was set up to identify and characterize asfv strains in infected domestic pigs with symptoms of asf from different smallholder farms in the south kivu province in order to increase epidemiological knowledge of asfv, and to generate information for improvement of control strategies. ethical approval for the study reported here and the permission for the collection of samples was provided by the interdisciplinary centre for ethical research (cire) established by the evangelical university in africa, bukavu, dr congo, with reference (uea/sgac/km 132/2016). a consent form which described the aim of the study was signed by farmers willing to participate in the study after translation into local languages. the study was carried out in south kivu province of the democratic republic of congo (drc), situated in the eastern part of the country. it is a large region with an area of 66,814 km 2 , located between longitudes 26°10′ 30″ and 29°58′ east, latitudes 00′ 58″ and 4°51′ 21″ south. comparatively, the south kivu province is over two times the size of burundi (27,834 km 2 ) and rwanda (26,338 km 2 ) put together. the province experiences two main seasons: a 9-month long rainy period, from september to may, and a 3-month dry period (june to august). the annual average rainfall is 1300 mm. six out of eight territories were selected for purposes of this study including; fizi, kabare, kalehe, mwenga, uvira and walungu (fig. 1) . a key factor in selecting the sample sites was the inclusion of the main pig-producing, marketing, and consuming areas, with a particular focus on locations where suspected asf outbreaks had been recently reported by the provincial ministry of agriculture livestock and fishery. a cross-sectional study was conducted where the target population was households that keep pigs, and where suspected asf cases were notified based on the reports from the local veterinary and provincial ministry of agriculture livestock and fishery during december 2018 to january 2019. in general, the number of pigs per farm varied between 1 and 5 and they shared housing. thus, farms with pigs presenting symptoms such as high fever, reddening of the skin, particularly ears and snout, coughing and difficulties in breathing, hemorrhagic diarrhea and vomiting, inability to walk, loss of appetites, general weakness, were considered for sampling and all the pigs were sampled. drc has a pig population of approximately 1 million. the recommended sample size for a population of that size, using a confidence level of 95% and a margin of error of 5% would be 384 [32] . based on this, a total of 391 blood samples from suspected asfv infected pigs were collected in edta (anticoagulant) tubes and were used for pcr analysis. all blood samples were collected from the jugular vein of pigs of over 3 months of age. after collection, all collected blood samples were transported to the université evangélique en afrique (uea) and stored at − 20°c before being shipped on ice packs to the pan african university institute of science technology and innovation (pauisti) in nairobi then to beca-ilri hub, for subsequent analysis. total dna was extracted directly from 200 μl of whole blood using the dneasy blood and tissue kit (qiagen, usa) following the manufacturer's recommendations. to detect the presence of asfv dna, polymerase chain reaction (pcr) amplification assay was carried out using the asfv diagnosis primers ppa1/ppa2 (peste porcine africaine) that target the virus vp73 (p72) coding region to generate an amplicon of 257 bp [33] . pcr products were confirmed using a 2% agarose gel electrophoresis. all ppa-positive samples were characterized in subsequent analyses. five separate pcr experiments were set up to amplify ppa-positive samples: (i) for p72 genotype classification, the c-terminal region of the p72 protein gene was amplified using the primers p72-u/d [15] ; (ii) for p54 genotyping, the gene e183l encoding the p54 protein was amplified using the primers ppa722/ppa89 [11] ; (iii) the b602l gene characterized by the central variable region (cvr) was amplified using the primer pairs cvr-fl1 and cvr-fl2 as previously reported [24] ; (iv) for determining the origin, and to distinguish between closely related asfv strains circulating in the south kivu province, a 356 bp fragment, specific for identification of tandem repeat sequences (trs), located between the i73r and i329l genes was amplified using the primer pairs eco1a and eco1b [34] ; (v) to determine the serogroups of the strains, the partial ep402r gene encoding the cd2v protein [27] was amplified and sequenced using two sets of primers to generate two overlapping fragments. the primers used for the diagnosis and genotyping are presented in the table 1. pcr amplicons were confirmed using 2% agarose gel electrophoresis in the presence of molecular weight markers. for sequencing, pcr products were purified using quick pcr purification kit (qiagen, usa) following the manufacturer's instructions and sent to macrogen europe bv (amsterdam, the netherlands) for sanger sequencing. open reading frames present within the sequences generated from the amplified cvr dna fragments were translated into amino acid sequences using emboss-transeq software [19] . both strands of purified amplicons were sequenced using the 7 primer sets for genotyping described above. to verify similarity with known sequences, the amplicon sequences obtained were submitted to blast (basic local alignment search tool) [35] against non-redundant genbank database. multiple sequence alignments of sequences were generated using clustal w [36] , whereas for each locus, the unrooted maximum likelihood method (ml) phylogenetic tree with 1000 bootstrap replications was estimated by mega 7 program and kimura 2-parameter model [37] was selected based on the best-fit substitution model (ml) with the lowest bayesian information criterion (bic) score. asfv sequence data of strains and isolates available in the genbank were included as references. sequences from this study have been submitted to genbank with accession numbers mn689307 to mn689322 (for p72) and mn704903 to mn704917 (for p54). a total of 391 blood samples collected from symptomatic pigs were screened for the presence of the asf viral dna using conventional pcr with the diagnostic primers ppa1/ppa2. a total of 26 blood samples showed clear amplicons of the expected size (257 bp) and data were distributed as shown in table 2 , with the highest number of positive samples found in the uvira territory 9/68 (13.2%), while the lowest was in mwenga 2/65 (3.07%). sequence analysis of asfv based on the b646l (p72), e183l (p54) and b602l (cvr) genes of the 26 asfv positive samples using ppa diagnostic primers, we successfully amplified and sequenced 19 (73.07%) samples for p72 and 15 (57.69%) samples for p54 ( table 2 ). the p72 amplicon sequences shared 99-100% identity due to some few synonymous mutations while the p54 sequences were 100% identical (data not shown). thus, clustal protein sequence alignment showed 100% identity between all the p72 and p54 sequences in the study samples. sequences of p72 and p54 amplicon were compared with 25 other p72 and p54 asfv sequences retrieved from the gen-bank database and the phylogenetic analysis revealed that the south kivu asf virus strains analyzed clustered with p72 genotype x including strains reported in previous studies in burundi (af449463), kenya (ay261360) and tanzania (jx403648, af301546, mf437291) ( fig. 2a and b) . this is the first report of genotype x in the drc. in addition, the predicted amino acid sequences of the cvr nucleotide sequences were generated from 15 samples (2 fizi, 2 kabare, 2 kalehe, 2 mwenga, 5 uvira, 2 walungu) and specific features based on the previously reported asfv tetrameric amino acid repeats within the cvr [38, 39] were obtained. analysis of the cvr signature of the b602l gene showed two different signatures when compared with sequences of strains of the same genotype from burundi, tanzania and uganda. all asfv strains contained a cvr with 3 tetrameric amino acids, namely cast (a), cadt (b) and nvdt (n). however, in strains from the uvira territory the cvr sequence was repeated 10 times with the profile aaaabnaaba. in contrast, in strains from the five other territories, the cvr sequences contained only 8 repeats with the signature aabnaaba (table 3 ). both cvr signatures were different from the strains tan13/moshi, bur 84/1, bur84/2 and ug95/3 [38] [39] [40] . 15 15 no. strains positive for asfv using the 3 pcr assays 13 a pcr assays were performed on the 26 samples positive for ppa pcr sequence analysis of the intergenic region between i73r and i329l genes and the ep402r gene amplification of the ep402r gene (encoding cd2v protein) was performed, and pcr amplicons of 8 strains from 4 territories were successfully sequenced. comparative analysis of the 8 sequences obtained was carried out together with 20 other asfv sequences retrieved from the genbank database and previously characterized as serogroups. in this study, the phylogenetic analysis showed that the south kivu strains belonged to serogroup 7 and were grouped with the uganda strain (km609361), the only available serogroup 7 in the gen-bank. this research suggests that the strains from this study may have a similar hemadsorption inhibition (hai) characteristics as the only known strain serogroup 7 (fig. 3) . the analysis of whole-genome sequences of asfv has facilitated identification of several regions containing tandem repeat sequences, important for discriminating between closely related asfv strains and for predicting the origin of the virus [26] . in this study, the intergenic region between the i73r and i329l genes was analyzed for 15 strains from the 6 territories studied. the south kivu asfv strains were compared to the kenyan 1950 strain (ay261360), which was identified from a domestic pig. the sequence alignment showed an indel of 33 bp (5′-cctatatacctataatcttataccctataa tct-3′) between nucleotide position 226 to 258 (fig. 4 ). african swine fever constitutes the major obstacle to the development of the pig industry in the drc, with sporadic outbreaks occurring across various areas throughout the year [24] . despite recurrent occurrence of suspected asf outbreaks in south kivu province, information on the virus characterization remains scarce. to determine the prevalence of asf and genotypes of asfv in circulation in the south kivu province, a study was carried out in the south kivu province from january to august 2016, a period with no report of asf outbreaks a b fig. 2 phylogenetic relationships of p72 and p54 genotypes. the evolutionary history was inferred by the maximum likelihood method based on the kimura 2-parameter model [33] . phylogeny was inferred following 1000 bootstrap replications, and the node values show percentage bootstrap support. scale bar indicates nucleotide substitutions per site. scale bar indicates nucleotide substitutions per site. a p72 genotypes. the analysis included 19 b646l (p72) sequences from this study (plain circle ) and sequences from the genbank database. the genbank accession numbers for the different b646l (p72) genes are indicated in parenthesis. b p54 genotypes. the analysis involved 15 e183l (p54) gene sequences of african swine fever viruses from this study (black diamond ◆) and sequences from the genbank database. the sequences for the different b646l (p72) and e183l (p54) genes are starting by genbank accession numbers or cases in the sampled area [31] . we conducted a cross-sectional study in 5 of the 8 districts of the province and 267 pig blood from 250 smallholder pig farms were screened for presence of the asfv antibody and viral genome using indirect enzyme linked immunosorbent assay (elisa) and polymerase chain reaction (pcr), respectively, on asymptomatic domestic pigs. we found that 37% of pigs contained asfv antibodies whereas virus dna was present in 22.8% of pigs. sequence analysis revealed that all the asfv detected from asymptomatic pigs belonged to the genotype ix. continuous characterization of asfv strains is key in endemic regions to better understand disease outbreak patterns and map the different strains according to their geographical regions, in which they circulate [41] . the present study was targeting domestic pigs showing asf clinical signs with the aim to characterize asfv in symptomatic animals in the south kivu province. we confirmed the presence of asfv in domestic pigs with clinical signs of asf in the six studied territories of south kivu province: kabare, kalehe, fizi, mwenga, uvira and walungu. although this study was not designed to determine the prevalence of asfv, low rate of infection was observed in mwenga and kalehe (3 and 3.1%, respectively), whereas the highest infection rates were registered in walunga and uvira (9 and 13.2%, respectively). in our previous study which included asymptomatic pigs [31] , walungu had the highest prevalence of asfv (33.7%) while the lowest asfv prevalence was found in kalehe (15.8%). the overall low infection rate may be attributed to the sensitivity of the assay used. indeed, the conventional pcr method used in this study is less sensitive than other molecular methods such as nested-pcr [42] and real-time pcr [43] and may fail to detect potentially positive samples containing very low amount of viral genetic material. in addition to the low sensitivity of the conventional pcr used, other conditions may have contributed to the observed low prevalence including: (i) most pigs sampled may not have been infected or may have low virus load not detectable by the pcr technique used; and (ii) suspected pigs may have been affected by other diseases and conditions with similar symptoms to asf such as porcine reproductive an respiratory syndrome, porcine dermatitis and nephropathy syndrome, salmonellosis. our results confirmed asf viral infections in pigs with clinical signs of asf in the south kivu province. from the 26 ppa-pcr positive samples, 19, 15 and 15 samples were successfully amplified and sequenced for b646l (p72), e183l (p54) and b602l (cvr) genes, respectively. the combination of these three viral regions is to ensure a high-level resolution for asfv discrimination. the p54 genotyping study corroborated the p72 analysis. both p72 and p54 phylogenetic analyses clustered asfv strains in circulation in symptomatic domestic pigs during the december 2018 -january 2019 outbreaks in the south kivu province with asfv genotype x, which is the major genotype associated with asf outbreaks throughout burundi, in some parts of tanzania, kenya and uganda [38, 39] . genotype x has been reported to be a sylvatic cycle-associated genotype that include asfv identified from domestic pigs, warthogs as well as ticks in these three countries [15, 27, 44] . furthermore, alignment of the 433 bp long sequence from the variable 3′-end of the b646l (p72) gene in the south kivu viruses showed 100% identity with asfv strains from burundi 1984 (data not shown). it is a possibility that viruses in this study may originate from, or could have expanded to burundi. this scenario seems plausible as the south kivu province is bordering burundi through the river rizizi and lake tanganyika, and uncontrolled cross-border movements of pigs and pork products are observed in the region and may constitute a major route of transmission of asf in this endemic area [45] . our current result contrasts with our previous finding of circulating asfv strains of genotype ix in asymptomatic domestic pigs in the studied area during a period with no asf outbreaks or cases [31] . it is unlikely that data from both studies suggest that asfv of genotype ix may not cause disease in pigs whereas [40] . although the report did not have any cases in the south kivu province, it identified asfv of genotype i in the neighboring province of maniema. nevertheless, further investigation in relation to both the host and virus genetics will be important to understand our findings. we are currently working on the lab-isolation of viruses of genotype ix and x in circulation in asymptomatic pigs and symptomatic pigs, respectively, for complete genome sequencing and comparative genomic analysis. data obtained will improve our understanding of this contrasting finding in pigs within the south kivu province. to the best of our knowledge, this is the first report of asf virus genotype x in the dr congo. as all the strains were p72/p54 genotype x, we further characterized them at a higher resolution using the intra-genotypic central variable region (cvr) of the bl602l gene. based on the tetrameric repeat sequences (trs), our analysis identified two different cvr variants, clustering the strains into two subgroups. subgroup 1 was composed only of strains from uvira characterized by 10 trs whereas all other strains formed the subgroup 2 and had only 8 trs. the profile of the subgroup 2 (aabnaaba) was almost identical to the cvr amino acid sequence of uganda 95/3 (aabnbaba), having the b code (cadt) in place of a at the 5th repeat [39] . the number of trs repeat observed is relatively small compared to reports from some studies in the same geographic region describing the trs motif repeated over 20 to 50 times [38, 46] . however, mulumba-mfumu et al. also observed this sequence repeated only 5 or 6 times in some dr congo strains [24] . the two cvr variants found in our study were different from the previously reported variants in dr congo asfv strains [40] and to any other known viruses causing outbreaks or asf cases, thus suggesting that the asfv genotype 10 in circulation in the south kivu province of dr congo identified in this study may be unique [45, 47] . within the vaccine field, it has been suggested that protective immunity is serotype-specific, as defined by asfv hemadsorption inhibition (hai) serological assay, with viruses within a serogroup cross-protecting against one another [17, 18] . the hai assay can be used to type asfv of a given genotype into distinct and individual serogroups, based on the asfv proteins cd2v (ep402r) and/or c-type lectin (ep153r). thus, hai-based serogroup classification has been suggested as a better correlate for in vivo cross-protection among strains compared to the p72 genotyping [17] . in our study, we obtained cd2v sequences of 8 strains from 4 territories and comparative sequence analysis revealed that they were all identical. moreover, phylogenetic analysis showed that the uganda strain (genbank acc. no. km609361.1), which represents the only member of the serogroup 7, was closest related to the south kivu viruses, suggesting that the asfv strains, identified in this study, may belong to serogroup 7. the high bootstrap value of 99% grouping the south kivu strains with the uganda serogroup 7 and the fact that strains from this study showed 99.2% amino acid identity with the uganda serotype 7 strain strongly support the genetic relatedness between these two groups. it is worth noting that strains of serogroups 1 and 2 have been reported in drc [18] . overall, our data showed that these south kivu asfv strains are serologically different from other strains reported so far. analysis of the intergenic region between the i73r and i329l genes has previously been used for distinguishing between closely related asfvs [26] . characterization of fig. 4 partial nucleotide sequence alignments of the intergenic region between i73r and i329l genes. sequences of african swine fever virus (asfv) strains from the south kivu province, eastern drc, showing tetrameric repeats of representative genotypes, including a reference sequence of a virus isolated in 1950 in kenya (kenya 1950; genbank accession no. ay261360.1). the indel that results from the insertion of the nucleotide sequence cctatatacctataatcttataccctataatct in the asfv from kenya is boxed this intergenic region genes did not identify any genetic diversity among the south kivu strains. however, all the 15 strains analyzed had high sequence identity with the kenyan strain 1950 (genbank acc. no. ay261360) but lacked an insertion of 33 bp. indels have also been reported in a similar analysis [26] . altogether, our study provided evidence of circulating asfv genotype x which were antigenically related to serogroup 7 in domestic pigs with clinical signs of asf in eastern drc. the genotyping approach was also supported with the hai serotyping for improved diversity analysis and finer discrimination of asfv strains. this represents the first report of asfv genotype x in drc. in this study, asfv isolated from symptomatic domestic pigs in the south kivu province of the democratic republic of congo were characterized for the genetic diversity. all the asfv strains analyzed in this study belonged to the p72 genotype x and the cd2v serotype 7. this is the first report of circulating asfv genotype x in drc. the genetic similarity of these strains suggests that they may originate from a common source. however, cvr tetrameric sequence repeat analysis clustered the strains into a subgroup with 10 tsr (uvira strains) and a subgroup with 8 trs 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fever by a new real-time pcr using universal probe library african swine fever viruses with two different genotypes, both of which occur in domestic pigs, are associated with ticks and adult warthogs, respectively, at a single geographical site transmission routes of african swine fever virus to domestic pigs: current knowledge and future research directions prevalence of african swine fever virus in apparently healthy domestic pigs in uganda molecular characterization of african swine fever virus in apparently healthy domestic pigs in uganda publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we acknowledge the biosciences eastern and central africa authors' contributions bnp collected samples for dna isolation, performed laboratory work and wrote the manuscript; jro supervised the study, conceived and designed the study, and edited the manuscript; ckt performed the laboratory work and edited the manuscript; emm performed the laboratory work and sequence analysis; ebb conceived and designed the study and edited the manuscript; ls supervised the study and edited the manuscript; rp supervised the study, performed sequence analysis, wrote and edited the manuscript. all authors read and approved the manuscript. this work was funded by the biosciences eastern and central africa -international livestock research institute (beca-ilri) hub, through africa biosciences challenge fund (abcf). the datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.ethics approval and consent to participate see material and methods section. not applicable. the authors declare that they have no competing interests.author details 1 department of molecular biology and biotechnology, pan african university, institute of basic sciences, technology and innovation, nairobi, kenya. key: cord-102885-5y9nkal3 authors: lee, hyeon-seung; dean, derek; baxter, tatiana; griffith, taylor; park, sohee title: deterioration of mental health despite successful control of the covid-19 pandemic in south korea. date: 2020-11-13 journal: nan doi: 10.1016/j.psychres.2020.113570 sha: doc_id: 102885 cord_uid: 5y9nkal3 south korea was able to successfully control the spread of covid-19 without nationwide lockdowns or drastic social distancing efforts, but pandemic-related psychological outcome of the general population remains unknown. between march and june 2020, 400 south korean residents participated in an online study of depression, anxiety, stress, psychosis-risk and loneliness, as well as indices of social network, physical health and demographics. clinical levels of depression, anxiety or stress were reported by 45% of the respondents, and psychosis-risk was present in 12.8%; a drastic increase above the base rate reported by previous studies conducted in south korea prior to the pandemic. subjective feelings of loneliness, but not the size of the social network accounted for poor mental health. women were especially at increased risk for mental health problems. thus, despite effective mitigation of the pandemic, there was a striking deterioration of mental health. as the psychological burden of the continuing pandemic accrues, the probability of an impending mental health crisis is increasing, especially in countries with greater infection and death rates than south korea. comprehensive efforts to address the psychological aftermath of the pandemic are urgently needed. as of august 2020, covid-19 has infected more than 22 million people worldwide (ecdc.europa.eu). however, successful mitigation of the pandemic has been achieved in many countries owing to their nationwide efforts to administer and manage public health policies based on science. the case of south korea (population of 50 million) is particularly illuminating in this respect. after reporting the first case of covid-19 on january 20th, 2020 (gralinski, & menachery, 2020; hyun et al., 2020) , south korea experienced exponential growth of confirmed covid-19 cases in the next two months (kuhn, 2020; shim et al., 2020) . to take control of the pandemic, widespread testing and contact tracing began almost immediately ) through a wellcoordinated partnership between the government and private sectors. novel test settings were launched (e.g., drive-through screening, kwon et al., 2020) and fast tracking of infected cases with transparent disclosure of information was made available . although extremely restrictive measures such as immigration control or nationwide lockdowns were not enacted, south korea brought the pandemic under control through an extraordinarily large volume of testing, efficient contact tracing, monitored quarantines for those who were exposed or suspected to have been exposed to the virus and universal adherence to science-based public health policies by the general public (cohen, & kupferschmidt, 2020; park et al., 2020; al-rousan, & al-najjar, 2020) . there was almost 100% compliance with mask use, self-quarantine protocols and social distancing rules. with daily cases dropping below 50 ) and a very low mortality rate (her, 2020) by june, the vast majority had been spared of the disease. while the mitigation of covid-19 nationwide is undoubtedly a success story, the psychological wellbeing of the population during this period has not yet been closely examined. outcome data from previous epidemics (e.g. severe acute respiratory syndrome in 2003, and the middle east respiratory syndrome in 2012) forewarn adverse psychiatric consequences (chan, & chan, 2004; sim et al., 2004; mak et al. 2009; . for example, the risk for post-traumatic stress disorder (ptsd) increased for both the survivors of these diseases and healthcare workers and psychiatric symptoms remained elevated up to six months after the end of the quarantine period (jeong et al., 2016) . furthermore, the psychological consequences of pandemics can be extensive across the general population regardless of exposure to the disease itself. past research indicates that, although the vast majority of the population was never infected, there was a significant psychological toll on the general population (park and yu, 2020) . given the severity and the scale of the current pandemic, a worldwide mental health crisis is expected in the near future (see holmes et al., 2020) . in addition to chronically elevated levels of stress, anxiety and fear that interfere with daily functioning due to the pandemic (jung, & jun, 2020) , public health strategies designed to curb the spread of the virus may have an unintended negative impact on mental health. lockdowns, quarantines and social distancing protocols protect the public but these measures also separate individuals from their regular social networks. prolonged social isolation is associated with exacerbation of stress, panic, depression, anxiety and psychosis (bo et al., 2020; kim, & su, 2020; rossi et al., 2020; wang et al., 2020; zhang, & ma, 2020; selten et al, 2017) . social isolation and loneliness have long been linked to poor mental and physical health outcomes (see leigh-hunt et al., 2017 for a review) . importantly, it has been shown that the subjective feelings of loneliness rather than objective measures of social contact or network contribute to psychosis-risk (badcock, adery and park, 2020; michael and park, 2016; benson and park, 2019) . indeed, the national lockdown enacted earlier this year to stem the spread of covid-19 may have already resulted in increased psychosis risk in the general population in italy (d'agostino et al., 2020) . although korea was able to avoid a nationwide lockdown, the widespread closure of public spaces, educational institutions, places of worship and other social venues have been disruptive, especially among young people whose social world collapsed when schools and colleges shut down. social isolation and disconnection due to the pandemic are likely to be even more burdensome to vulnerable individuals. indeed, as early as mid-march of 2020, mental illness was the third most frequent underlying condition of those who died of covid-19 in south korea (kang, 2020; kim, & su, 2020) . a recent survey of hong kong residents underscores the pivotal role of loneliness in extraordinarily high levels of psychiatric distress during the pandemic, with almost two-thirds of the respondents reporting depression or anxiety disorders and about a quarter meeting the criteria for psychosis-risk (tso and park, 2020) . similar to south korea, hong kong was not severely affected by covid-19 owing to its early and successful public health efforts to limit the spread of the disease. in contrast to koreans, hong kong residents were forced to undergo a complete lockdown leading to extreme social isolation. furthermore, hong kong had been under prolonged political turmoil and uncertainties that were already generating high levels of stress before the covid-19 pandemic hit (ni et al., 2020) . thus, one might expect the psychiatric impact of covid-19 to be less severe in korea than in hong kong. the major aim of the present study was to survey mental health and social wellbeing during the covid-19 pandemic among the general population in south korea where effective public health strategies and high compliance by the residents were able to successfully stop the spread of the virus. by investigating psychological consequences of the pandemic in a country, which largely escaped the ravages of the covid-19, we sought to observe mental health outcomes under the best case scenario. in particular, we wanted to elucidate demographic factors (e.g., age, gender, living situation) associated with increased risk or protective factors for psychiatric conditions. moreover, we hypothesized that there would be adverse psychological consequences of living under the pandemic conditions in relation to social disconnection. four hundred three participants viewed the introduction page of the online survey in korean from march 22, 2020 to june 31, 2020. among those, 400 (99.2%) met the criteria for the survey by their self-reported age (i.e., over 18) and current residence in south korea at the time of the survey). all 400 respondents completed the survey. all participants completed the survey in korean using the google form platform (available at https://forms.gle/4zkooaxm4zfyznuya). the survey link was disseminated using social media, local online communities, websites and by word-of-mouth in south korea. this study did not collect any personal or identifying information, such as name, date of birth, contact information, ip address, ethnicity or other potentially identifying information, guaranteeing the total anonymity and privacy of the respondent, and therefore received an exempt status from the vanderbilt university institutional review board (irb# 201000). participants were asked to respond to questions about their demographic information (age, sex, education level, occupation, marital status), 4 levels of concern about the covid-19 pandemic from "not at all concerned" to "extremely concerned", general physical health status, mental health, loneliness and social network. for general physical health, participants reported their health status on a 5-point likert scale, from "poor" to "excellent". subjects also reported the number of days in the past month that they experienced health problems with respect to physical and mental health, disturbances in daily activities, alcohol and tobacco use, pain and worry. the 42-item version of the depression anxiety stress scale (dass; lovibond, & lovibond, 1995) and the 16-item version of the prodromal questionnaire (pq-16; ising et al., 2012) were used to assess the mental health of the respondents. dass was used to assess depression, anxiety and stress levels, classifying the severity from "normal" to "extremely severe". pq-16 assessed psychosis risk with a total score of 6 or higher indicating high-risk status (ising et al., 2012) . in addition to pq-16, there were two items that asked directly about dissociative experiences (out-of-body experience) and voicehearing. the ucla loneliness scale (russell, 1996) was utilized to measure subjective feelings of loneliness. the size and the diversity of social network of the respondents were collected to obtain an objective index of social isolation using the social network index (sni; cohen, 1997) . first, descriptive data for demographics, general health questions and mental health items were examined. then, we compared physical and mental health status between demographic subgroups. we used independent t-tests to compare participants in terms of age (old vs. young), sex, employment status and occupation (healthcare worker vs. non-healthcare worker). family relationships play an outsized role in the quality of life of south koreans. the majority of south koreans live with their families until marriage, and often after marriage as well (see yang, 2003) . we classified family and living arrangement across the whole sample with three groups: married couples (or cohabiting partners), singles living with family and singles living alone. we expected the singles living alone to fare worse during covid-19 since they are the most likely to be socially disconnected. a series of one-way ancovas, controlling for age and sex, were used to examine family and living arrangement differences. a series of hierarchical linear regression analysis was used to examine the contributions of loneliness and social network size on physical and mental health variables. in the first step, independent variables for age, sex and concern for covid-19 were used to form the basic model. in the second step, loneliness, social network diversity and social network size were included in the full model. for each dependent variable (e.g., self-reported health, days physically ill, days when physical and mental health limited engagement in usual activities, days in which pain limited functioning, days mentally ill, days feeling anxious, dass and pq-scores), the change in r 2 between the basic model and full model was used to examine whether the addition of loneliness and social network explained more of the variance in each physical or mental health variable, after controlling for age, sex and covid concern. bonferroni correction of p < 0.0045 was applied to minimize type i errors. the majority of the respondents (71.75%) identified as female, 27.5% as male and 0.75% as other or preferred not to answer. mean age was 31.68 years (sd =12.31; range, 18-72). mean years of education was 14.83 (sd =3.01). 68.25% were single, 29.75% were married or cohabiting with a partner and the rest preferred not to answer. 30.5% were employed and 62.5% were unemployed (7% preferred not to answer). only 6% (n = 24) of the total sample were healthcare workers, who made up 9.6% of the total number of employed participants. please see table 1 for details. --table 1 --no respondent reported a diagnosis of covid-19. one participant was in selfquarantine due to suspected exposure to covid-19 but was asymptomatic. the mean rating for self-reported overall health (excellent =5; very good = 4; good =3; fair =3; poor=1) was 3.07 (sd = 0.93), with 69.5% reporting 4 (good) or above. forty-percent of the respondents reported one or more of the following types of illnesses in the past 30 days: head cold or chest cold (11.75%); gastrointestinal illness with vomiting or diarrhea (16.75%); flu, pneumonia or ear infections (6.75%); or an ongoing or chronic medical condition (4.75%). only 6.75% smoked (m = 0.45 packs/day, sd = 0.39) but 49.5% drank alcohol (m = 2.13 drinks/week, sd = 1.64). among the smokers and drinkers, 25.9% reported smoking and 16.2% endorsed drinking more than usual in the past 30 days. figure 1 represents the number of days (in the past month) during which participants reported experiencing significant health problems. psychological problems (i.e., poor mental health, or feeling worried, anxious or tense) were responsible for more days lost to illness or disability than physical health issues (i.e., poor physical health or pain). ---figure 1 --depression, anxiety, and stress (dass-42). the mean subscale scores were 11.66 (median = 9, sd = 9.89) for depression; 7.34 (median = 5, sd = 7.18) for anxiety; 12.19 (median = 11, sd = 9.05) for stress. we used the published cut-off scores (crawford, & henry, 2003) to determine the proportion of participants experiencing at least moderate levels of depression, anxiety and stress. depression was present in 36.75%, anxiety in 29.5%, and stress in 24.5% of the participants. furthermore, 45% (n = 180, 95% ci [40.12%, 49.87%]) of the respondents endorsed moderate or higher symptoms on one or more of the subscales. see figure 2 . prodromal psychosis (pq-16). mean endorsed items was 2.6 (median = 2, sd = 2.67, range = 0 -14). mean distress score was 3.69 (median= 2, sd = 5.59, range = 0 -45). according to the published cut-off score of 6 or more endorsed items (ising et al., 2012) , 12.75% (n = 51, 95% ci [9.48%, 16.02%]) of the respondents were at increased risk for psychosis. in addition to the pq-16, there were two items that asked directly about the presence of out-of-body experience (obe) or auditory hallucinations. 7% reported experiencing obes, and 16.25% reported having auditory hallucinations. loneliness. on the ucla loneliness scale, the mean score of the 400 respondents was 43.28 (median = 42; sd = 12.47), comparable to the reported norms of the north american (russell, 1996) , and validated norms from south korean (kim, 1999a (kim, , 1999b samples. social network index. the mean number of high-contact social roles was 4.45 (median = 4, sd = 2.03, range = 0 -12). the mean number of people with whom the respondents had regular contact (i.e., at least once every 2 weeks) was 13.49 (median = 13, sd = 8.64, range = 0 -62). we examined the effect of age by splitting participants into two groups about the mean (m = 31.68, sd = 12.31). older participants reported greater concern for covid-19 (t 398 = 4.29, p < .001) and worse general physical health (t 311.42 = -6.37, p < .001). there were no differences in age groups for days of physical health (t 397 = .63, p = .53), there were significant differences between women and men on most physical and mental health variables. women reported worse general health ratings (t 395 = -3.39, p = .001), more days of physical (t 308.10 = 3.80, p < .001) and mental health problems (t 213.38 = 3.84, p < .001), more days when their usual activities were affected by health problems (t 258.68 = 2.78, p < .01) or pain (t 324.37 = 2.41, p = .02), and more days when they felt worried, anxious or tense (t 393 = 2.53, p = .01). men and women did not differ on the levels of concern for covid-19 (t 395 = 1.46, p = .15). on the dass subscales, women scored higher than men on stress (t 395 = 2.48, p = .01) and depression (t 395 = 2.50, p = .01) but not on anxiety (t 395 = 1.68, p = .09). more women (40.4%) reported clinical levels of depression than men (26.4%) (ï� 2 = 6.78, df = 1, p < .01). clinical levels of one or more of the dass subscales were reported by 46.1% of women compared to 36.4% of men (ï� 2 = 4.42, df = 1, p = .04), indicating heightened emotional distress in women during the pandemic. there were no sex differences in the pq-16 scores (total: t 395 = 1.56, p = .12; distress: t 395 = 1.35, p = .18) and loneliness (t 395 = 1.24, p = .22). see figure 3 . -----figure 3 ----with regard to family and living arrangements, there were no differences between family groups in terms of covid concern, self-reported general health, days physically ill, days when usual activities were affected by health problems, days affected by pain, days mentally ill, dass-stress, dass-anxiety and pq-16. there were significant differences between singles living with family, married couples, and singles living alone for days feeling worried, anxious or tense (f 2, 388 = 4.45, p = .01), dass depression (f 2, 390 = 3.39, p = .03), and ucla loneliness (f 2, 390 = 3.72, p = .03). posthoc comparisons using a tukey hsd correction showed that singles living with family experienced more days of worry than people who were married. there was a marginal difference between for days feeling worried between singles living alone and married couples. single people living alone and with family reported experiencing more depression and loneliness than married people. there were no differences between singles living alone or with family in terms of depression and loneliness. detailed information can be found in the supplementary table s1 . employment, education and healthcare worker status did not have a significant effect on any of the physical or mental health variables. hierarchical linear regression was used to examine the effect of loneliness and social network on general health and mental health ratings. each full model showed a significant change in the magnitude of r 2 , suggesting that loneliness and social networks explained some of the variance in general health and mental health variables. when individual estimates were examined within each model, loneliness but not the size of social network was solely responsible for the change in r 2 , ranging from 5.1% to 45.4%. see table 2 and supplementary table s2. --table 2 --the primary goal of the current study was to investigate the psychological wellbeing of south korean residents during the covid-19 pandemic. successful management of covid-19 in south korea was achieved by proactive, nationwide interventions conducted by the government and the high compliance of the general public. however, the results of the present study indicate signs of psychological distress. many respondents reported suffering from mental health issues and feeling worried, anxious or tense 7 days out of 30 on average. importantly, clinical levels of depression, anxiety or stress were reported by nearly half of the respondents. these numbers vastly exceed previously reported 12-month prevalence rates of depression (1.5%) and generalized anxiety disorder (0.4%), surveyed by the korean ministry of health and welfare using a similar measure, prior to the current pandemic (see hong et al., 2016) . psychosis-risk was elevated in a noticeably higher proportion of the population during the covid-19 pandemic compared with the prevalence of 6.6% reported in a validation study of the korean version of the prodromal questionnaire . overall, these findings suggest a significant psychological impact of the covid-19 pandemic on the mental health and social wellbeing in south korean, with high rates of depression, anxiety, stress and psychosis-risk. we observed significant sex differences in psychological and physical wellbeing; physical and psychological suffering were greatly exacerbated in women. women reported significantly more days with physical and mental health problems and higher levels of stress and depression than men. according to the korean government, the 12month prevalence rates of depression and anxiety prior to the pandemic were higher for women than men but the difference was small. however, our data indicate a stark and concerning sex difference in mental health outcomes of women during the pandemic. this observed gender disparity in our study may reflect the fact that gender inequality in south korea is consistently ranks as one of the worst in the world despite the fact that women are well-educated, participate in the workforce and have excellent healthcare. the gender pay gap, already one of the worst among the industrialized nations (the world economic forum, 2017) got much worse during the pandemic as the unemployment rate among women disproportionately skyrocketed (kim, 2020) . these disparities are layered upon cultural expectations that place disproportionate burden of housework and childcare on women, which may greatly compound the pandemicrelated distress. however, to better understand these findings, more comprehensive investigations of women's mental health are warranted and our findings underscore the importance of developing targeted strategies for supporting women during the pandemic. loneliness was not significantly elevated above the reported pre-pandemic norms from north american (russell, 1996) or south korean (kim, 1999a (kim, , 1999b studies. however, the majority of the respondents (75%) lived with their families and there was no nationwide lockdown in korea. thus, a partial maintenance of social life was possible for most people even though schools, colleges and many workplaces were closed for a prolonged period. nevertheless, loneliness emerged as a significant predictor for the self-reported general health ratings and mental health variables, even after controlling for age, sex and the degree of concern for covid-19. in contrast, objective measures of social isolation (e.g. social network size) did not significantly predict physical or mental health variables. these findings underscore the importance of loneliness in the context of public health but it is crucial to understand how and why loneliness might arise. it is commonly assumed that living with family would reduce loneliness. families are often sources of emotional, social and financial support but some families are also fraught with hostilities, conflict and distress. we found that marital status and family living arrangement played a significant role in loneliness and depression. in korea, single adults (i.e., unmarried or without long-term romantic partner) usually live with their families rather than alone. we asked if singles who live with their families fare better than singles who live alone. singles, regardless of their living arrangements fared worse than couples especially with respect to depression and loneliness but surprisingly, there was no difference in mental health outcome between singles living alone versus singles living with family. in other words, living alone itself was not necessarily detrimental to mental health during this period. however, the quality and type of relationships mattered more than physical proximity to family members. for example, singles living with family reported more days spent worrying than did married couples. here, the concept of expressed emotion (ee) may be relevant (see hooley, 2007) . ee is a measure of family environment that captures the degree of hostility and negative emotions. importantly, high ee predicts worse clinical outcomes across a wide range of psychological conditions (hooley, 2007) . during the pandemic when korean residents suffered a significant narrowing of their usual social life, time spent at home increased dramatically. extended contact with family members may reduce social isolation but could also increases exposure to high ee. we do not have data on family dynamics but anecdotally, we observed that out of 13 participants who reported experiencing some form of abuse (verbal or physical) recently, the majority were singles living with family. whilst this sample is too small to draw any conclusions, this observation underscores the complex relationships among family dynamics, loneliness and mental health. future research could further elucidate individual differences and family environment that may contribute to increased risk for mental illness. overall, the impact of loneliness on mental health needs to be interpreted in the context of family structures and culture as each society struggles to adapt to the pandemic. compared to a recent study in hong kong (tso, & park, 2020) , the psychological impact of covid-19 appears to be milder in south korea. fewer people met the clinical levels of depression, anxiety, stress and psychosis-risk in south korea. moreover, the average number of days the respondents reported feeling worried, anxious or tense was half (7.4 days) of that reported by those in hong kong (14.1 days). south korea's adoption of less restrictive social distancing measures might be a factor, but the greater severity of psychological distress reported by hong kong residents might also reflect ongoing civil unrest that had already traumatized the city (ni et al., 2020) . sociopolitical unrest is widespread, with many countries including the united states experiencing violent conflicts. mental health consequences of covid-19 should be examined within the social and political context of each nation in order to implement culturally appropriate interventions. there are several caveats. first, a large number of the respondents were young university students and was disproportionately made up of women, which limits generalizability to the whole south korean population. second, the results of this study convey a snapshot of a highly organized and efficient country meeting the unprecedented challenges of a global catastrophe; sociocultural aspects of the response to the pandemic may not generalize to other countries. fourth, this crosssectional design does not allow us to track psychological wellbeing over time. future studies are needed to build a fuller picture of the psychological impact of covid-19 as the pandemic settles into a chronic situation. nevertheless, the results of this study clearly indicate that successful management of the pandemic is insufficient to protect the general public from disconcerting deterioration of mental health. since the beginning of the covid-19 pandemic, many have predicted future mental health crises (holmes et al., 2020) . whilst covid-19 might have a greater psychological impact on individuals with existing psychiatric disorders (kang, 2020; kim, & su, 2020) , our findings indicate that the general public is also at elevated risk for psychiatric disorders even when the pandemic is under control. it is important to reduce loneliness, improve the quality of social relationships and provide targeted support for women. as covid-19 continues to disrupt the lives of billions of people, comprehensive public health efforts must be implemented to meet the difficult challenges of prolonged psychological distress. ï�· covid concern: self-reported concern for covid-19 in 5-point likert-like scale (1=not at all concerned to 5= very concerned) ï�· general health: self-reported general health in 5-point likert scale (1=poor to 5= excellent health) ï�· days physically ill: the number of days physical health was not good in the past month ï�· days disable: the number of days usual activities were affected due to health problems in the past month ï�· days difficult: the number of days usual activities were affected due to pain in the past month ï�· days mentally ill: the number of days mental health was not good in the past month ï�· days anxious: the number of days felt worried, anxious, or tense in the past month ï�· dass: the 42-item version of the depression anxiety stress scale ï�· pq: the 16-item version of the prodromal questionnaire ï�· loneliness: a total score on the ucla loneliness scale better together: effects and treatments of loneliness and social isolation across the schizophrenia spectrum data analysis of coronavirus covid-19 epidemic in south korea based on recovered and death cases loneliness in psychosis: a practical review and critique for clinicians increased plasticity of bodily self-experiences in individuals who may carry latent liability for schizophrenia posttraumatic stress symptoms and attitude toward crisis mental health services among clinically stable patients with covid-19 in china psychological impact of the 2003 severe acute respiratory syndrome outbreak on health care workers in a medium size regional general hospital in singapore the depression anxiety stress scales (dass): normative data and latent structure 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contribute to the etiology of psychosis: a narrative review transmission potential and severity of covid-19 in south korea severe acute respiratory syndrome-related psychiatric and posttraumatic morbidities and coping responses in medical staff within a primary health care setting in singapore covid-19: a potential public health problem for homeless populations alarming mental health status among hong kong residents during the covid-19 epidemic: role of loneliness immediate psychological responses and associated factors during the initial stage of the in china family structure and relations patients with mental health disorders in the covid-19 epidemic impact of the covid-19 pandemic on mental health and quality of life among local residents in liaoning province, china: a cross-sectional study sohee park: conceptualization, methodology, writing (original draft, reviewing and editing), resources, supervision, project administration, funding acquisition formal analysis, writing methodology, data curation, writing (original draft, reviewing and editing) methodology, data curation, writing (original draft, reviewing and editing). declarations of interest: none we would like to thank lenie torregrossa, hafsah diakhate, jason scott, sunil shenoy, iris kim and catherine martinez for their helpful comments and support.funding information.this work was supported in part by the gertrude conaway vanderbilt endowment. key: cord-263625-gqzly8xw authors: dighe, amy; cattarino, lorenzo; cuomo-dannenburg, gina; skarp, janetta; imai, natsuko; bhatia, sangeeta; gaythorpe, katy a. m.; ainslie, kylie e. c.; baguelin, marc; bhatt, samir; boonyasiri, adhiratha; brazeau, nicholas f.; cooper, laura v.; coupland, helen; cucunuba, zulma; dorigatti, ilaria; eales, oliver d.; van elsland, sabine l.; fitzjohn, richard g.; green, william d.; haw, david j.; hinsley, wes; knock, edward; laydon, daniel j.; mellan, thomas; mishra, swapnil; nedjati-gilani, gemma; nouvellet, pierre; pons-salort, margarita; thompson, hayley a.; unwin, h. juliette t.; verity, robert; vollmer, michaela a. c.; walters, caroline e.; watson, oliver j.; whittaker, charles; whittles, lilith k.; ghani, azra c.; donnelly, christl a.; ferguson, neil m.; riley, steven title: response to covid-19 in south korea and implications for lifting stringent interventions date: 2020-10-09 journal: bmc med doi: 10.1186/s12916-020-01791-8 sha: doc_id: 263625 cord_uid: gqzly8xw background: after experiencing a sharp growth in covid-19 cases early in the pandemic, south korea rapidly controlled transmission while implementing less stringent national social distancing measures than countries in europe and the usa. this has led to substantial interest in their “test, trace, isolate” strategy. however, it is important to understand the epidemiological peculiarities of south korea’s outbreak and characterise their response before attempting to emulate these measures elsewhere. methods: we systematically extracted numbers of suspected cases tested, pcr-confirmed cases, deaths, isolated confirmed cases, and numbers of confirmed cases with an identified epidemiological link from publicly available data. we estimated the time-varying reproduction number, r(t), using an established bayesian framework, and reviewed the package of interventions implemented by south korea using our extracted data, plus published literature and government sources. results: we estimated that after the initial rapid growth in cases, r(t) dropped below one in early april before increasing to a maximum of 1.94 (95%cri, 1.64–2.27) in may following outbreaks in seoul metropolitan region. by mid-june, r(t) was back below one where it remained until the end of our study (july 13th). despite less stringent “lockdown” measures, strong social distancing measures were implemented in high-incidence areas and studies measured a considerable national decrease in movement in late february. testing the capacity was swiftly increased, and protocols were in place to isolate suspected and confirmed cases quickly; however, we could not estimate the delay to isolation using our data. accounting for just 10% of cases, individual case-based contact tracing picked up a relatively minor proportion of total cases, with cluster investigations accounting for 66%. conclusions: whilst early adoption of testing and contact tracing is likely to be important for south korea’s successful outbreak control, other factors including regional implementation of strong social distancing measures likely also contributed. the high volume of testing and the low number of deaths suggest that south korea experienced a small epidemic relative to other countries. caution is needed in attempting to replicate the south korean response in populations with larger more geographically widespread epidemics where finding, testing, and isolating cases that are linked to clusters may be more difficult. coronavirus disease 2019 (covid-19) has become a global pandemic with 18,519,579 cases and 700,539 deaths reported as of august 5, 2020 [1] . one of the first countries to be affected by covid-19 was south korea, where the first confirmed case was reported on january 20, 2020, detected at incheon international airport [2] . prior to february 14th, the majority of the 28 reported cases were imported or were household contacts of imported cases [3] . following identification of the cluster of local transmission amongst members of the shincheonji religious group in daegu linked to the 31st reported case in the country on february 20th, testing was expanded to suspected cases based on the physicians' judgement, including individuals with no travel history [4] . case incidence peaked on february 29th, shortly after daegu and cheongdo were declared "special management regions" and citizens were asked to refrain from leaving their homes for at least 2 weeks [5, 6] (fig. 1a and additional file 1: table s1 ) [4, and has since generally been declining. the decline started approximately 3 weeks before stricter social distancing measures (including stay-at-home recommendations and restriction of non-essential retail) were implemented nationally [7] . as of july 13th, south korea has reported a total of 13,479 cases with 62 new cases on the last day. the pattern of covid-19 deaths in south korea has not followed the same clear epidemic pattern as cases (fig. 1b) , with a total of only 289 deaths up to and including july 13th, distributed throughout the period since february 20th with a peak, by date of the report, of only 9 deaths per day. despite a rapid growth of cases early in the global timescale, south korea has brought the transmission of the causative agent of covid-19 (severe acute respiratory syndrome coronavirus 2 (sars-cov-2)) under control with less stringent national social distancing policies relative to countries such as italy, france, and the uk [36] . this has led to substantial interest in their "test, trace, isolate" strategy, as other countries begin to relax their "lockdowns" and transition to more sustainable packages of interventions. however, it is important to understand the epidemiological peculiarities of the south korea outbreak and characterise their effective response package before trying to apply these measures to other settings. we conducted a quantitative review of south korea's interventions in response to the covid-19 epidemic to draw insights into the different components of the response. we characterised temporal trends in (i) transmission, by estimating the time-varying reproduction number r; (ii) testing capacity; (iii) case origins and how they were identified; and (iv) case isolation. we discuss possible implications for other countries' strategies for lifting stringent social distancing interventions. we systematically reviewed each daily update on covid-19 in south korea published by the korea centers for disease control and prevention (kcdc) for the period from january 20 to july 13, 2020 [37] . using a mixture of manual extraction and automated data scraping scripts written in r software, we extracted the number of suspected cases being tested, pcr-confirmed cases (polymerase chain reaction), deaths and recoveries, and confirmed cases in isolation for each day, forming a time series. where available, we also manually extracted the number of imported cases per day (from march 30th onwards) and the numbers of confirmed cases with an identified epidemiological link and/or origin to assess the efficacy of contact tracing and identification of transmission clusters (from march 25th onwards). when unable to calculate statistics of epidemiological importance such as delays to case-based interventions from our extracted data, we reviewed the published literature to attempt a holistic review of the interventions implemented by south korea. we also utilised announcements by the kcdc, the ministry of health and welfare (mohw), and the ministry of education to identify policy changes to complement our quantitative time series data. we used an approach similar to those previously described [38, 39] to quantify transmissibility over a 7-day sliding window, from the case incidence time series, assuming a certain distribution for the serial interval (the time between symptom onset in a case and symptom onset in their infector). we assumed that transmissibility was constant over that 7-day window and measured it through the reproduction number, r t , defined as the average number of secondary cases infected by an infected individual. our method accounts for imported cases, which would otherwise tend to inflate r t , as previously described [40] , and fig. 1 incidence of confirmed cases by date of the report from daily kcdc press releases with key intervention timings (a) and deaths (b). interventions are separated into border control, testing, isolation and social distancing. sources of interventions: kcdc press releases, ministry of health and welfare, and ministry of education assumes that the daily incidence of locally acquired cases can be approximated by a poisson process using the so-called renewal equation: is the "true" incidence of locally acquired cases on day t, r t is the reproduction number on day t, i t − s is the total (local and imported) number of incident cases arising s days before day t, and w is the probability mass function of the generation time. since the date of infection is rarely known, when estimating r t case, incidence based on the date of symptom onset is often used in place of true incidence and the serial interval in place of the generation time. as onset dates were not available for all cases in our dataset, r t was estimated based on cases by date of the report using data from kcdc using the r software packages epiestim and orderly. all analyses were undertaken with r software (version 3.6.3) [38, [41] [42] [43] . we assumed a gamma-distributed serial interval with mean 6.48 days and standard deviation 3.83 days [44] and uninformative prior distributions on r t (mean 1 and standard deviation 10). to assess the sensitivity of the r t estimates to the assumed prior distribution of r t , we ran our analysis with a range of prior distributions (additional file 1: table s3 ) and found that our conclusions were consistent. epiestim is robust to under-reporting but assumes that this reporting rate remains constant. this was not the case in south korea due to the changes in the case definition and testing criteria, most notably the scaleup in testing to include local transmission from february 20th (fig. 3 ). this causes bias in the r t estimate during the period in which testing processes changed. we truncated the data to conservatively exclude this period of bias following the scale-up in testing and present r t estimates from march 30th onwards to align with the period for which imported case numbers are available. to calculate the rolling 7-day average of cases per test, we first calculated the right-aligned 7-day rolling average of cases and tests separately using the roll_mean function from the r software package rcpproll [45] . we then divided the average number of cases by the average number being tested for each day to obtain an estimate for the average number of cases per test. we chose to calculate the rolling average for the number of people being tested, as testing varied considerably over consecutive days, with no tests conducted some days. we also calculated the rolling average for 3-, 4-, 5-, and 6-day windows, but window size did not impact the general trend. kcdc press releases break down cumulative numbers of cases into imported cases, linked to an imported case, part of shincheonji cluster, part of another cluster, a contact of a confirmed case, or under investigation. we used this to look at the change in the cumulative proportion of cases attributed to different categories over time. as epidemiological investigations develop, there is a bidirectional movement of cases between categories, so it was not possible to create a time series of case incidence by type. instead, we extracted data from the pie chart showing the types of cases over the 2 weeks prior to the date of each press release. this provided us with a 14-day rolling average breakdown of incident cases by type. our estimates of sars-cov-2 transmissibility in south korea vary substantially over time (fig. 2) . we estimated the time-varying reproduction number r t using previously published methods [38] for cases between march 30th and july 13th, since the relative contributions to r t from increased testing and increased transmission cannot be disentangled early on in the epidemic and imported case numbers were not initially available. using a 7-day sliding window and confirmed cases by date of report, we estimated that r t initially dropped below 1 in early april before increasing above one twice during may, first up to a maximum of 1.94 (95% cri, 1.64-2.27) and then again in late may up to 1.56 (95% cri, 1.37-1.79) (fig. 2 ). these increases in estimated r t coincide with the growth of highly localised transmission clusters in the seoul metropolitan region (seoul, incheon city, and gyeonggi province). in early june, r t dropped below 1 again where it remained until the end of our study on july 13th. unlike other countries affected by covid-19, south korea has not implemented a national "lockdown". however, similar measures have been applied in a shortterm localised manner in high-incidence regions such as daegu where residents were asked to refrain from leaving their homes for at least 2 weeks after the large cluster of cases associated with the shincheonji religious group was reported [6] (fig. 1a) . kcdc reported that movement decreased nationally by 38% during february 24th to march 1st as compared to january 9th to 22nd before the first case had been detected in south korea [46, 47] . this decrease in movement is corroborated by park et al. who found that the daily traffic volume decreased by 80% and 50% in daegu and seoul, respectively, following the identification of the shincheonji cluster [47] . schools were closed on february 23rd nationally, and the country transitioned to remote learning until schools reopened gradually between may 20th and june 3rd [12, 14, 31, 48] . on march 22nd, in response to the ongoing emergence of local small clusters, imported cases, and a reported increase in population movement up to 28% below baseline [46] , the korean government implemented a stronger social distancing campaign nationally (fig. 1a) . people were asked to leave their houses only for daily necessities, healthcare, and commuting to work, and many community spaces were closed with the potential for non-compliant facilities to be handed administrative orders [49, 50] . on april 19th, low-contact outdoor facilities and churches could reopen. on may 6th, south korea transitioned again with the intention of establishing long-term routine distancing [34, 51] . the kcdc criteria for sustaining the routine distancing policy include low daily case numbers, low incidence of detecting apparently sporadic cases, and detection of > 80% of new cases in individuals who are already in selfquarantine. these conditions were being met until the increase in cases in the seoul metropolitan region led to the daily threshold being exceeded on may 28th [52] . in response to increased local transmission, enhanced epidemic control measures have been introduced in the region until daily case numbers are back below 10 [13, 53] . high-risk facilities including nightlife venues, karaoke rooms, and pc cafes are subject to gathering bans or limited operation with potential legal action against non-compliance. residents are requested to not attend social gatherings or venues frequented by lots of people. following further transmission in churches, additional infection control guidelines became mandatory on july 10th including instruction not to hold face-to-face meetings outside of regular services, to check symptoms upon entry, and not to partake in singing or food sharing during services [22] . south korea has a population of 51 million [54] . by licencing private companies and clinics to conduct tests early in the epidemic, testing capacity was rapidly expanded from 3000/day on february 7th to 15,000-20,000/day with a fig. 2 estimates of time-varying effective reproductive number r t based on confirmed cases by date of the report and accounting for imported cases. r t is estimated using a sliding window of 7 days and an uninformative prior distribution with mean 1 and standard deviation 10. the black line represents the posterior mean value of r t , and the shaded region shows the 95% credible interval (cri). the dotted horizontal line shows r t = 1 [4] . testing protocol in south korea changed multiple times throughout the outbreak ( fig. 3 and additional file 1: table s1, table s2 ) [35, [55] [56] [57] [58] . initially, only symptomatic individuals with a history of travelling in areas with known infections, or contact with confirmed cases were tested [59] . however, the policy changed on february 20th to include testing of symptomatic individuals based on the physicians' judgement regardless of travel history and to test close contacts of confirmed cases regardless of symptoms if deemed necessary [60] . this coincided with the shincheonji religious group cluster and explosive growth in cases. the average number of positive cases per test increased during this period (fig. 4) . mass testing has also been used in highrisk facilities such as hospitals and care homes in high incidence areas since march 18th. in daegu, a total of 33, 610 high-risk individuals have been tested with 322 testing positive as of april 4th [51] . as case numbers decreased, the average number of cases per test decreased again until the mid-may increase in cases, which resulted in another increase in the average number of cases per test. we are unable to infer the delay from symptom onset to testing from our data set collated from the kcdc daily press releases. a study of the first 28 patients (identified from january 20th to february 10th) estimated the mean delay from symptom onset to diagnosis to be 5.2 days (range 0-16 days) [61] . we did not find data on delays to testing later in the outbreak. a high proportion of cases have been epidemiologically linked throughout the outbreak. case-based contact tracing in south korea can be separated into (i) cluster investigation utilising targeted mass testing of hospitals and communities and (ii) identification and follow-up of individual cases and their contacts (see additional file 1: section 2. contact tracing for more detailed protocol) [30, [62] [63] [64] [65] [66] [67] [68] . clusters now account for 66% of south korea's cumulative cases nationally, while individual casebased contacts account for only 10% (fig. 5a) . the large cluster associated with the shincheonji religious group accounts for 39% of cases nationally. although focused in daegu, the cluster included group members in most regions of the country and made considerable contributions to overall case numbers in gyeongbuk, gyeongnam, gangwon, ulsan, and gwangju (see figure s1 for the regional breakdown of case type by epidemiological link or origin). later in the epidemic, after the march 25th, the shincheonji cluster contributed very few new cases. other smaller clusters make up the further 27% of cases (ranging in size from 2 to 196 people). prior to may 8th, these clusters were mainly in workplaces, hospitals, and churches, with most clusters of > 100 cases occurring in hospitals, where mass testing protocols were in place [69] . the relative contribution of local transmission to new cases steadily decreased until 82% of new cases in the fortnight prior to may 8th were imported; however, the itaewon nightclub cluster [35] brought the relative contribution of local clusters back up to 40% of new cases reported in the fortnight ending on of may 11th (fig. 5b) . since then, the majority of reported cases have been linked to clusters in the seoul metropolitan region, largely associated with entertainment venues, religious events, after school private academies, and a string of door-to-door promotional events [13, 53] . the contribution of local transmission clusters to overall fortnightly case incidence reached a peak of 75% in june before beginning to decline back down to around 50% at the end of the study period (fig. 5b) . isolation of cases and self-quarantine of contacts has been a consistent feature of the south korean response. as of july 13, there were 986 confirmed cases currently isolated (fig. 6) . although we were unable to identify accessible data sources that reported the number of contacts isolated over the course of the outbreak, media outlets reported that approximately 30,000 people were in self-quarantine on march 6th [70] , 27,000 on april 2nd [71] , and 46,000 on april 7th [72] . in addition, a study of contact tracing in south korea between january 20th and march 27th found that for the 5706 index cases with at least one contact, 59,036 contacts were identified (who according to kcdc policy would have been required to self-quarantine) [73] . based on the severity and risk factors, confirmed cases were either isolated in a hospital, at home, or in a residential treatment centre (rtc). cases were isolated in a hospital in their own rooms or grouped with patients with the same clinical characteristics when ventilation and structural barriers between patients were available. cases were isolated in rtcs when symptoms were too severe for home isolation, but did not require hospitalisation, when home isolation was not possible because no individual room was available or because they live with a highrisk person [66] . medical staff in rtcs and public health managers (for home isolation) monitored and recorded the patient's symptoms twice per day, transferring them to medical facilities if necessary. close contacts of confirmed cases were asked to selfquarantine for 14 days and monitored daily. we were unable to estimate the delay to isolation of a confirmed case from the kcdc press release data. another study, which fitted gamma distributions to case data of 211 confirmed cases, estimated the mean delay from symptom onset to isolation of cases as 4.3 days, before the red alert warning on february 23rd and 3.3 days after [74] . the same study estimated the mean delay from exposure to isolation as 7.2 days before the red alert and 6.5 days after. confirmed cases were required to test negative twice in 24 h before release from isolation [66] . close contacts fig. 4 rolling 7-day average of the confirmed cases per number of people tested until july 13, 2020. the dashed vertical line indicates the date on which south korea changed its testing protocol from testing suspected cases with contact with a case or travel history to a country with infections to testing all suspected cases (february 20). source: kcdc press releases with no symptoms in the 14 days following contact were released from home quarantine. if close contacts were health care workers or caregivers, they were released pending a negative at the end of the quarantine period. this analysis of south korea's response to covid-19 highlights how, despite a sharp growth in cases early in the pandemic, transmission was rapidly controlled, resulting in a relatively small epidemic made up of large linked clusters. the shincheonji religious group cluster accounted for 39% of all cases. we estimate r t to have been brought below one in april, and although estimates rose above one during may and early june, this reflected transmissibility within highly localised clusters rather than widespread national transmission. as of july 13th, 13,479 cases and 289 deaths have been reported since the first case on january 20th [2] . the rapid expansion of test capacity, early localised strengthening of social distancing measures in daegu, voluntary reduction in movement prior to the mandated enhanced national social distancing campaign, and continued case-based contact tracing across the large clusters in seoul metropolitan fig. 5 a cumulative proportion of confirmed cases by epidemiological link and/or origin from march 25 to july 13. the proportion of cumulative confirmed cases that are linked to existing cases or imported (white line) as opposed to "under investigation" (which includes apparent sporadic cases). linked cases are broken down into whether they are connected to an imported case, part of the shincheonji cluster, a smaller cluster or a non-cluster contact of a confirmed case. b non-cumulative proportion of new cases reported during the 2 weeks prior to the date on the x-axis, by type of case. source: kcdc press releases region have all likely contributed to help contain south korea's epidemic. south korea has not implemented a national lockdown. instead, the comprehensive approach ranges from case-based testing and isolation, investigation of large clusters of confirmed cases, and short, targeted strong social distancing measures in the most heavily affected regions. early identification and management of cases, clusters, and contacts have been a key strategy of the south korea response. combined with the expanded testing capacity, the use of mass testing in high-risk facilities and clusters has allowed the majority of new cases to be traced back to existing clusters (fig. 5) , such as the shincheonji religious group, a call centre in seoul, healthcare institutions in daegu, and the itaewon nightclubs. there are several limitations to this analysis. south korea's response was characterised by multiple measures including rapid large-scale testing and social distancing measures, and we did not find enough evidence to attribute the success in controlling the covid-19 outbreak to one particular aspect of their response. although it is possible to attribute changes in transmission to specific policies for a single population, it is often difficult to identify the effect of a single intervention because many are in force at the same time. therefore, we chose not to attempt such inference here, leaving multi-population estimates of intervention efficacy to future work, similar to that of flaxman et al. [75] . when estimating r t , we assumed constant reporting, which does not hold for the south korea dataset. the testing protocol changed considerably on february 20th, and a number of imported cases were only available from march 30th onwards meaning we could only estimate r t reliably between march 30th and july 13th. during this period, we assumed testing efforts to be constant; however, there were smaller protocol changes ( fig. 3 and additional file 1, table s1 ). these changes largely pertained to the expansion of testing of travellers, except for may 25th when south korea began mass testing of individuals who visited public venues visited by confirmed covid-19 cases. mass testing had been part of cluster investigations previously, but this change may have impacted our estimates of r t . in the absence of symptom onset data, we used the date of the report as a proxy for incidence, meaning our estimates of r t are subject to a lag from incubation period and delay from symptom onset to report. estimated dates of symptom onset would improve the accuracy of r t estimates for south korea. a dynamic transmission model could help disentangle the relative contribution of different measures and account for changes in reporting. through a nonsystematic review of the published literature and a systematic review of governmental sources (kcdc), we were able to identify important data gaps. the nationallevel dataset we collated did not contain information on how many contacts each individual case had (and the proportion who tested positive), although data on the total number of contacts per confirmed case were available for some municipalities [76, 77] . furthermore, we could not estimate a delay from confirmation of test result to the isolation of cases or their contacts from our dataset. there is a need for reliable up-to-date information on the number of contacts isolated at any one time. finally, it was unclear whether the number of suspected cases being tested each day includes individuals tested more than once, and testing of asymptomatic close contacts who would not fit within the formal definition of a suspected case. like other countries looking at exiting their lockdowns, the long-term strategy in south korea involves a mix of social distancing policies, behavioural interventions, and testing. south korea moved to a phase of partially relaxed social distancing on may 6th [34] . this included allowing activities in low-risk venues (e.g. recreation parks, forests, closed-door sporting events) while maintaining partial restrictions on the use of highrisk facilities (e.g. religious facilities, fitness venues) and non-essential public gatherings which are all subject to strict infection prevention and control guidelines [33] . additionally, schools reopened in late may and a growing number of companies have eased their "smart-working" policies [12, 14, 48] . consultations between government, industry, and community-based bodies have been conducted to increase preparedness, reduce conflicts, and maximise uptake of long-term "every day" social distancing [78] . it is important to emphasise some key aspects particular to the outbreak in south korea, which are relevant when attempting to apply lessons to other settings. the number of sars-cov-2 infections in south korea has been far smaller than the usa or most european countries. over two thirds of cases were linked to a few major clusters, which were promptly identified and tested en masse. south korea has implemented effective strategies for detecting and quarantining imported cases, reducing the risk of secondary transmission. all these measures have contributed to the outbreak remaining geographically localised. however, cluster-based management will be more difficult in settings with much more widespread transmission. finally, the south korean response was facilitated by structures and processes such as additional legal powers for quarantine, surveillance systems, and digital technologies introduced after the 2015 middle east respiratory syndrome (mers) outbreak [79] which may be lacking in other countries. these key aspects may limit the extent to which the testing and contact tracing strategies adopted by south korea can be translated to other settings. south korea has avoided a large covid-19 epidemic and has retained the ability to maintain case-based or cluster-based interventions. individual case-based contact tracing is a relatively minor aspect of their control program, with cluster investigations accounting for two thirds of cases identified. while early adoption of testing and contact tracing are important factors for south korea's successful outbreak control, rapid implementation of localised strong social distancing measures in areas with high transmission, border control, and careful monitoring of high-risk contacts are likely to have substantially reduced transmission. at present, it is not possible to estimate the extent to which each measure has contributed to low case counts in south korea. some caution is advised in attempting to duplicate their response in other settings with more widespread transmission and higher case numbers. supplementary information accompanies this paper at https://doi.org/10. 1186/s12916-020-01791-8. additional file 1 : table s1 . a detailed timeline of key events and policy changes throughout the covid-19 outbreak in south korea. table s2 . most recent case definitions for suspected cases and patients under investigation for covid-19 infection (source: mohw, last updated june 25th). section 2. contact tracing of individualsdetailed protocol for contact tracing in south korea. figure s1 . a regional breakdown of the change in epidemiological links of confirmed cases over time. table s3 . the prior means and standard deviations explored in our sensitivity analysis of the r t estimates. european centre for disease prevention and control. covid-19 situation update worldwide the first 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smartphone app | mit technology review the latest: south korea says over 27,000 selfquarantined -wtmj more than 46,000 people are in self-quarantine in south korea contact tracing during coronavirus disease outbreak, south korea reduction in time delay of isolation in covid-19 cases in south korea 2 3. medrxiv estimating the effects of non-pharmaceutical interventions on covid-19 in europe corona 19 gwangju metropolitan city korean ministry of health and welfare. regular briefing of central disaster and safety countermeasure headquarters on covid-19 preliminary epidemiological assessment of mers-cov outbreak in south korea not applicable authors' contributions ad, lc, gcd, js, ni, nmf, and sr conceived the study. ad, lc, gcd, js, and ni collected and extracted the data and information on the testing strategies. ad, lc, gcd, and js carried out the analysis. sb and kamg assisted in the coding and analysis. ad, lc, gcd, js, ni, and sr wrote the first draft of the manuscript with input from nmf. all authors contributed to, read, and approved the final draft.funding acg, nmf, id, ad, and js acknowledge the support from the wellcome trust. we acknowledge the joint centre funding from the uk medical research council and the department for international development, grant reference: mr/r015600/1. this work is also supported by the national institute for health research health protection research unit in modelling methodology, the abdul latif jameel foundation, and the edctp2 programme supported by the european union. the funders played no role in the design of the study and collection, analysis, and interpretation of the data or in writing the manuscript. the data used in this analysis were collated from publicly available kcdc press releases and are made available in a public github repository (https:// github.com/mrc-ide/covid19_south_korea_report) and assigned a permanent doi on zenodo (https://doi.org/10.5281/zenodo.3978101). in the eventuality that the original links become unstable or cannot be opened by the reader, pdf versions of the kcdc press releases and other governmental webpages referenced in our manuscript have also been uploaded to the repository and can be found using the aforementioned doi.ethics approval and consent to participate not applicable. secondary analysis of published, publicly available data. not applicable. secondary analysis of published, publicly available data. the authors declare that they have no competing interests. springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord-299573-vq6ckqtd authors: lee, meong-hun; jeoung, hye-young; park, hye-ran; lim, ji-ae; song, jae-young; an, dong-jun title: phylogenetic analysis of porcine astrovirus in domestic pigs and wild boars in south korea date: 2012-09-11 journal: virus genes doi: 10.1007/s11262-012-0816-8 sha: doc_id: 299573 cord_uid: vq6ckqtd porcine astrovirus (pastv) belongs to genetically divergent lineages within the genus mamastrovirus. in this study, 25/129 (19.4 %) domestic pig and 1/146 (0.7 %) wild boar fecal samples tested in south korea were positive for pastv. positive samples were mainly from pigs under 6 weeks old. bayesian inference (bi) tree analysis for rna-dependent rna polymerase (rdrp) and capsid (orf2) gene sequences, including mamastrovirus and avastrovirus, revealed a relatively geographically divergent lineage. the pastvs of hungary and america belong to lineage pastv 4; those of japan belong to pastv 1; and those of canada belong to pastv 1, 2, 3, and 5, but not to 4. this study revealed that the pastvs of korea belong predominantly to lineage pastv 4 and secondarily to pastv 2. it was also observed that pastv infections are widespread in south korea regardless of the disease state in domestic pigs and in wild boars as well. their association with enteric diseases is not well documented, with the exception of turkey and mink astrovirus infections [2] . family astroviridae is separated into two genera. viruses of the genus mamastrovirus infect mammals, and those of avastrovirus infect avian [3] . avastroviruses include duck astrovirus 1 (dastv-1), turkey astrovirus 1 and 2 (tastv-1 and tastv-2), and avian nephritis virus (anv) [2] . mamastroviruses appear to have a broad host range, including human [1] , sheep [4] , cow [5] , pig [6] , dog [7] , cat [8] , red deer [9] , mouse [10] , mink [11] , bat [12] , cheetah [13] , brown rat [14] , roe deer [15] , sea lion and dolphin [16] , and rabbit [17] . porcine astrovirus (pastv) was first detected by em in the feces of a diarrheic piglet [6] and was later isolated in culture [18] . molecular characterization of the capsid (orf2) gene from this isolate followed some years later [19] . since then, research groups have successfully used pcr approaches to investigate the presence and diversity of pastv [20] [21] [22] . pastv has been detected in several countries, including south africa [23] , the czech republic [20] , hungary [22] , canada [21] , and colombia [24] . in south korea, there have been studies done on astrovirus but were only limited to its detection in human infection. there has been no attempt yet to know the extent of astrovirus infection in the pig population of the country. it was, therefore, the aim of this study to investigate the genetic groups of korean pastv in domestic pigs and wild boars and to identify the incidence of co-infection with other porcine enteric viruses as well. a total of 129 fecal samples of domestic pigs (60 piglets under 3 weeks old, 45 weaned pigs, 14 growing-finishing pigs, and 10 sows over 1 year old) was collected from six piggery farms with good breeding facilities in four provinces of south korea from january to june 2011. out of these collected samples 90 were from diarrheic and 39 were from non-diarrheic pigs. a total of 146 fecal samples of wild boars over 1 year old was collected from the wildlife areas in five provinces of south korea during the hunting season from december 2010 to january 2011. out of these collected samples 34 were from diarrheic and 112 were from non-diarrheic boars. viral rna was extracted from the feces using trizol ls b according to the manufacturer's instructions. pastv was detected in fecal specimens by rt-pcr, as previously described [22] , with primers specific for the rdrp and orf2 regions of pastv (pastv-f, 5 0 -tgacatttt gtggatttacagtt-3 0 and pastv-r: 5 0 -cacccagg gctgacca-3 0 ). the rt-pcr process resulted in the amplification of a 799-nt-long fragment at an annealing temperature of 45°c. products of the expected size were cloned with the pgem-t vector system ii tm (promega, cat. no. a3610, usa). the cloned gene was sequenced with t7 and sp6 sequencing primers on an abi prism ò 3730xi dna sequencer (applied biosystems, foster city, ca, usa) at the macrogen institute (macrogen, seoul, korea). the sequences of all the positive samples for pastv were submitted to genbank under accession numbers jq696831-jq696856. the astroviruses used in this study are listed in table 1 along with their genbank accession numbers. to investigate the relationship between astroviruses and other economically important viral diseases that cause diarrhea in piglets in asia, screening tests were conducted to detect porcine epidemic diarrhea virus (pedv), transmissible gastroenteritis virus (tgev), and porcine group a rotavirus (gar), as previously described [25] . the primer pairs used in this study were p1 (ttctga gtca cgaacagcca, 1466-1485) and p2 (catatg cagcctgctctgaa, 2097-2116) for the s gene of pedv, t1 (gtggttttggtyrtaaatgc, [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] [33] [34] [35] and t2 (cactaaccaacgtggarcta, 855-874) for the s gene of tgev, and rot3 (aaagatgctagggacaaa attg, 57-78) and rot5 (ttcagattgt ggagcta ttcca, 344-365) for the segment 6 region of group a rotavirus. the sizes of the expected products of multiplex rt-pcr were 859 bp for tgev, 651 bp for pedv, and 309 bp for rotavirus, which could be differentiated by agarose gel electrophoresis. out of the 129 domestic pig fecal samples tested, 25 were positive for pastv. prevalence of pastv in weaned pigs (35.6 %, 16/45) was higher than that in suckling piglets (15.0 %, 9/60) and in growing-finishing pigs (9.1 %, 1/14) ( table 2 ). only one wild boar which is coming from the province of gyunggi tested positive for pastv (0.7 %, 1/146). the low prevalence of pastv in wild boars might have been due to the fact that usually older animals (over 1 year old) have lesser susceptibility to infection and generally wild pigs are more resistant to many diseases than the domesticated ones. the percentage of samples that were pastv-positive differed among the six pig farms: chungchong a, 28.6 % (10/35); chungchong b, 22.9 % (8/35); kangwon, 20.0 % (4/20); gyunggi a, 7.1 % (1/14); gyunggi b, 20.0 % (3/15), and gyungsang, 0 % (0/10). the low or no incidence of pastv in gyunggi a (growing-finishing pigs) and gyungsang (sows) can likewise be attributed to the lesser susceptibility of adult pigs to infection. the proportion of non-diarrheic and diarrheic pig fecal samples was 14.0 % (18/129) and 6.2 % (8/129), respectively. these results suggest that pastv is widespread in south korea regardless of the disease status (with or without clinical manifestations) of pigs. although astroviruses are highly prevalent in young pigs and are mostly present in diarrheic pigs, pastv is a common finding as well in the fecal samples of apparently healthy pigs [21, 22] . the clinical significance of pastv infection remains to be clarified. the clinical symptoms of diarrhea are frequently reported to be associated with rotavirus, coronavirus, and calicivirus-like infections in piglets [6, 18, 20, 21, 26] . although pedv and tgev infections were not identified in any of the fecal samples, porcine gar infection was identified in 6.2 % (17/275) of the samples collected from suckling pigs under 3 weeks old (table 2) . furthermore, coinfection with pastv and gar was observed in two cases (one in diarrheic and one in non-diarrheic pig fecal samples). however, it is not cleared yet if gar is directly associated with astrovirus infection in pigs. all astrovirus sequences were aligned initially with the clustalx 1.8 program [27] . the nucleotide sequences were translated and the nucleotide and amino acid sequence identities among the astrovirus strains were calculated with bioedit 7.053 [28] . bayesian trees were generated with mrbayes 3.1.2 [29, 30] using best-fit models which were selected with prottest 1.4 [31] for amino acid alignment. markov chain monte carlo (mcmc) analyses were run with 1,000,000 generations for each amino acid sequence. bayesian posterior probabilities by mrbayes 3.1.2 were estimated on the basis of a 70 % majority rule consensus of the trees. for each analysis, a chicken astrovirus (nc_003790) was specified as the outgroup and a graphic output was produced with treeview 1.6.1 [32] . the best modelssof the rdrp and orf2 amino acid sequences were obtained using protest 1.4, which showed wag ? i ? g and wag ? g ? f, respectively, according to the results of the akaike information criterion (aic). bi trees for the rdrp (fig. 1) and orf2 (fig. 2 ) amino acid sequences revealed the presence of five unrelated pastv lineages. the first lineage (pastv 1) contained the poastv12-3 strain (hm756258) from canadian pig and two porcine strains (y15938 and ab037272) derived from japanese pigs, interestingly, rat astrovirus (hm450382) and porcine poastv cc12 (jn088537) have formed two different lineages on the bayesian trees for the rdrp and orf2 amino acid sequences (figs. 1, 2) . astrovirus strains contained in group 1 (g1), 2 (g2), and 4 (g4) on the two bayesian trees showed similar topologies. however, astrovirus strains in group 3 (g3) on the bayesian tree for the orf2 amino acid sequence were divided into g3 and group 5 (g5) on the bayesian tree for the rdrp amino acid sequence (figs. 1, 2) . a strain isolated from a hungarian wild boar in 2011 [33] belonged to pastv 4 or group 4 (g4) that also contained pastk31 derived from korean wild boar. a previous study suggested that the number of pastv lineages extends to a total of five, all of which most likely represent distinct species of different origins [34] . however, with the available astvs research data from countries around the world, future studies could unveil diverse genetic lineages. in this study, the porcine astrovirus strains appeared to be phylogenetically related to not only prototypical human astroviruses (as was already known) but also the recently discovered novel human strains. this finding suggests the existence of multiple cross-species transmission events between the hosts and the other animal species. several recent studies have shown that bats form multiple independent lineages [35, 36] . bat astrovirus strains in this study also showed independent lineages and specifically, the ld71 (fj571067) strain had a close relationship with astrovirus strains of human, sheep, mink, and sea lion (figs. 1, 2) . a previous study suggested that porcine astvs have played an active role in pigs in the evolution and ecology of the astroviridae [21] . recent studies have shown evidence of multiple recombination events between distinct pastv strains and between pastv and human astrovirus (hastv) in the variable region of orf2 [24] , as well as interspecies recombination between porcine and deer astroviruses [37] . a study of the molecular epidemiology and genetic diversity of human astrovirus in south korea from 2002 to 2007 revealed genotype 1 to be the most prevalent, accounting for 72.19 % of strains, followed by genotypes 8 korean pastvs are shown in bold prints, and strains isolates from korean and hungarian wild boar are marked with a star and an arrow, respectively. the numbers above the nodes represent posterior probabilities (9.63 %), 6 (6.95 %), 4 (6.42 %), 2 (3.21 %), and 3 (1.6 %) [38] . this finding suggests that little interspecies (between human and pig) transmission has occurred until now in south korea. in conclusion, this study extends current knowledge of pastv in wild boar and domestic pig. a more extensive study should be done on wild life pastvs to further elucidate their potential role in the epidemiological landscape of the astrovirus infection in domestic pig population. to a greater length, continuous surveillance on the prevalence of both pastvs will provide a wider understanding of the possible cross-species or human transmissions, in particular. virus taxonomy. eighth report of the international committee on taxonomy of viruses acknowledgments we are grateful to mr. min-heg lim and ms. sa-ra choi for technical assistance. key: cord-252843-vd81pftu authors: doherty, tanya; kroon, max; reynolds, louis; fawcus, sue; lake, lori; solanki, geetesh title: building back from the ground up: the vital role of communities date: 2020-10-07 journal: bmj glob health doi: 10.1136/bmjgh-2020-003928 sha: doc_id: 252843 cord_uid: vd81pftu nan globally the covid-19 pandemic has destabilised health systems and communities. governments in low-and middle-income countries (lmics) followed the approaches adopted by the global north and advocated by international bodies such as the who, and instituted varying degrees of nationwide stay at home orders (lockdowns) from strict restrictions (such as in south africa, india and zimbabwe) to weakly enforced lockdown as in brazil. 1 many have questioned the appropriateness of these measures in lmic contexts 2 where key preventive behaviours such as social distancing and frequent hand washing are impossible to implement in densely populated informal housing settlements. people rely on crowded public transport to get to work, households are cramped and lack easy access to water and sanitation; loss of income leads to food insecurity and hunger as well as high levels of stress and violence. in such conditions viral spread is impossible to control and economic devastation is inevitable. in this commentary we examine (1) some of the unintended impacts of this approach for lmics and (2) the steps that need to be taken in the short-term and longer-term to mitigate these impacts and the vital role of civil society and communities in this recovery process. the response from lmic governments to contain the covid-19 pandemic aimed primarily to limit virus spread. the unintended consequences of the instituted measures are wide reaching. unicef reports from the early months of the covid-19 pandemic suggest a 30% reduction in the coverage of essential nutrition services in lmics and declines of 75% to 100% under lockdown contexts. 3 a preliminary assessment by the un food and agricultural organization suggests the pandemic may add between 83 and 132 million people globally to the total number of undernourished in 2020 as a result of loss of income and livelihoods. 4 in terms of health service access, a who survey reported that 55% of essential health services were at least partially disrupted in the african region in response to the pandemic. family planning services were disrupted in 68% of countries, 53% of countries reported partial disruptions in antenatal care services and 32% in facility-based birth services. 5 despite who and country guidance to the contrary, mother-newborn separation has occurred in many lmics. research from nepal has described a 3.5% decline in breast feeding within 1 hour of birth during lockdown, from an already low rate of 46%. 6 disruption or suspension of outreach immunisation services was reported by 86% of countries in the african region and disruption of immunisation services at health facilities for 44% of countries. 7 lockdowns exacerbated the silent pandemic of gender-based and intimate partner violence in countries with already high levels. research undertaken during the lockdown in bangladesh found significantly increased summary box ► the medicalised response to covid-19 in low-and middle-income countries has had unintended and far-reaching consequences. ► communities, non-governmental organisations and civil society organised themselves from the 'groundup' to alleviate the economic, social and health impacts of covid-19. ► urgent intersectoral mitigation strategies required for covid-19 recovery will not be fulfilled through state services alone. ► investing in community cadres and organisations has the potential to build social solidarity, mitigate the impact of covid-19 and strengthen intersectoral collaboration and safety nets for future crises. bmj global health levels of emotional, physical and sexual violence among women living with their husbands. 8 in south africa, data collected from the government gender-based violence and femicide command centre revealed more than 120 000 victims in the first 3 weeks of lockdown. 9 as a result of these unintended impacts, there is a high probability that covid-19 will deliver us into the next set of crises in the form of increasing inequality, poverty and food insecurity, outbreaks of vaccine preventable diseases, unintended pregnancies and rising child malnutrition which will be felt for generations to come. while lmic governments have focussed almost exclusively on reducing covid-19 case numbers, many communities organised themselves with 'ground-up' mitigation measures to address the worsening unintended effects. examples have emerged from many lmics of neighbourhood initiatives to support vulnerable families. in india, the health focussed non-governmental organisation (ngo) swasti brought together a group of ngos to found the covid-19 action collaborative. its 150 member organisations are now coordinating efforts and sharing knowledge to provide integrated health, nutrition, social protection, livelihood and financing support to over 2 million vulnerable people across 15 states. 10 women's empowerment groups in kerala helped to map where older people live to ensure they had access to medicine and food while social distancing. 11 in south africa, a movement of self-organising, neighbourhoodlevel community action networks (cans) has contributed significantly to the community-based response to covid-19. without any financial support from the government these cans have initiated community support activities such as establishing community kitchens, developing communication materials, distributing clothing and skills upliftment training. 12 concerted civil mobilisation also led to a court case 13 brought by civil society organisations breast feeding potential for declines due to mother-infant separation and health worker fears of covid-19 transmission. rapidly disseminate strong messages through community-based organisations and chws about the importance of breast feeding in the context of covid-19, and the harmful consequences of separating mothers and newborns. declines in routine immunisation due to health service disruptions, reallocation of staff to covid-19 and fears of mothers to attend health facilities. visits by chws to all households with children under 5 years of age to check immunisation status. catch up immunisation campaigns in schools and early child development centres. chronic medication disruptions to chronic medication distribution leading to gaps in adherence. establish community distribution points chws supporting medication distribution to households with elderly or ill. weak community platform with too few chws to augment public sector response to crises chws re-assigned to covid-19 unable to perform their usual household visits and functions. strengthen community delivery platforms with increased numbers of chws. high coverage of households to undertake detailed assessments of covid-19 recovery needs. civil society actions to support covid-19 were implemented in parallel to government actions with little/no co-ordination or community consultation on the appropriateness of government solutions. policy mandated forums for community consultation and accountability mechanisms to ensure feedback and progress tracking. prioritisation of domestic spending covid-19 stimulus packages risk deepening inequity by prioritising large companies and leaving behind small business and community enterprises. embark on a transparent, participatory prioritisation process to inform the allocation of covid-19 stimulus funding with a focus on growing 'township' economies. chws, community health workers. and school governing bodies to have the national school nutrition programme which provides a daily meal to roughly nine million children, reinstated 4 months after school closures. the intense lockdown periods and burden of covid-19-related illness have revealed the inadequacies of strained, under-resourced public health facilities, and in some instances inept lmic governments' responses to crises; and the critical role of resilient, mobilised community structures. the urgent intersectoral mitigation strategies required for covid-19 recovery will not be fulfilled through state services alone. the efforts already being led by ngos and civil society need to be supported and harnessed, both to develop context-specific solutions and to implement them. several areas will require short-term and long-term mitigation measures implemented through strong primary healthcare systems and community participation. some specific illustrative examples are given in table 1. an important community cadre that has the potential to play a critical role in mitigation strategies in lmics are community health workers (chws). chws have been at the forefront of efforts to screen and trace individuals as part of the covid-19 response in many lmics including south africa, 14 india 15 and brazil. 16 however, this additional work has meant neglect of their usual functions of providing health promotion, prevention and care to vulnerable families. long-term covid-19 mitigation strategies should prioritise increasing the number of chws to ensure an optimal ratio of workers to households to cope with the more intensive covid-19 recovery period. through home visits chws can assess and identify household needs such as catch up immunisation, family planning, antenatal care, growth monitoring, birth registration, hiv, tuberculosis and chronic disease management and mental health. increasing the numbers of female chws serves not only to improve coverage of care for households and thus a return on investment due to a healthier population, but there are other important societal benefits. modelling based on the south african situation estimated that increasing the number of chws to 96 000 (from 60 000) and paying the minimum wage would cumulatively, over 3 years, contribute an additional r13.6 billion (south african rand) to the economy (equivalent to 0.3% of gdp (gross domestic product)) given that the employed women would spend this salary primarily on the health, education and nutrition of their children thus also benefitting their local community economies. 17 appropriately funded community cadres and organisations have the potential to build social solidarity that would enable a more rapid intersectoral response for future crises. the recovery process and accompanying investments (domestic or multilateral) are an opportunity to embark on open and transparent prioritisation processes to determine how best to use resources with a pro-equity focus. given the enormous constraints facing lmic governments in the covid-19 aftermath, it is only through the active participation of communities and civil society in designing and implementing solutions, that lasting sustainable societal improvements will be realised. the challenges highlighted by the covid-19 epidemic in lmics are in many respects an acute manifestation of long-standing chronic problems and the recovery phase should address them. the resource constraints faced by governments in lmics (sometimes compounded by inappropriate decision-making and undermined by corrupt disbursement of covid-19 funding) and the generally weak public healthcare systems of these countries means that they cannot be solely relied on to address such crises. the covid-19 experience has further demonstrated the contributions communities and civil society can make and the critical need to incorporate them into efforts to mitigate the health, social and economic effects of covid-19. this is the only way to move towards sustainable positive change that better builds resilience for the inevitable future crises. covid-19 in brazil an appeal for practical social justice in the covid-19 global response in low-income and middleincome countries situation tracking for covid-19 socioeconomic impacts food and agricultural organization of the united nations. the state of food security and nutrition in the world pulse survey on continuity of essential health services during the covid-19 pandemic effect of the covid-19 pandemic response on intrapartum care, stillbirth, and neonatal mortality outcomes in nepal: a prospective observational study immediate impact of stayat-home orders to control covid-19 transmission on socioeconomic conditions, food insecurity, mental health, and intimate partner violence in bangladeshi women and their families: an interrupted time series shocking stats on gender-based violence during lockdown revealed sowetan live philanthropy's distinct role in india's covid-19 response.devex covid-19 care in india: the course to self-reliance what is covid-19 teaching us about community health systems? a reflection from a rapid community-led mutual aid response in cape town, south africa judgement in the matter between equal education, the school governing body of vhulaudzi secondary school, the school governing body of mashao high school and the minister of basic education. high court of south africa community-based screening and testing for coronavirus in cape town, south africa: short report india's first line of defense against the coronavirus is an army of 900,000 women without masks or hand sanitizer buzfeed news community health workers reveal covid-19 disaster in brazil saving lives, saving costs: investment case for community health workers in south africa. cape town: south african medical research council key: cord-299631-snaslr0r authors: clements, hayley s.; biggs, reinette; cumming, graeme s. title: cross-scale and social-ecological changes constitute main threats to private land conservation in south africa date: 2020-11-15 journal: j environ manage doi: 10.1016/j.jenvman.2020.111235 sha: doc_id: 299631 cord_uid: snaslr0r conserving biodiversity in the long term will depend in part on the capacity of protected areas (pas) to cope with cross-scale, social-ecological disturbances and changes, which are becoming more frequent in a highly connected world. direct threats to biodiversity within pas and their interactions with broader-scale threats are both likely to vary with pa spatial and management characteristics (e.g., location, dependence on ecotourism revenues, governmental support). private land conservation areas (plcas) are interesting case study systems for assessing cross-scale threats to pas and their determinants. despite the growing number of plcas around the world, there is considerable uncertainty regarding the long-term capacity of these privately owned areas to conserve biodiversity. their potential impermanence is commonly raised as a key concern. to better understand the threats to which different types of plcas are likely to be vulnerable, we asked 112 plca landholders in south africa what they perceived as the top threats to their plcas. landowners identified direct threats to the biodiversity within their plcas (e.g., poaching, extreme weather, inappropriate fire regimes, alien species) as well as describing broader socio-economic threats (e.g., regional crime, national legislation and politics, global economic recessions), which were noted to interact across scales. we found support for the hypothesis that patterns in the perceived multi-scale threats to a plca correspond with its management and spatial characteristics, including its remoteness, dependence on ecotourism or hunting revenues, and richness of megafaunal species. understanding the threats to which different plcas may be vulnerable is useful for developing more nuanced, targeted strategies to build plca resilience to these threats (for example, by strengthening the capacity of self-funded plcas to cope with the threat of economic downturns through more innovative financial instruments or diversified revenue streams). our findings highlight the importance of considering interactions between broad-scale socio-economic changes and direct threats to biodiversity, which can influence the resilience of pas in ways that are not anticipated by more traditional, discipline-specific consideration of direct threats to the biodiversity within their boundaries. it is increasingly recognized that protected areas (pas) are socialecological systems, interacting with biological, social, economic, cultural and political contexts from local to global scales (cumming and allen, 2017; palomo et al., 2014; pollnac et al., 2010) . fulfilling their key role of conserving biodiversity in the long term will depend on the capacity of pas to cope with cross-scale, social-ecological disturbances and changes, which are becoming more frequent in a highly connected world (biggs et al., 2011; rocha et al., 2018) . the social-ecological resilience of a pa is its capacity to conserve biodiversity amidst disturbance and change (cumming et al., 2015; folke et al., 2016) . building pa resilience requires careful consideration of (1) the direct threats to biodiversity and the broader-scale changes that cause, magnify or interact with those threats; and (2) the factors that influence a pa's vulnerability to these threats and its ability to adapt and respond to them (cumming et al., 2015; jones et al., 2013; newton, 2011; strickland-munro et al., 2010) . a recent global assessment found that unsustainable hunting, natural system modifications from fire or its suppression, and disturbance from recreational activities were the most commonly reported direct threats to biodiversity within statutory pas (schulze et al., 2018) . patterns in the number and type of direct threats to biodiversity tend to correspond with pa spatial characteristics such as remoteness and size (e.g., more remote, hillier and larger pas are exposed to fewer threats) and location (e.g., pas in countries with lower human development scores may experience more threats; poaching is a greater threat in developing countries) (bowker et al., 2017; maiorano et al., 2008; schulze et al., 2018; tranquilli et al., 2014) . anthropogenic climate change, however, threatens even the most remote pas. for example, atolls in the remote chagos islands marine pa recently experienced coral bleaching due to high seawater temperatures (head et al., 2019) . depending on the management strategy that has been adopted in a pa, its capacity to protect biodiversity from direct threats and persist as a land use may be undermined by a range of broader-scale disturbances, such as local or global economic downturns that influence income streams from tourism, governments, or private donors; political whims; or opposition from local communities (cumming et al., 2015; jones et al., 2013; palomo et al., 2014) . understanding the relationship between the management of a pa and its vulnerability to multi-scale, social-ecological threats is therefore important for achieving the long-term goal of biodiversity conservation. private land conservation areas (plcas) provide an underresearched case study for understanding the vulnerability of pas to multi-scale, social-ecological threats. plcas are defined as areas that are managed for biodiversity conservation, and owned or otherwise secured by individuals, corporations or nongovernment organizations (pasquini et al., 2010) . the past several decades have seen considerable growth in the number of plcas, with 25 countries now reporting plcas in the world database on protected areas (bingham et al., 2017; stolton et al., 2014) . plcas have been shown to complement statutory pas in australia, brazil, peru and south africa by conserving threatened plant and vertebrate species, and improving landscape connectivity (archibald et al., 2020; clements et al., 2019; pegas and castley, 2016; shanee et al., 2017) . they can also contribute to regional and national economies through nature-and wildlife-based enterprises that create jobs, attract tourists to a region, and provide diverse ecosystem services (clements and cumming, 2017; langholz and lassoie, 2001; pegas and castley, 2014) . despite growing recognition of their important role in biodiversity conservation, considerable uncertainty exists about the resilience of plcas to a changing world (cortés capano et al., 2019; langholz and lassoie, 2001) . uncertainty regarding permanence is a common cause of private land being omitted from international conservation reporting mechanisms and excluded from national conservation strategies (stolton et al., 2014) . plcas have been shown to be more at risk than statutory pas to contract releases (hardy et al., 2017) , degazettement and human modification (fouch et al., 2019) . we currently lack a detailed answer to the 'resilience to what?' (carpenter et al., 2001; helfgott, 2018) question for plcas, and this limits our ability to understand and build their resilience. there is therefore a need to better understand the threats to plcas, and what influences their vulnerability to these threats. measurement of threats in social-ecological systems has several different but closely inter-related dimensions: (1) possible threats; (2) actual threats; and (3) perceived threats. addressing the first requires assembling an exhaustive list from which threats would need to be ranked; the second requires long-term data; and the third can be measured through interviews with people in the system. perceived threats are likely to correspond to experienced threats, but not inevitably. in terms of understanding management actions, however, local perceptions of threats are possibly a more important driver of action than actual threats , and there is a growing body of research highlighting the value of local knowledge for building pa resilience (berkes, 2007; jones et al., 2013; palomo et al., 2014) . we focused on the third category of threat measurement: that of determining which threats landholders perceive as important for their plcas. we collected data in south africa, where plcas are estimated to cover 14-17% of the land area and contribute significantly to the economy through ecotourism, trophy hunting, hunting for meat, and wildlife trade (taylor et al., 2020) . the increase in plcas in south africa in recent decades has been driven by (a) legislation enabling the ownership of wildlife on private land; (b) the increasing viability of wildlife-based land-uses in the country's more arid areas; and (c) the recent establishment of regional biodiversity stewardship programs (child et al., 2012; cumming and daniels, 2014; . south african plcas include private nature reserves, which are legally gazetted under the pa act (act 57, 2003) ; biodiversity agreements, which have legal status by virtue of a legally binding contract; and conservation areas, which are not legally recognized but receive some form of protection by the owners and are managed at least partly for biodiversity conservation (cumming and daniels, 2014) . plcas in south africa have diverse spatial characteristics (e.g., size, accessibility, topography) and management strategies (child et al., 2013; clements and cumming, 2017; taylor et al., 2020) . some plcas are funded by the owners while others are dependent on revenues generated by ecotourism or hunting operations that target local or international visitors. some plcas have reintroduced charismatic megafauna and other antelope species (which were historically extirpated) in order to attract paying visitors. in addition to documenting the multi-scale threats that were perceived as important to 112 plca landholders in two of south africa's nine provinces, we tested the hypothesis that trends in the threats perceived by landholders would correspond with their plca's spatial and management characteristics. a list of plcas in the eastern and western cape provinces of south africa was compiled from the south african pa database (department of environmental affairs, 2016) and augmented by online searches with keywords such as private, game, nature, and reserve. of the 412 plcas that were identified, contact details could be sourced for 151 (76 in the eastern cape and 75 in the western cape). given time constraints on data collection, 112 randomly selected plcas from this list were included in the study. plcas were contacted by telephone, and interviews were arranged with either the managing owner or the manager (hereafter referred to collectively as 'landholders'). semi-structured in-person interviews were undertaken with participating landholders between october 2012 and february 2015, subsequent to approval by the science research ethics committee, university of cape town. interview duration ranged from one to 3 h, and interviews included questions related to each plca's ecological characteristics, management strategies, and key threats (appendix 1). if a plca was managed by multiple individuals, interviews were undertaken with the landholder who was available and willing to be interviewed. all interviews were recorded, and open-ended questions were later transcribed by the lead author. during the interview, the landholder was asked "what do you perceive to be the most disturbing impacts/threats to the park's objectives?" (appendix 1). their answers to this question were recorded and later transcribed. following the strategy of grounded theory, these transcriptions were analysed by way of thematic coding. codes (phrases representing a single idea) were identified and then allocated into broader threat themes, based on critical reading of all transcribed interviews and guided by the international union for the conservation of nature-conservation measures partnership (iucn-cmp) classification scheme (salafsky et al., 2008) and the broader literature on pas. the iucn-cmp scheme was used as a guide given its widespread use in identifying and categorizing biodiversity threats (e.g., hausmann et al., 2019; joppa, 2016; schulze et al., 2018) , thus promoting comparability with other studies. the iucn-cmp scheme defines direct threats as "the proximate human activities or processes that have caused, are causing, or may cause the destruction, degradation, and/or impairment of biodiversity targets" (salafsky et al., 2008, p 898) , and classifies these threats into 11 broad categories (table 1 ). if coded interview statements aligned with one of these threat categories, they were assigned to that category. the remaining codes identified from interview transcriptions were not reflective of any of the iucn-cmp categories of direct threats. these were allocated into four additional categories (see results) that were defined to be as mutually exclusive as possible, such that each threat mentioned by a landholder fitted within only one category. threat categories were differentiated according to their scale of emergence, given the growing literature on the importance of cross-scale interactions in social-ecological systems in general (reyers et al., 2018; rocha et al., 2018; scholes et al., 2013) and pas in particular (cumming et al., 2015; de vos et al., 2017; wade et al., 2011) . thus, each threat mentioned by plca landholders was allocated to one of 15 categories (11 direct threat categories table 1 , and 4 broader-scale categoriessee results). we used transcriptions of landholders' threat descriptions to identify any interactions that were mentioned between threats. these interactions were identified by statements including more than one threat category, where a threat in one category was stated to have an impact on a threat in another category. plca spatial attributes were quantified (table 2) , following previous studies on pas (bowker et al., 2017; schulze et al., 2018) . plca boundaries were compiled from the south african cadastral data based on farm names provided during the interview (appendix 1), and plca size (1) was calculated. hilliness within each plca was measured as the standard deviation of the property's elevation (2), using shuttle radar topography mission digital elevation data version 4. remoteness was measured as the distance to the nearest town (3) (>50,000 residents; bowker et al., 2017) and road (4), with road and town data obtained from the south african census. these analyses were performed in arcgis 10. during the interview, landholders were asked about their plca management (appendix 1). for this study we quantified six attributes that have been shown to reflect different plca management strategies (clements and cumming, 2017) . each interviewee was asked whether the landholder was dependent on revenues generated by the plca to cover its operational expenses ("financial dependence"; 1), what proportion of the plca's revenue was generated from ecotourism (2) and hunting (trophy and meat hunting) (3), and to rate the importance of international tourists to the plca on a scale from one (not important) to five (very important) (4). finally, we asked landholders to provide us with a species list (only mammal lists were consistently available), from which we determined the number of megafauna (5) (i.e., megaherbivores such as elephant and rhinoceros, and large predators such as lion and cheetah) and antelope (6) (i.e., equid and bovid species) that the plca supported. most plcas in south africa are former farmland on which large mammals were extirpated; megafauna and antelope therefore have to be actively reintroduced as part of the management strategy, with megafaunal introduction requiring adequate perimeter fencing and being particularly desired by ecotourists (clements and cumming, 2017) . the richness of megafaunal and antelope species on a plca is thus considered to be part of its management strategy. to test our hypothesis that patterns in perceived threats would correspond with plca spatial and management characteristics, we performed co-inertia analyses (coias), excluding three plcas for which landholders identified no threats, as well as 26 plcas for which we did not have complete data (resulting in a sample size of 83 plcas). given the low number of plcas mentioning the iucn-cmp direct threat categories of residential and commercial development, energy production and mining, transportation and service corridors, human intrusions and disturbance, pollution, agriculture, and geological events (see fig. 1 ), these categories were excluded from the coias. six direct threat categories were thus included, together with the four additional socioeconomic threat categories. coia is a multivariate method that identifies co-variances between two data matrices (such as two principal component analyses; pcas), based on tucker's inter-battery analysis (tucker, 1958) . it is used in a similar manner to canonical correlation analysis, but is more flexible and robust in situations where the number of variables is high relative to the number of samples, as is the case here (borcard et al., 2011; dray et al., 2003) . three coias were performed: comparing patterns in perceived threats (n = 10 categories) to (1) plca spatial characteristics (n = 4); (2) plca management characteristics (n = 6) and (3) both spatial and management characteristics (n = 10; table 2 ). in each of the three analyses, a pca of the standardized data (correlation matrix) was first performed on each of the two data tables (threats and plca characteristics), with the number of axes to be retained in each analysis specified as three based on the broken stick method (borcard et al., 2011) . the overall similarities between the two correlation matrices were then determined using a coia (borcard et al., 2011) . a multivariate generalization of the pearson correlation coefficient (rv-coefficient) was used to assess the degree of similarity between matrices, calculated as the ratio of the total co-inertia to the square root of the product of the squared total inertias of the separate analyses (dolédec and chessel, 1994; dray et al., 2003) . a higher rv-coefficient (within the range of 0-1) indicates a higher degree of covariance, and a monte-carlo permutation test (permutated 1000 times) was used to assess its significance. the significant coia with the largest rv score (see results) was then interpreted using a pair of biplots that represent the contribution of the variables in each data matrix to the canonical space. the percentage of total co-variation captured by the two axes of that biplot was determined. the more similar the directions of biplot arrows representing variables, the stronger the positive covariance between those variables. pcas, coias and rv-coefficients were performed and plotted with the ade4 r package (functions "dudi.pca", "coinertia" and "rv.rtest", respectively) (dray and dufour, 2007) . of the 112 interviewed landholders, 109 perceived at least one threat to their plca. direct threats to biodiversity, as defined by the iucn-cmp categories, were mentioned by 73% of landholders. biological resource use was the most commonly mentioned direct threat (23% of landholders), almost entirely due to poaching concerns, with many landholders mentioning rhino poaching specifically (fig. 1) . severe weather (droughts and floods) was a concern to a fifth of landholders, while just less than a fifth were concerned about natural system modifications (inappropriate fire regimes) and problem species and disease (alien invasive plant species, predators that kill antelope, and diseases that affect antelope; fig. 1 ). residential, commercial and transport (road and railway) development and energy production (gas drilling, mining, wind farms) were of concern to less than 15% of landholders, while human intrusions (recreational activities and trespassing); pollution (pesticides and herbicides); and agriculture were of concern to a less than 5% of landholders (fig. 1) . geological events were of no concern. the majority of landholders (72%) also mentioned threats that were not represented by any of the iucn-cmp categories of direct threats to biodiversity. these threats were grouped into four categories (table 3) . a sixth of landholders were concerned about globally emergent socioeconomic changes, including a volatile global economy, population growth, and growing anti-trophy hunting sentiments. governance and national socio-economic policies, including the current government, south african political situation, political instability and/or south african legislation, were a concern for 41% of landholders. legislation commonly perceived to be a threat included policies regarding land reform (i.e., land redistribution to previously disadvantaged communities), tax and interest rates, minimum wages, and antelope and megafaunal translocation permits. just over a sixth of landholders were concerned about socio-economic challenges in the region surrounding the plca, including crime, unemployment, pressure from labour unions, a lack of education, and bad relations with (non-plca) neighbours. finally, a third of landholders were concerned about plca management challenges (table 3 ). the most common management concern pertained to maintaining the financial viability of the plca, as well as concerns about difficulties with staff and tourists, a lack of capacity for lodge and ecological management, megafauna and antelope overstocking and space limitations, and concerns about landholder succession. landholders described how direct threats to biodiversity on their plcas (fig. 1) were influenced by broader-scale, socio-economic threats (table 3) . for example, there were concerns that global change increased the frequency of extreme weather (e.g., "climate change is increasing the risk of flooding"), and that regional and national political instability and economic downturns could cause increased poaching (depending partly on the feedbacks between governance, economic growth, and rural-urban migration). one landholder stated that "political threats, safety and security is an issue i think in a remote place like this, to anyone that's living on the farm and to the wildlife, because the worse things get the more poaching happens". beyond their impact on biodiversity within plcas, direct threats were also noted by landholders to present other management challenges that threatened their plcas. one landholder stated that "if it doesn't rain here we're in big trouble here, we've got hippos in dams, if the rivers dry up. if we have to feed animals here, financially it won't be sustainable for longer than 3 months". the cost of managing (moving, feeding or culling) antelope if there was no rain can thus threaten plca financial viability. plca financial viability can similarly be threatened by the cost of managing alien vegetation (e.g., "managing alien invasion takes a lot of effort and money") and the reduced live market value of wildlife (particularly rhino) caused by the rising costs of preventing poaching ("poaching drops the value of game"). plca financial viability was also threatened by broader-scale socioeconomic events, such as regional crime (e.g., "crime in the region, it erodes value of reserve which means less money for conservation"), national legislation (e.g., "labour has become too expensive through minimum wages with the labour act") and global economic environments (e.g., "globally there are some financial pressures, i think people have less disposable income to visit far lying places like ours"). global changes can also result in national changes that then threaten plcas. for example, there were concerns that global anti-hunting sentiments would result in national legislation that restricted or prevented trophy hunting in the country (e.g., "people make wrong hunting choices, which gives opponents [the global anti-trophy hunting community] ammunition, and puts pressure on governments to stop hunting"). spatial characteristics of plcas alone not did not correspond significantly with patterns in landholders' perceived threats (rv = 0.065, p = 0.4, n = 83). by contrast, when considered collectively, plca spatial and management characteristics corresponded significantly with patterns in perceived threats (rv = 0.117, p = 0.01, n = 83; fig. 2 ). landholders of plcas that were far from roads and generated revenues through hunting were most concerned about national socio-economic changes, problem species and extreme weather. by contrast, fig. 2 . biplots illustrating the correspondence between (a) landholders' perceived threats to their private land conservation areas (plcas) and (b) plca spatial (brown) and management (green) characteristics. similarity in arrow direction indicates positive correlation between variables, while dissimilarity in arrow direction indicates negative correlation between variables; perpendicular arrows represent unrelated variables (borcard et al., 2011) . the first and second co-inertia axes accounted for a respective 46.9% and 30.7% of the co-variation between perceived threats and plca characteristics. (for interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.) landholders that generated revenues through ecotourism were most concerned about regional socio-economic changes and, to a lesser extent, plca management challenges. landholders of plcas that supported megafauna and attracted international tourists tended to be most concerned with poaching and regional socio-economic change, and to a lesser extent global socio-economic change. global socio-economic concerns also corresponded with landholders of large plcas that supported many antelope species and were financially dependent on revenues generated from their plcas. landholders of plcas that were remote, hilly and small with few megafauna and antelope species were consistently concerned about inappropriate fire regimes and tended to not be concerned about global or regional socio-economic change or poaching. by documenting the perceived multi-scale threats to over 100 plcas in south africa, our findings contribute to addressing uncertainty around the likely permanence of private land conservation. we demonstrate that the threats to this permanence are determined not only by the spatial characteristics of plcas, but also by how they are managed and the socio-economic environments in which they are embedded. the potential for interactions between direct threats to biodiversity, plca management challenges, and broader-scale socioeconomic threats highlights the complex, multi-scale arena in which private land conservation functions. illegal hunting (i.e., poaching) was the most commonly mentioned concern for plcas in this study, mirroring the recent finding that unsustainable hunting was the most widespread threat to statutory pas in developing countries (schulze et al., 2018) . private landholders are custodians of around half of south africa's rhinos, with poaching on private land therefore a direct threat to this species . the risk of rhino poaching presents management challenges, since anti-poaching activities are extremely costly to private landholders . given that south african plcas typically receive no funding support, and perceive financial viability to be a key threat, an inability to cover the increased running costs arising from threat mitigation activities could cause many to change land use or sell. a direct threat to one species can thus threaten biodiversity more broadly through its impact on plca financial viability. direct threats to biodiversity on south african plcas (fig. 1) were found to be influenced by broad-scale socio-economic factors (e.g., international and national politics and economics influence the threat of poaching). broader-scale socio-economic changes can, however, also directly threaten plcas as a land use. international and national politics (e.g., growing anti-trophy hunting sentiments) and economics (e.g., recessions) were perceived by landholders to have a negative effect on ecotourism and hunting industries. many plcas depend on these industries to remain financially viable, and have stated that they would adopt an alternative land use like farming if their plca became unviable (parker et al., 2020; taylor et al., 2020) . biodiversity on these plcas is therefore not just at risk from direct threats, but also ultimately from the loss of capacity to persist as a conservation land use in the long term, which depends on plca resilience to broader socio-economic change and its consequences for management. this finding for plcas supports a growing body of research on statutory pas highlighting the influence of multi-scale, social-ecological contexts on pa resilience (cumming et al., 2015; palomo et al., 2014) . as has been observed for statutory pas (bowker et al., 2017; schulze et al., 2018) , south african plcas that were further from towns and hillier tended to be exposed to fewer direct threats to biodiversity (with inappropriate fire regimes being the only consistent concern; fig. 2 ). these plcas also tended to be smaller, however (fig. 2) , which is contrary to findings that smaller statutory pas are more vulnerable to threats than larger pas (bowker et al., 2017; tranquilli et al., 2014) . rather, patterns in many of the threats perceived by landholders were better explained by plca management characteristics than spatial ones. for example, landholders of ecotourism-focused plcas were consistently concerned with regional socio-economic change. ecotourism enterprises typically employ more staff and require them to be more skilled than hunting enterprises, and accommodate more visitors per year (sims-castley et al., 2005; taylor et al., 2020) . this may make them susceptible to challenges from labour unions, a regional shortage of skilled labour, and management challenges associated with staff and visitors. by contrast, national government and legislation were consistent concerns for south african plcas that generate revenues through hunting (fig. 2) . this industry is regulated by policies that influence the type and number of antelope that can be stocked, translocated and hunted (cousins et al., 2010) . hunting plcas also tend to be less profitable than high-end ecotourism properties in the region , which may make them more susceptible to legislation that increases minimum wages and interest/tax rates. landholders of hunting plcas are often distrustful of government and its regulation of the industry due to a perceived lack of consultation and inconsistent regulation (brink et al., 2011; pasquini et al., 2010) . landholders of hunting plcas were also consistently concerned about extreme weather, supporting previous findings that hunting plcas are vulnerable to low rainfall since it reduces the number of antelope that can be sustainably hunted (clements and cumming, 2018) . it is important to reiterate that the threats described in this paper are landholders' perceived threats. if a landholder does not mention a threat, it does not mean that their plca is not vulnerable to the threat. a good example is the threat of a global pandemic, which no landholders mentioned but which currently threatens the viability of many plcas due to the impact of covid-19 on global travel and thus plca revenue streams (stoddard, 2020) . conversely, landholders may be concerned h.s. clements et al. about threats that never materialize. while it could therefore be argued that asking landholders to state their concerns is not a robust approach for understanding threats to private land conservation, the fact that landholders anticipate certain threats may itself influence their behaviour and thus resilience. for example, farmland prices in south africa have fallen by a third since the national government proposed to amend the constitution to enable land expropriation without compensation, for the purposes of redistributing land to previously disadvantaged demographic groups (monteiro, 2019) . the proposed expropriation may never materialize; yet the fear of it under current political uncertainty is causing some landholders to sell their land (monteiro, 2019) . both actual and perceived vulnerabilities to threats are thus important to consider. an ability to anticipate threats is becoming increasingly important in our highly connected and rapidly changing world (biggs et al., 2011; rocha et al., 2018) . to address the challenge of managing social-ecological systems under increasing uncertainty, there is a growing consensus that managers would benefit from engaging with different perspectives to develop trust, facilitate learning and collaboration, and develop a more widely shared understanding of management challenges and the systems in which they are embedded palomo et al., 2014) . furthermore, trends in the threats perceived by different types of plcas enable the identification of more nuanced strategies to build resilience to these threats. for example, the prevalent threat of lost financial viability suggests a need to strengthen the capacity of self-funded plcas to cope with revenue and/or running cost fluctuations, and a clear niche for more innovative financial instruments that will help landholders cope better with risk. diversifying the tourists that plcas attract (e.g., not focussing solely on international tourists or those from a specific country) can buffer plcas to socio-economic changes influencing certain markets (biggs et al., 2012) . similarly, diversifying revenue-generating activities could build the capacity of plcas to cope with growing anti-trophy hunting sentiments (naidoo et al., 2016; parker et al., 2020) . the historic transition of many landholders from livestock-to wildlife-based land uses reflects the capacity of landholders to respond to change (child et al., 2012) . this transition was largely enabled by a policy change that allowed private landholders to own wildlife, emphasizing the influence that policy can have in promoting adaptations that benefit conservation (child et al., 2012; . given the largely self-funded and emergent nature of private land conservation in south africa, much of the onus for building the resilience of plcas to threats is likely to lie with the landholders themselves, through strategies such as those described in the previous paragraph. however, the notable influence of government on revenues (through the influence of politics on tourism), running costs (through tax, interest, labour and wildlife legislation) and other management challenges (through the need for skilled employees and fair labour unions) highlights the importance of context-relevant and co-produced policy interventions and governance systems for strengthening the resilience of the sector (cocklin et al., 2007; pasquini et al., 2010) . the provincial biodiversity stewardship programs that have emerged over the past decade present an example of how the government is directly supporting landholders in mitigating threats such as fire and alien invasive species (cumming and daniels, 2014) . notable threats to plcas are not only those that impact biodiversity directly, but also the local to global socio-economic changes that interact to threaten plca viability as a land use. these interactions can influence the resilience of pas in ways that are not anticipated through the consideration of direct threats that are assumed to act independently. while the complexity of the threat landscape may seem unmanageable, we have demonstrated that understanding the spatial and management-related factors that influence plca vulnerability to these threats can help identify targeted strategies to build the resilience of this important conservation mechanism. the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. differences among protected area governance types matter for conserving vegetation communities 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inter-battery method of factor analysis a multi-scale assessment of local and contextual threats to existing and potential u.s. protected areas. landsc. urban plann we acknowledge funding support from the claude leon foundation (hc), the south african national research foundation (rb), and the australian research council and james s. mcdonnell foundation (gc). we thank the landholders who kindly participated in this research. supplementary data to this article can be found online at https://doi. org/10.1016/j.jenvman.2020.111235. key: cord-306741-3ibprszo authors: fitchett, jennifer m; swatton, deryn-anne title: exploring public awareness of the current and future malaria risk zones in south africa under climate change: a pilot study date: 2020-11-11 journal: int j biometeorol doi: 10.1007/s00484-020-02042-4 sha: doc_id: 306741 cord_uid: 3ibprszo although only a small proportion of the landmass of south africa is classified as high risk for malaria, the country experiences on-going challenges relating to malaria outbreaks. climate change poses a growing threat to this already dire situation. while considerable effort has been placed in public health campaigns in the highest-risk regions, and national malaria maps are updated to account for changing climate, malaria cases have increased. this pilot study considers the sub-population of south africans who reside outside of the malaria area, yet have the means to travel into this high-risk region for vacation. through the lens of the governmental “abc of malaria prevention”, we explore this sub-population’s awareness of the current boundaries to the malaria area, perceptions of the future boundary under climate change, and their risk-taking behaviours relating to malaria transmission. findings reveal that although respondents self-report a high level of awareness regarding malaria, and their boundary maps reveal the broad pattern of risk distribution, their specifics on details are lacking. this includes over-estimating both the current and future boundaries, beyond the realms of climate-topographic possibility. despite over-estimating the region of malaria risk, the respondents reveal an alarming lack of caution when travelling to malaria areas. despite being indicated for high-risk malaria areas, the majority of respondents did not use chemoprophylaxis, and many relied on far less-effective measures. this may in part be due to respondents relying on information from friends and family, rather than medical or governmental advice. malaria is a dangerous and potentially fatal vector-borne disease caused by the plasmodium parasite, transmitted to humans through the bite of an infected female anopheles mosquito (cohuet et al. 2010; cella et al. 2019) . in 2018, an estimated 228 million cases of malaria were reported globally, similar to 231 million cases for 2017, with a death toll of4 35,000 in 2017 and 405,000 in 2018 (alonso and noor 2017; who 2019a,b) . the burden of malaria was disproportionately borne by developing nations, particularly in the african continent, which accounted for 92% and 93% of the malaria cases and deaths recorded in 2018, respectively (alonso and noor 2017; who 2019b) . in 2016, in an effort to combat malaria, the world health organization launched the e-2020 initiative in which it identified 21 countries with the potential to eliminate malaria within their borders by the year 2020 (who 2018). south africa was one of those countries, with an additional local objective of elimination by 2018 (baker 2018) . however, in 2017, south africa experienced a severe setback in achieving both objectives, reporting 7897 imported and 19,706 indigenous cases of malaria-the highest number of cases reported by any of the 21 identified countries, and more than four times the number of indigenous cases reported in the country in 2016 (who 2018; maharaj et al. 2019; abiodun et al. 2020) . this increase in numbers was due to a range of factors, including an increase in rainfall, temperature, and humidity following an abnormally mild winter (baker 2018) . as a result, the world health organization has classed south africa as "off-track" and has made a number of recommendations as to how the country can steer itself back on course (who 2018) . among these are efforts to refine malaria risk maps, to improve public awareness, and to revisit malaria strategies (who 2018) . due to the unlikelihood of achieving malaria elimination within south africa by 2020, the south african government has now adopted the self-mandated goal of zero malaria transmission by 2023, which it announced in the malaria elimination strategic plan for south africa 2019-2023 (national department of health 2019). one of the primary objectives of the malaria elimination strategic plan is to "ensure that 90% of the population affected by malaria receives information and education communication messaging by 2023" (national department of health 2019: 25). this objective speaks directly to the recommendations given by the world health organization (who 2018) . the national guidelines for the prevention of malaria in south africa comprise five key components which are summarized as the "abc" of malaria prevention, namely awareness and assessment of malaria risk, avoidance of mosquito bites, compliance with chemoprophylaxis when indicated, early detection of malaria disease, and effective treatment (ndoh 2018a; baker 2018; schmidt 2019a, b) . adding fuel to the fire, climate change is resulting in both an increase in the extent of the south african malaria risk area and the incidence of malaria transmission due to increases in temperature and changes in rainfall patterns (morris et al., 2013; abiodun et al., 2020) . the spatial distribution of malaria globally is strongly determined by climate (caminade et al. 2014; cella et al. 2019) . by 2050, a 50% increase in the probability of malaria incidence is projected globally due to increases in temperature and changes in rainfall patterns (cella et al. 2019) . temperature has been found to affect both the extent of malaria areas and malaria transmission incidence across the african continent (eikenberry and gumel 2019) . for south africa, both temperature and rainfall have been found to affect the malaria rate, with a notable increase in cases following flood events induced by strong tropical storms (adeola et al. 2019; makinde and abiodun 2019) . a change in malaria area extent is documented in the frequent updating of the national department of health malaria risk maps for south africa (coetzee et al. 2013; morris et al. 2013) . mathematical models have been developed to explore the role of climate in malaria incidence and to aid in projecting future changes in malaria risk distribution, and the risk of transmission (cella et al. 2019; eikenberry and gumel 2019) . at a local scale, seasonal malaria forecast models are being developed for south africa (kim et al. 2019; landman et al. 2020) . the modelling of the climate impact on malaria distribution and incidence and projections for future incidence are valuable in developing public health policies, and in communication to the public. however, the increased incidence of malaria cases in south africa in recent years would suggest that effectiveness of the distribution of these maps, particularly with regular updates, remains limited. a range of studies relating to disparate diseases have revealed the importance of public awareness and understanding of disease risk in determining the precautionary measures that they will adopt (cf. erhardt and hobbs 2002; glik et al. 2004; goldman et al. 2006; young et al. 2008 seale et al. 2010 . the role of sources of information, and the level of frequency of communication regarding diseases, is key in the veracity of public awareness (young et al. 2008 ). this has been widely understood in south african malaria control efforts (blumberg et al. 2014) , with malaria risk maps for the public dating back to 1938 (coetzee et al. 2013) . however, the efforts in assessing communities' awareness and understanding of malaria risk have largely been limited to regions within the high-risk zone, due to resource scarcity (maartens et al. 2007; cox et al. 2018) . in line with the who (2018) recommendations, this pilot study seeks to expand on previous work to explore public understanding of the location of the contemporary high-risk malaria zone, the anticipated future expansion of the high-risk malaria zone under climate change, and public behaviour regarding malaria precaution and prophylaxis, among those who reside outside of the malaria risk area, but travel into the high-risk zone on vacation. the aim of this study is to develop a methodology to explore any disconnects between reported and demonstrated awareness and behaviour regarding malaria for gaps in understanding to be addressed more effectively through government intervention, and for targeted awareness campaigns to be developed. malaria can be found in each of south africa's neighbouring countries, barring lesotho, where the altitude and consequent colder temperatures make it inhospitable to the malariacarrying anopheles mosquito (blumberg et al. 2014) . within south africa itself, malaria is confined to the north-eastern reaches of the country, where it is endemic to three of south africa's nine provinces, namely limpopo, mpumalanga, and northern kwazulu-natal (maharaj et al. 2019; adeola et al. 2019 ; fig. 1 ). according to the latest malaria risk map produced by the south african national department of health in december 2018, areas of moderate risk (where chemoprophylaxis is indicated for all travellers from september to may) are concentrated along the border between south africa and mozambique and zimbabwe (fig. 1) . these areas of moderate risk can be found in the mpumalanga municipality district of ehlanzeni and in limpopo in the mopani and vhembe municipality districts (fig. 1 ). areas of low risk (where malaria is still present, but only non-drug preventative measures are indicated), however, extend as far west as limpopo's waterberg district and as far south as the umkhanyakude district in kwazulu-natal province ( fig. 1 ). at present, the regions of highest malaria risk in south africa have relatively low population density, with no major cities and a large proportion of the high-risk area limited to the kruger national park. this does however pose a threat to both local and international tourists visiting the kruger national park and nearby game farms and nature reserves, who may be unaware of the risk levels within south africa. this research explores respondents' malaria awareness and self-reported behaviours. therefore, questionnaires were selected as the most appropriate instrument for data collection. types of questions ranged from multiple choice and likert scale questions to more open-ended, paragraphstyle questions (bird, 2009) . topics included respondents' demographics and travel histories, awareness and perception of malaria distribution and risk in southern africa, understanding of climate change, and attitudes towards malaria prophylaxis-both in terms of bite prevention and chemoprophylaxis. the closing question of the questionnaire required respondents to draw two lines, in different colours, on a map of southern africa: a blue line indicating where they understand the boundary of the present malaria risk zone to be located and a red line indicating where they think the boundary of the malaria risk zone will be located in 20 years' time. the map was created using arcmap and displayed national and provincial borders, but contained no other information to avoid leading respondents. questionnaires were distributed in hard copy. respondents were identified through a combination of purposive and snowball sampling (bernard 2013) . to ensure a degree of standardization throughout the study sample for this initial pilot study, a target population was identified and a number of parameters were defined. in order to qualify for the study, respondents had to live within the gauteng province of south africa (currently not a malaria area), have at least an undergraduate university degree, and have travelled to a malaria risk area within southern africa within the last 5 years for leisure purposes. this ensured that the data gathered were relevant and that all respondents were middle-to upper-class leisure tourists with financial means to access to a wide range of precautionary measures to avoid contracting malaria when travelling to malaria areas, and have a reasonable level of education and understanding of health risks. this sample is not intended to be representative of the population of south africa nor the gauteng province. rather, this subgroup is used to determine whether any issues in awareness, behaviour, or use of chemoprophylaxis may warrant further, more extensive investigation. ethics clearance was obtained from the university of the witwatersrand's human research ethics committee (non-medical) prior to entering the field (ethics clearance: gaes-2019-06-01). given the target population and the minimum requirement of a completed undergraduate degree, no individuals under the age of 18 were approached. finally, it is important to note that this research dealt exclusively with the data collected from the completed questionnaires and no medical records were accessed or used in this study. responses to closed-ended questions from the questionnaire were analyzed using descriptive statistics, while responses to open-ended questions underwent thematic coding and content analysis (bernard 2013) . the hand-drawn maps generated in the last question of the questionnaire were digitized and layered over one another to create composite maps showing areas of consensus/disagreement among respondents. this particular methodology was adapted from a study conducted by roffe et al. (2019) which mapped agreement among experts regarding rainfall seasonality in south africa. finally, the composite maps were compared to the official malaria risk map created by the south african national department of health in 2018 to assess their accuracy. a total of 38 questionnaires were completed. of these, six questionnaires were excluded from analysis as the respondents did not fall within the defined parameters of the target population, in most instances as a result of not having visited a malaria area within the past 5 years. four maps were deemed unusable as the lines drawn could not be digitized as a contiguous vector line and/or what was drawn could not be meaningfully interpreted. neither the excluded questionnaires nor the unusable maps were used in the creation of the composite maps. in the cases where maps were unusable, but respondents met the selection criteria, the questionnaire responses were captured and included in descriptive statistics and content analysis. while the intention was to obtain a relatively even distribution of respondents across age groups, due to difficulty accessing people within the older age brackets who met the selection criteria (specifically the criterion relating to tertiary education), a skewed age distribution resulted. of the 32 respondents who submitted admissible questionnaires, the highest number (n = 14) fell into the 20-29 age group. the remaining age groups were comparatively poorly represented, with the 30-39 and 40-49 age categories comprising five respondents each, and the older age groups (50-59 and 60+) each representing one-eighth (n = 4) of the sample group. the majority (n = 17) of respondents held only a bachelor's degree, while nine held honours degrees (a postgraduate qualification in south africa), one held a master's degree, and two held a phd. the remaining three respondents selected "other" qualifications, in two cases citing university qualifications in the medical or nursing field. this last group, however, cannot be read independently, as respondents with medical or similar degrees may equally have chosen the equivalent qualification to their degree-type from the list provided. the overall spread of tertiary qualifications indicates a well-educated subset of the population. it is worth noting that the various levels of education were spread across the age groups, and it was not simply a case of the older the respondent, the higher their qualification. for example, all respondents in the 40 to 49year-old age group (n = 5) reported only holding a bachelor's degree, whereas of the two respondents in possession of a phd, one fell into the 30-39 age group and the other into the 60+ age group. this distribution is important, as it means that age and highest qualification are not collinear, but are rather independent factors each of which could be possible determinants of perception, risk assessment, and behaviour. we reiterate that the results of this small group cannot be read as representative of any sub-population, but rather the variety of results indicates a heterogeneity which reveals the importance of further, extensive, investigation. the questionnaire included a mapping exercise in which respondents were required to draw a line across a map of southern africa indicating where they understood the boundary of the present malaria risk zone to be located. in this question, respondents were instructed to include the entirety of the southern african region in the drawing of their malaria zone boundaries. however, eight of the 28 respondents who created usable maps only drew lines across south africa. therefore, for the sake of consistency, only the portion of the drawn risk areas which fell within the borders of south africa was digitized. overall, the composite map created from all 28 usable maps reveals a fairly high degree of awareness among respondents regarding the general location of malaria risk areas in south africa (fig. 2) . darker blue areas, which show a higher degree of consensus among respondents, can be found in the north-east of the country, concentrated along the border between south africa and mozambique and zimbabwe (fig. 2) . the majority of respondents have also included eswatini, northern kwazulu-natal, and more westerly parts of limpopo and mpumalanga in their assessment of malaria risk areas (fig. 2) . this is consistent with the official south african malaria risk map produced by the national department of health in 2018 (fig. 1) . however, the composite map also shows that many respondents believe that the malaria risk zone extends further west and south than is indicated on the governmental malaria risk map, with one respondent including the entirety of south africa in their rendering of the malaria risk zone. another respondent included the west coast of the northern cape, and many drew lines which either dissected or encompassed lesotho. this indicates a poor awareness of the government-communicated malaria risk maps of south africa, and moreover a limited understanding of the relationship between climate and malaria distribution, or at least limited awareness of the climate in these areas. in addition to instructing respondents to map their understanding of malaria risk areas in southern africa, the study also sought to assess the accuracy of respondents' selfreported awareness. respondents were asked whether, prior to taking the questionnaire, they were aware of malaria risk areas in the region. of the 32 respondents, the vast majority (n = 25) indicated that they were aware, while one respondent answered that they were not, and one did not respond. the remaining five respondents stated that they had limited awareness. with such a high degree of self-reported awareness, one would expect more accurate maps than were captured (fig. 2) . respondents were aware of the general location of malaria risk areas, but could not reliably recount their extent. this indicates a general, and perhaps intuitive, awareness among respondents, but little true, informed awareness. interestingly, despite the majority of respondents indicating that they were aware of malaria risk zones, only six felt that there was enough information available to the general public regarding malaria distribution, precautions to take against contracting malaria, and how to identify and treat malaria. respondents who indicated that they were either aware of malaria risk areas prior to taking the questionnaire, or who indicated that they had some degree of awareness, were then asked to stipulate where they accessed this information. importantly, government or official publications/websites were the least consulted (n = 2) source of information, while family, friends, or colleagues were the most frequently cited (n = 15) sources (fig. 3) . many of the 11 respondents who selected "other" indicated that they had accessed their information at school, through the media/news, or had been advised by a medical professional (fig. 3) . this could explain the lack of convergence between the government malaria map and those drawn by respondents. respondents were asked to rate the level of risk posed by malaria to south african citizens on a likert scale of 1 to 5, with 1 being low risk, 3 being moderate risk, and 5 being high risk. respondents most commonly (n = 11) rated the level of risk as moderate (as can be seen by the single peak), with a slight bias towards higher risk (fig. 4) . approximately three quarters (n = 23) of respondents indicated that they had taken precautions against contracting malaria during their most recent trip to a malaria risk area in southern africa, while eight reported taking no precautions and one declined to answer the question. among the eight respondents who did not take precautions, the most commonly reported reasons were issues around risk assessment and lack of awareness. interestingly, two respondents indicated that their risk assessment was informed by the advice of locals, with respondent 18 stating: i heard from people who live there that it was not a risk. similarly, respondent 30 reported: been travelling to mozam[bique] for a few years and nothing happened. locals there also say they moved there and lived there for yearsnothing happened. a further two respondents stated that they were not aware that their destination was a malaria area before departing, and only found out once they returned. for one of these respondents, their destination was mozambique, a country classified as high risk in its totality. of the eight respondents who did not take precautions, only one quarter (n = 2) indicated that they would change their behaviour and employ preventative measures on future trips. for the 23 respondents who did take precautions, insect repellent was the most popular (n = 18) preventative measure used (fig. 5) . insect repellent, along with travelling outside of the rainy season, were the two most common precautions used in isolation, each with four respondents. only 12 respondents used more than one method simultaneously. both respondents who selected the "other" option (fig. 5 ) cited wearing long trousers and long-sleeved shirts in the evenings. while this would minimize the chances of mosquito bites to the arms and legs, and is effective in reducing the irritation of mosquito bites, the efficacy of clothing worn in the evenings as a method of significantly reducing the risk of contracting malaria remains uncertain (nakazawa et al. 1998; del prete et al. 2019) . long clothing worn throughout the day and night (baker, 2018) , and impregnated with insecticides (shellvarajah et al. 2017) , shows more promise, but this is not the approach indicated by the respondents. in this context, wearing long clothing only in the evenings is less effective than these alternatives, and their combined use with chemoprophylaxis (baker, 2018) . of the 23 respondents who did take precautions against contracting malaria, five indicated that they would only do so again on their next trip to a malaria area if it was in the rainy season/summer. one respondent (respondent 11) stated that they would not take any precautions, as they believed that: risk is not significantly high when travelling for short time periods this is a misconception, and studies of imported cases of malaria in europe and the middle east resulting from tourists' short trips to southern africa underscore this (see ben-ami et al. 2005; baranova et al. 2019) . these erroneous sentiments are particularly concerning given the large proportion of respondents who obtain information on malaria risk from family, friends, and colleagues instead of government publications (fig. 3) . chemoprophylaxis is indicated for travel to all malaria areas considered moderate to high risk (schmidt, 2019a, b) . these areas can be found in all of south africa's neighbouring countries, and within south africa in limpopo and mpumalanga (fig. 1) . of the 32 respondents who submitted usable questionnaires, almost all (n = 30) indicated that they had travelled to malaria areas considered moderate or high risk. however, only one-third (n = 10) of these respondents reported that they had taken antimalarial drugs on their most recent trip to one of the areas. even more alarmingly, of the 10 respondents who had only travelled locally within south africa, to either limpopo or mpumalanga, only one-fifth (n = 2) had taken chemoprophylaxis. this indicates a very low level of compliance with chemoprophylaxis in indicated settings, which is particularly concerning among a sample group who have the level of education and socio-economic status to enable compliance. climate change awareness and impact on future malaria risk zones all 32 respondents indicated they understood what was meant by the term "climate change". respondents were then asked whether they thought climate change would impact malaria risk and distribution in southern africa, and if so, how. almost all respondents (n = 28) indicated that they believed that climate change would increase malaria risk in southern africa, while the remaining four indicated that they did not know. no respondents answered that climate change would decrease malaria risk in southern africa or have no effect. respondents also drew a line across indicating where they thought the boundary of the malaria risk zone would be located in 20 years' time. the composite map produced shows a far greater extent of malaria distribution than the composite map produced for current malaria risk (fig. 6) . respondents indicated that they believed the malaria risk zone would extend further west and south into the country's interior, with the majority of respondents including large parts of limpopo and mpumalanga (fig. 6) . this is consistent with the trend shown by the malaria risk maps produced by the government over the past century (coetzee et al. 2013; morris et al. 2013 ). the composite map indicates that respondents are cognizant of the increased risk of malaria projected for south africa in future decades, and significantly aware of the spatial patterns projected for the increase in the distribution of malaria risk. however, many respondents indicated an expansion of the malaria risk zone 20 years from now which is geographically impossible, and exceeds the model outputs for malaria projection. notably, the expansion into the mountainous highlands of lesotho, the temperate climates of the southern coast of south africa, and the arid west coast of south africa are unlikely in the next 20 years, if ever. these exaggerated perceptions of future risk, when not realized, may result in further complacency among respondents, particularly as relates to chemoprophylaxis. efficacy of the "abc" of malaria prevention in increasing public awareness the first tenet of the "abc" of malaria prevention relates to public awareness and the accurate assessment of malaria risk (ndoh 2018a). this emphasis on awareness and perception is further echoed in the malaria elimination strategic plan for south africa 2019-2023 which aims to "ensure that 90% of the population affected by malaria receives information education communication messaging by 2023" (national department of health 2019:25). when respondents were surveyed, it was found that while there is a relatively high level of self-reported awareness regarding the general location of malaria risk areas in south africa, the majority of respondents were unable to reliably recount the extent of these areas. the behaviour of the population regarding malaria avoidance similarly was not in line with governmental advice and scientifically determined best practice. this indicates that at least a proportion of the south african population are unaware of the precise location of the malaria risk zone, and their perceived awareness is incongruous with the demonstrated awareness or reality. this is consistent with prior research in kwazulu-natal (maartens et al. 2007 ). further research is needed to determine whether this lack of awareness in a statistically representative population amounts to greater than 10%. within the existing medium to high-risk malaria zones (fig. 1) , targeted governmental efforts at increasing awareness have been conducted actively at the community level, rather than solely passively through websites and risk maps in clinics which is the case for the respondent group from gauteng province (govere et al. 2000; cox et al. 2018) . for example, members of communities in the vhembe district in largely rural limpopo province who have been involved in the governmental malaria awareness programme (map) are found to have a 3.3 times greater knowledge on malaria transmission risk and 2.8 times higher awareness of prevention methods than those who had not been involved in these programmes (cox et al. 2018) . the perceptions of residents living in current malaria risk zones regarding the boundary of these zones would be a valuable avenue of future research. it is notable that among the respondents, government and official publications/websites were the least consulted sources of information, while family, friends, and/or colleagues were the most frequently consulted. as only six of the 32 respondents believed that there was enough information available to the general public regarding malaria distribution, precautions to take against contracting malaria, and how to identify and treat malaria, this suggests a weakness in policy's strategies regarding modes of delivery of malaria education and highlights the possibility of the transmission of misinformation from person to person. while targeted initiatives in high-risk malaria regions are of course imperative in addressing the epicentre of the problem, the significant tourism sector in south africa, and the large proportion of people migrating back to their homes in malaria areas during holiday periods, does necessitate a broader geographic reach of these activities (blumberg et al. 2014; raman et al. 2016) . following discrete epidemics, this has been facilitated through tourism operators distributing information (maartens et al. 2007 ), but this would not address tourists staying in less formalized accommodation. the incorrect perceptions that malaria risk is not high when travelling for short periods (see ben-ami et al. 2005; baranova et al. 2019) , or can be mitigated through wearing long clothing only in the evenings, reveal the dangers of relying on non-official sources of information when planning precautionary measures to avoid malaria (raman et al. 2016 ). these respondents appear to have misunderstood that while the longer the visit to a malaria-prone region, the greater the risk, short stays do not carry no or low risk; likewise, while long clothing is advised at all times, wearing it for short periods is not sufficient in preventing the risk of bites or malaria (baker 2018) . this misconception appears relatively unique to this study; an investigation into foreign tourists' awareness of malaria while at or tambo international airport in gauteng indicated that medical practitioners and travel agents were by far the greatest source of information on malaria (waner et al. 1999) . the low rates of use of chemoprophylaxis among respondents warrant particular concern. for persons with no immunity to malaria, which includes our study sample group, but also much of south africa (fig. 1) , chemoprophylaxis is indicated for the period of travel (freedman 2008; morris et al. 2013; schmidt, 2019a, b) . doxycycline, atovaquone-proguanil, and mefloquine are currently recommended for use in south africa, with an efficacy of~90% when taken correctly (baker, 2018; schmidt, 2019a, b) . the former two drugs have recently been downscheduled to s2, allowing for pharmacists to dispense these without prescription (baker 2018) , thus increasing access and reducing costs slightly through eliminating the necessity for a consultation with a doctor . while there are medical uncertainties regarding the safety of certain antimalarials, particularly mefloquine, in terms of neuropsychiatric adverse effects fig. 6 overlaid map of respondents' perceptions of future malaria risk boundaries in south africa in 20 years' time (n = 28) (freedman 2008; baker 2018) , these were not cited by the respondents as the reasons for non-compliance. more minor side effects, by contrast, were indicated as a reason for non-compliance, a theme which is echoed in studies of international tourists (waner et al. 1999) . a lack of awareness of the need for chemoprophylaxis, due to poor knowledge of the malaria areas, or to a lack of understanding of the severity of the risk may explain some of respondents not having used this precaution (leggat et al. 2002; maartens et al. 2007 ). however, as the majority of respondents over-estimated the expanse of the south african malaria risk area, this seems unlikely. a significant barrier to the use of chemoprophylaxis is the cost (leggat et al. 2002; ukpe et al. 2013) . even among more affluent travellers, the large cost of the antimalarial drugs serves as disincentive, particularly for trips of short duration or outside of the rainfall season (leggat et al. 2002) . greater medical aid coverage for antimalarials and a reduction in the cost of the drugs would be important in addressing this component. despite a relatively low sample size, this study reveals notable gaps in the awareness and risk-taking decision-making among persons who travel into malaria areas, who are resident in a country in which some but not all areas carry a high malaria risk (blumberg et al. 2014) . this is distinct to the majority of studies for south africa which either assess the awareness and behaviour of international tourists visiting malaria areas (cf. waner et al. 1999; freedman 2008) , or of local communities within high-risk malaria areas (cf. govere et al. 2000; morris et al. 2013; cox et al. 2018 ). this group is important because they do not receive the same level of travel advice as international tourists (waner et al. 1999 ), yet frequently travel into and through high-and medium-risk malaria areas (maartens et al. 2007 ), often through self-booking (de jager and ezeuduji 2015). the greatest awareness among local tourists has been found to directly follow major malaria epidemics, which is coupled with booking cancellations for accommodation establishments in malaria-prone regions (maartens et al. 2007) . the changes in the methods of malaria risk mapping, and the extent of the risk areas in these maps, particularly under climate change, further yield much of the information that regular travellers might have outdated (coetzee et al. 2013; morris et al. 2013) . policy improvements therefore need to be aware of both the limitations in knowledge and shortfalls in risk-aversion behaviour, and the potential for these factors to worsen under climate change. for effective policy adaptation, however, a much larger sample group with greater socioeconomic heterogeneity would be valuable. while the regularly shifting extent of the malaria risk zone is posited as one of the reasons for a poor awareness among respondents, it could be argued that under climate change, an even more frequent updating and reporting of risk may be beneficial. seasonal malaria forecasts are being produced for south africa by local researchers (kim et al. 2019; landman et al. 2020) , which could be presented to the public biannually to refine malaria prevention behaviour. frequent and standardized government publication of season-specific information would potentially result in a greater reliance on these resources over word-of-mouth based on travel which occurred less recently. the avenues of the dissemination are also an important consideration in effective communication of malaria information (blumberg et al. 2014 ). finally, this study was conducted during 2019, prior to the covid-19 pandemic (gilbert et al. 2020) . this pandemic has, both globally and in south africa, revealed an unprecedented public engagement with disease epidemiology and risk-aversion, and the extensive use of social media in government communication (gao et al. 2020) . south africa has been ranked second in the world for the most reliable covid-19 information, due in part to the conditions of the national lockdown which prohibit the dissemination of fake news (ryklief 2020) . announcements directly from the national institute for communicable diseases and the minister of health, each of which distributed both to the press and via social media, have allowed the public to follow both case numbers and the state of knowledge on precautionary measures. this provides valuable insight into methods of effective communication with the national populace involving disease prevention (young et al. 2008 ). this pilot study explores the self-reported risk behaviour and awareness of malaria area boundaries among south africans who are resident outside of the high-risk malaria area. while respondents in this study claim to have a high level of awareness relating to malaria, the vast majority overestimate the spatial extent of both the current and future malaria areas and do not practice the indicated precautionary measures when visiting regions that they report to understand to be malaria-prone. part of this disjunct between their understanding of the malaria areas and their behaviour appears to relate to their sources of information, with a considerable reliance on friends and family, rather than official sources. while this pilot study involves a small target group who cannot be considered representative of any broader sub-population, we provide insight as to avenues for more comprehensive research, and a methodology which could be used. this more extensive research would provide valuable insight to improve policy and intervention. investigating the 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perceptions of disease publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord-279401-eehb5yny authors: haffejee, sadiyya; levine, diane thembekile title: ‘when will i be free’: lessons of covid-19 for child protection in south africa date: 2020-09-04 journal: child abuse negl doi: 10.1016/j.chiabu.2020.104715 sha: doc_id: 279401 cord_uid: eehb5yny background: covid-19 has highlighted and amplified structural inequalities; drawing attention to issues of racism, poverty, xenophobia as well as arguably ineffective government policies and procedures. in south africa, the pandemic and the resultant national lockdown has highlighted the shortcomings in the protection and care of children. children in alternative care are particularly at risk as a result of disrupted and uncoordinated service delivery. objective: the aim of this study was to explore the experiences and impact of the pandemic and the resulting social isolation on the wellbeing and protection of children living in a residential care facility. methods and participants: we used qualitative, participatory approaches – specifically draw-and-write methods – to engage with 32 children (average age = 13.5 years) living in a residential care facility in gauteng. findings: children in care demonstrated an awareness of the socio-economic difficulties facing communities in south africa, and shared deep concerns about the safety, well-being and welfare of parents and siblings. although they expressed frustration at the lack of contact with family members, they acknowledged the resources they had access to in a residential care facility, which enabled them to cope and which ensured their safety. discussion and conclusion: we focus our discussion on the necessity of a systemic response to child welfare, including a coordinated approach by policy makers, government departments and child welfare systems to address the structural factors at the root of inequality and inadequate, unacceptable care. this is essential not only during covid-19 but also in preand post-pandemic context. with care facilities either shutting down and releasing children prematurely or keeping children in-care, without access to family and friends. emerging reports from south africa confirm this, showing that key government departments responsible for vulnerable children in residential care have been severely hampered by the crisis (wolfson-vorster, 2020a). continuity of care as well as coordination of services between all essential service providers; key activities in ensuring the safety and protection of children, has been constrained (fallon et al, 2020) . in this exploratory study, we consider the impacts of covid-19 for children in one non-governmental organisation in johannesburg, south africa, which aimed to provide continuous and consistent care for children living in residential care. we ask 'what can the experiences and perspectives of south african children in care during lockdown tell us about the themes we should focus on to improve care moving forward? we focus on children's experience of the lockdown as well as covid-19; their concerns as well as the protective resources that enables them to cope. we frame the experiences of these children in care against a background of a crippled social system and reflect critically on what systemic changes are needed to support children. this study offers a way forward and contributes to an emerging body of research on the impact of pandemics on child well-being and protection. to address a global pandemic such as covid-19 requires inspired, informed leadership and co-ordination between all sectors of government and civil society. this has occurred to a limited extent in south africa. in comparison to the hesitancy that characterised some of the global responses to the pandemic, south africa's initial response was decisive. the complete national lockdown which began on the 26 th march 2020, saw trade, places of worship, and recreational activities shut down. a national curfew was mandated and movement between provinces prohibited. these stringent measures were considered necessary to flatten the curve and to ready the health system for a potential influx of cases. some rights groups and commentators however raised concerns about the impact and feasibility of such measures in a context with gross pre-existing and historic socio-economic inequalities (world bank, 2018) and a struggling economy (marais, 2020) . acknowledging these challenges and to mitigate against the worst impacts of the pandemic, the south african government introduced a number of temporary social and economic relief measures, which included increasing the health budget, economic support through the unemployment insurance fund, support for small business and tax relief measures. social relief support measures included the establishment of the special covid-19 social relief distress (srd) grant of r350 per month (£16/$20) as well as increases to existing social welfare grants, for example, the basic child support grant was increased by an additional r440 per month (£20/$26). the government, through the department of social development, also pledged to distribute food packages to communities most in need. as predicted however in a country with such disparate, intense needs these resources have simply not been enough, failing to buffer the majority of south africans from worsening j o u r n a l p r e -p r o o f social and economic conditions (van bruwaene, et al., 2020) . findings from the national income dynamics study-coronavirus rapid mobile survey (nids-cram), found that almost 3 million people lost their jobs during the most intensive lockdown period and during this time 1 in 7 children reported that they had gone hungry in the week before they were interviewed during may or june (nids-cram, 2020) . compounding, what is rapidly being seen as a humanitarian crisis, is the constrained leadership at national and provincial level and lack of co-ordination between government departments (thebus, 2020) . the department of social development (dsd), a key department in the care and protection of children and its minister, have been severely criticised for providing little leadership during this period (weiner, 2020) . for example, dsd's delivery of the much needed and promised food parcels have been hampered by reports of corruption and theft, cumbersome processes, lack of capacity to distribute food packages, lack of data on who needs this assistance and insufficient funds to meet the needs of the population (wolfson-vorster, 2020a). similarly, distribution of the covid srd grant has been challenged by complicated processes making it difficult to access. activists report that as at july 2020, approximately four months into lockdown, 74% of individuals eligible to receive the grant have not received it (thebus, 2020) . the department of basic education (dbe), another crucial department, took a decision, at the beginning of the lockdown period to also stop the national school nutrition programme (nsnp), as a result, the 9.6 million children who are dependent on this one meal a day have had to go without food. a number of child's rights groups instituted legal action against the minister of basic education as well as the provincial mec's, arguing that the failure of government to recommence this nutrition programme was a regression of the rights to education and to basic nutrition (see www.centreforchildlaw.co.za). on the 17 july 2020, dbe was ordered to reopen the nsnp, with the judge asserting that in closing the programme, the j o u r n a l p r e -p r o o f minister, and her mecs were in breach of their constitutional and statutory duties (wolfson-vorster, 2020b). to understand the impact that covid-19 has on the individual child we reference a multi-systemic framework; this framework situates the individual within broader systems and contextual factors, acknowledging the interconnectedness between physical, individual, relationships, community, and society. masten and motti-stefanidi (2020) note that risks to individuals span across all of these levels and as the pandemic unfolds, the challenges to these systems also change. similarly, factors that enable and support resilience are situated across levels. here we draw on a covid-19 specific explanation of systemic risks shared by the alliance for child protection in humanitarian action (2019) as well as that used by unicef (2020). from this perspective, individual level risks during a pandemic, include increased risks of child abuse, neglect, violence, exploitation as well as potential psychological distress and a negative impact on development. challenges also include adjusting to the changed circumstances, with school closures, disrupted routines, isolation from friends and peers and fear of the unknown and losing loved ones (ghosh, dubey, chatterjee & dubey, 2020; orgiles, morales, delvecchio, mazzeschi & espada, 2020 , zhou, 2020 . these changes may result in increased feelings of anxiety and distress or may exacerbate existing mental health issues and enhance the risk of developing psychological disorders (alliance for child protection in humanitarian action, 2019; wang, xiao, sun, wang & xu, 2020) . at the level of the family, risks may include family separation, reduced access to social supports, caregiver distress, heightened risk of violence/domestic abuse, disruption to family earnings as well as disrupted family connections and support and fear of the disease (spinelli, lionetti, pastore & fasolo, 2020) . community level risks may include distrust within communities, competition over j o u r n a l p r e -p r o o f limited resources, inadequate access to support services including educational resources and support (fischer et al., 2020; sekyere, bohler-muller, hongoro & makoae, 2020) . lastly societal level risks include corrosion of social capital and disrupted and inadequate access to basic services (fischer et al., 2020; scott, 2020; sekyere et al., 2020) . as discussed, within the south african context, these systemic risks are amplified by pre-existing challenges. present day south africa continues to be characterized by deeply embedded inequalities and structural violence, a legacy of colonialism and apartheid (loffell, 2008; tshishonga, 2019) . this inequality manifests in high levels of poverty, discrimination, poor access to education, health and social services, poor service delivery and exposure to high rates of communal and interpersonal violence (zizzami, schotte & leibbrandt al, 2019) . children in south africa are particularly vulnerable as a result of these structural challenges; for example, poverty creates food insecurity which impacts on a child's physical, mental and cognitive development (hall & sambu, 2014) . research suggests that prior to the pandemic a quarter of children in south africa were stunted, 12.5 million children were dependent on child support grants, 59% of children lived below the upper-bound poverty line, 30% of children were without access to water and 8% of children lived in overcrowded households (hall & sambu, 2014 , 2019 lake et al., 2020; van der berg & spaull, 2020) . poverty is recognized as a significant barrier to children's well-being, impacting on health and educational opportunities and increasing vulnerability to child maltreatment (fernandez, delfabbro, ramiac & kovacs, 2019; loffell, 2008; manyema & richter, 2019; meinck, cluver & boyes, 2015) . artz et al (2016) found that approximately 40% of young people in south africa have had direct experiences of abuse. fear and additional stressors caused by the pandemic provides an enabling environment that may exacerbate or trigger diverse forms of violence against children and women (peterman et al, 2020) . given the j o u r n a l p r e -p r o o f existing high levels of gender-based violence, sexual abuse and child abuse in south africa, of significant concern, during these exceptional times, is the safety of children, especially as many are in close, constant proximity to potential abusers. lack of income and employment opportunities and food insecurity are likely to increase conflict within families, thereby increasing risk to children (mathews, jamieson & makola, 2020 similarly, disruptions in education risks the wellbeing of children both in the short-term and may have significant long-term consequences. while some children have been able to access online learning, for the majority of children living in conditions of poverty, with no access to a phone, television or computer this has not been possible, further deepening the digital divide (fore, 2020) . van der berg and spaull (2020) report that by the beginning of august 2020, at least 4 million children will have missed more than half (57%) of the number of school days and they note that the education system in south africa is unlikely to make up this time. this has significant long-term consequences in a country with staggeringly high rates of illiteracy (howie et al., 2017) . j o u r n a l p r e -p r o o f (mamelani, 2013) . children identified as vulnerable includes a child who i) has been abandoned or orphaned and is without any visible means of support; ii) displays behaviour which cannot be controlled by the parent or care-giver; iii) lives or works on the streets or begs for a living; iv) is addicted to a dependence-producing substance and is without any support to obtain treatment for such dependency; v) has been or is at risk of serious physical or mental harm; or vi) has been abused, neglected, or exploited (mahery, jamieson & scott, 2011) . given the wide range of needs of children entering care, cyccs are mandated to not only provide for the basic needs of children in terms of food and shelter and access to education, but are required to make therapeutic programmes available. section 191 of the children's act provides a comprehensive list of programmes that should be offered. jamieson (2017) schmid & patel, 2014). historically, poor coordination between social and health systems in south africa during periods of health crises has meant that services to child and youth care centres have been inadequate (allende & khota, 2020) . the lockdown has intensified these. many children living in residential care come from disadvantaged communities and have been exposed to one or multiple traumas within the home or the community and some have pre-existing health problems (meintjies et al, 2007) . in this context, children may be safer in care where they have access to regular meals, shelter, protection and access to educational resources. the aim of this rapid exploratory, qualitative study was to understand how children residing in a care facility in south africa understood and experienced the lockdown measures imposed as a result of covid-19. we focus on the concerns that children in care experienced during this period as well as what helped them to cope. our decision to speak with children was informed by an acknowledgement that children are experts in their lives and capable of speaking on their own behalf. titi and jamieson (2020) found that only 10% of stories focus on children and less than half this number includes the voices of children, noting that such exclusion is in fact a violation of their rights. children residing at a child and youth care centre in gauteng, south africa (herewith referred to as cycc x) were invited to participate in the study. a cycc is defined as a facility that provides residential care for more than six children who are not living with their biological families (children's act, 2005) . cycc x is situated in gauteng (south africa) and was established by a social worker in 1992, in response to a growing number of mainly black south african children living on the streets. during this period, south africa was slowly transitioning out of apartheid and the country was characterised by uncertainty and ongoing hostility between various racial groups. the needs of disadvantaged, black children were often not acknowledged and services for this group was lacking or non-existent (loffell, 2008 for over 5000 children and is an active member in the child and youth care sector (newsletter, august 2020). the majority of children at cycc x have been exposed to one or more risk factors, including poverty, neglect, physical, emotional and/or sexual abuse and streetism. reasons for admission noted in the cycc's most recent progress report show that; 18% of children were admitted because of familial poverty, 5% of children were exposed to domestic violence, 23% reported parental neglect, 17% reported some form of abuse, 1% were placed in care for substance use, 8% were not attending school, 8% were street connected and 20% displayed uncontrollable behaviour prompting parents to request placement (progress report, 2020). as mandated in the children's act (children's act, 2005) , cycc x offers extensive programs to meet the physical, psychosocial, and trauma needs of these vulnerable children. this is delivered to children primarily through the in-care, residential programme and through a pre-care, prevention and early intervention programme and an after-care, transitory support programme. children in therapy consulted therapists online. although many of the schools that the children attended did not have an online teaching programme, educational activities continued throughout the period at the centre, with lessons delivered by teaching staff and online learning forums. information regarding the study was shared with children, who were then invited to participate in the study. participation was voluntary. a total of 32 children and youth chose to participate. the average age of participants was 13.5 years, 18 children identified as girls and 14 identified as boys. at the time of the study, all the participants were legally placed at the cycc. informed assent was obtained from the younger children and consent from the older children. to generate data, participants met in small groups, which were facilitated by a counsellor and a social worker, who both work at the centre. the decision to engage staff in j o u r n a l p r e -p r o o f facilitating groups was necessary during the initial, stricter levels of lockdown (when the data were generated) as non-essential staff were not allowed entry onto the premises. the first author has a working relationship with both the facilitators and provided information on the study aims and the methods. to guide the process, each participant was given a booklet with six open-ended questions related to covid-19 and the lockdown; each question had space allocated for participants to draw and/or write a response. the first question prompted participants to share something about themselves. the questions that followed included: -what are some of the things that are helping me cope? participants were then invited to share verbally in the groups what they had written, and what the drawing meant to them (angell et al., 2015) . this qualitative method, referred to as the draw, write and tell method of data generation, foregrounds the voice of the participants and is flexible and sensitive to the context and of the content (mitchell et al., 2011) . this method is particularly useful for use with children as it fun and non-threatening; it also gives children time to think through and structure thoughts before sharing and may also address linguistic difficulties (backett-milburn & mckie, 1999) . the method is, however, not without criticism with suggestions that it may undermine children's ability to adequately communicate their experiences, may be superficial and assumes that drawing is a fun activity for all children (angell et al., 2015; backet-milburn et al., 1999) . in our research, we gave children the option data comprised of the textual information generated by participants and was analysed following the six steps to inductive, thematic analysis described by braun and clarke (2006) . this method of analysis is used to identify, analyse and report themes within data (braun & clarke, 2006) . author 1 reviewed the data, becoming familiar with it and generated the initial codes and possible themes. these were then reviewed and refined by both authors and through a joint process, final themes were then defined and named. ethics approval for the study was granted by the university of leicester (9 april 2020). the director at cycc x, acting as legal guardian, granted consent and as mentioned above, informed assent was obtained for children younger than 12 and consent from those over 12. as well as delivering these fundamental ethical tasks, and aware of our positionality as researchers (both south africa, by birth, one indian and one white born during the apartheid era), our approach to ethics also accounted for four key dimensions accepted as important when delivering research in low resource settings experiencing chronic structural disadvantage j o u r n a l p r e -p r o o f association with cycc x and brought this experience to bear in ensuring a respectful approach was maintained throughout the data gathering process. author 2 visited the cycc x in 2019 and spent time with the staff team, with the intention of beginning to build a trusted working relationship. -risk-benefit ratioour exploratory project aimed to surface the key worries experienced by the participants, and had existing mechanisms in place to ensure they had adequate counselling and other support should significant issues arise. to ensure trustworthiness of the data, author 1 shared findings from the study with childcare staff and social workers based at cycc x; this group were in close contact with the children during the lockdown period and had engaged the children in similar conversations throughout the lockdown period. they were able to confirm the consistency of the findings. time constraints, for both children (including a demanding school schedule), staff (supporting online learning together with regular care duties) and ourselves, meant that, at the time of writing this, we were not able to share findings with the children. we used thick descriptions to describe the context and shared excerpts and images from the participants, ensuring we could begin to interpret the characteristics of each participant's contribution (schwandt, 2001) . findings from the study draws attention both to how the experiences and ways of coping for children in residential care are similar to that reported by children living in family contexts as well as how they differ. consistent with emerging literature on the impact of covid-19 on children's mental health, children in care reported experiencing a range of emotions ranging from frustration, anger and happiness and reported drawing on a host of resources to j o u r n a l p r e -p r o o f enable them to cope (ghosh et al, 2020) . children in care however differed with regards to their concerns, which centred primarily on worry for parents and siblings well-being. covid-19 as well as the variations in containment measures have raised concerns about the mental health and well-being of both adults and children (panchal et al., 2020) . for children in care, these feelings are exacerbated, as they are unable to have the normal contact visits with parents or extended family and tend to be under strict supervision, often grouped together with children with a variety of emotional and/or behavioural difficulties (lazzaro, 2020). children at cycc x similarly appeared to be experiencing a wide range of emotions in response to being under lockdown. fear, sadness and worry because of the virus, anger and frustration at having to be under lockdown away from family and school, as well as feelings of hopelessness and discomfort were mentioned. one of the participants aptly summarises the range of emotions she is experienced during this period, many of which were echoed by other the image (image 3) below by child 2 and her explanation reflects the complex relationship that children in care have with parents. for child 2, her concern for and attachment to her mum appears to override her mother's absence or potential parental neglect. speaking of her concern for her mum, [insert image 3: child 2 articulates her concern about her mother] in their concern, children and youth in care demonstrated an awareness of the 'i also think about school, when i will go back to school also if i will repeat a grade because i don't want to repeat.' these concerns are not unfounded, with child protection agencies asserting that many of the 1.5 billion children currently out of school worldwide will never return to school and will have limited future prospects (wolfson-vorster, 2020a). referring to the strict regulations that were of necessity imposed by the cycc, child 3 and child 32 both express frustration at not being able to leave the centre and go to school, in the image below (see image 4), child 3 draws attention to people that don't have homes. [insert image 4: child 3 expresses concern about those without homes.] the majority of children drew on internal, self-regulatory mechanisms to help them cope, this included exercise, reading, listening to music and watching television. this was accompanied by engaging with others through play and group sports. some of these resources, like television and radio, were easily accessible for children while in residential care. engaging with others through play was especially important for the younger participants, while for some of the older children helping staff with chores and younger children with homework appeared to give them a sense of purpose and stopped them from feeling bored. complaining. going to home work class and helping the staff with whatever they need help with.' sense of purpose has previously been identified as a potential protective factor in psychological resilience during adolescence (e.g. wang et al, 2017) . in addition to these internal mechanisms, structural resources provided by the cycc enabled children to cope. the ability to access education, through access to the online learning programme, 'doing my homework online' (child 4), alleviated some of the children's fears of falling behind and also kept them occupied, facilitating coping. it is important to note here that for the majority of children in south africa accessing education through online forums was not possible (van der berg and spaull, 2020). the awareness of being safe also helped children cope; 'we are very safe, we are in our homes and in our shelters because if we were outside we should have been dead or killed' (child 9). child 10 echoes this saying, 'by knowing i am safe.' as above, these statements suggest that participants in care are fully aware of the dangers present in communities; as mentioned above, approximately 45% have had exposure to some form of violence. the structure and support offered by the cycc enables them to feel safe. this sense of safety also enabled some children to focus 'on the positive side of life' (child 18). the following images (images 5 and 6) from participants captures this range of protective, resilience-enabling resources. [insert: image 5 and 6: participants share their protective, resilience-enabling factors] covid-19 has been referred to as an unprecedented event, unparalleled in its impact. in this global reach, it highlights more than any other event in recent times, our global inter-j o u r n a l p r e -p r o o f communities and societies are differentially impacted. in south africa, the social and economic disruptions caused by the pandemic and associated lockdown, combined with long-term structural social, economic and political inequality, and failures within government has impacted on service delivery, access to resources and availability of supportive networks, the absence of which increases vulnerability and heightens levels of anxiety and stress in children. in this exploratory study we aimed to address the research question 'what can the experiences and perspectives of south african children in care during lockdown tell us about the themes we should focus on to improve care moving forward?' as the findings emerged, we noted that there were a number of domains of concern that reflect the social ecologies in which our participants operated. in spite of being 'out' of community contexts, our findings show that children in care situate themselves firmly within their social-ecologies. they continue to express concern for families and for communities (some who may have rejected them). they acknowledged the resources that they have access to while at the cycc and through their concern for parents, siblings and wider society also acknowledged the prevalence of hunger, violence and food insecurity in south africa. for many south african children, pre-existing structural challenges heightens exposure to a multitude of risks. covid-19 has increased these risks factors. the majority of children admitted into care at cycc x have been exposed to poverty and child maltreatment. (jamieson, 2017) . cycc x, as many others, tries to provide an environment that is consistent, stable, and built on supportive relationships; studies show that access to this sort of environment provides a measure of protection in the face of multiple adversities (collishaw et al, 2016; mosavel et al, 2015) . many of the children acknowledged the protection and support offered to them and which helped them to cope. thus, even while in careoften thought of as the last possible resort for vulnerable children -in this protective context, they were also able to access their own internal resources and reach out to support others. research shows that child-level resources are most easily accessed within the context of a responsive, accessible ecology (ungar, 2011) , the absence of which may negatively impact on the child's well-being. the importance of self-regulation in mediating resilience pathways our findings showed that participants drew on a range of internal resources to help them cope, which was facilitated by caregivers that were available, access to therapeutic support as well as access to resources, like television, sports, books and online learning forums. of significant concern for the participants in our study, was the closure of schools. this experience is consistent with findings emerging from other studies, across diverse contexts. ghosh et al. (2020) note that being quarantined in homes and institutions presents a bigger psychological burden than that of the actual pandemic; adding that school closures, lack of physical activity and aberrant eating and sleeping habits may potentially promote monotony, distress, impatience, annoyance and varied neuropsychiatric manifestations. isolation and the absence of routines imposed by schools may also lead to psychological distress as schools provide stability and may be a coping mechanism for some children (lee, 2020). in the context of the residential care facility, the psychosocial support offered by schools, takes on further importance in that it represents an additional, external space away from the confines of the facility. in addition to the supportive role that schools play, for children at cycc x, absence from school was seen as a significant obstacle, potentially jeopardising future plans. south african research with youth exposed to structural adversity show that access to education and the presence of future oriented plans enable positive adaptation in contexts of risk and is regarded as a means to securing a better more economically stable future (lundgen & schekle, 2019; theron & van rensburg, 2018; walker & mkwanazi, 2015) . in the context of an emergency, such as this one, protecting the rights of children in residential care requires collaboration across multiple sectors, including government ministries (better care network, 2020). masten and motti-stefanidi (2020) suggest that every disaster brings with it lessons for future resilience planning at multiple levels. as such, learnings from this experience may be leveraged to repair and transform the child protection sector, strengthening system responses and building resilience. the findings of our study suggest that it is only through co-ordinated, holistic, and strategically sound collaboration that we will be able to protect children in care in south africa. some of the challenges experienced by children during lockdown particularly with regarding concern for family members, suggests a need for creative problem solving by care facilities to ensure that children have continued contact with families. digital technologies may j o u r n a l p r e -p r o o f offer new solutions using 'free at the point of use' services for families to stay in touch with cyccs, if not children themselves if access to technology is not universal. regional or national policy programmes facilitating solar chargers for communication devices in cyccs, and devices themselves in limited numbers, would overcome this barrier at a relatively low cost. beyond this emergency response planning, the pandemic has reinforced the need for broad scale systemic changes, necessary to protect and assist the most vulnerable communities in south africa. strengthening economic support for families is essential given the increasing levels of poverty, food insecurity and growing rates of unemployment. current calls for a universal, unemployment or basic income grant and general increase in child support grants are positive developments in the right direction. our findings on the significant role that parents play, even in their absence, suggest a need for positive parenting skills and family strengthening interventions that will ensure that children are cared for in family environments. combining social support grants that provides a measure of protection against the impacts of poverty with family strengthening interventions promotes greater child and youth development and well-being (cluver et al, 2016). families and communities should be safe spaces for children; the appallingly high prevalence of gender based violence and child abuse demands greater accountability from government and co-ordinated action from all departments, including justice, social development and health. the promotion of social norms that protect against adversity and violence through public education campaigns, legislative approaches that acknowledge and prioritise gender based violations and that develop and implement gender sensitive solutions is necessary (cdc, 2019). participants concerns regarding the interruption of their schooling highlighted the centrality of education in nurturing hope for children exposed to adversity. the importance of j o u r n a l p r e -p r o o f the schooling system has also been the subject of much discussion in the country throughout the pandemic. the role that education and educational systems have on youth development suggests a need for increased efforts in ensuring that these spaces are fully resourced and accessible. efforts must be to ensure that digital poverty is addressed, and that all children have equal access to adequate schooling. this study took place under unusual circumstances demanded by a global pandemic. as a result, there are limitations to the conclusions we can reasonably draw that could be mitigated by future research. our intention was to capture, in the most systematic way we could, the immediate experiences of our participants during the most intense period of south africa's lockdown, and our design reflects these priorities. the study has four key limitations to which we draw attention. 1. the size of the sample and length of the data-gathering period invite further investigation, in other alternative care settings in south africa and beyond. 2. qualitative research is dependent in part on the skill and experience of the person gathering the data. we mitigated the risk of poor data quality by ensuring the approach was closely structured and supported by author 1, and that a common prompt tool was used across the sample. 3. the qualitative nature of the study facilitates a rich and trustworthy understanding of the perspectives and experiences of our participants, but should not be read to imply causality. 4. in order to increase trustworthiness, our study relied on a well-tested method; arguably future research of this type should seek to take a more africa(n)-aligned approach to gathering data, which will bring with it additional strengths and some risks. our study with vulnerable children in care has provided a living example of the ways in which the covid-19 pandemic exposes and exacerbates the inherent structural inequalities that characterise south africa. this exacerbation of existing inequalities lies at the interface between public health, and societal and systemic structures. covid-19, devastating in its impact, urges accountability and provides multiple opportunities to learn from and build the capacity and resilience of individual, family, community and societal systems. caring for children in uncertain times principle 10: strengthen children's resilience in humanitarian action draw, write and tell': a literature review and methodological development on the 'draw and write'research method relationship between resilience and selfregulation: a study of spanish youth at risk of social exclusion a critical appraisal of the draw and write technique social dimensions of covid-19 in south africa: a neglected element of the treatment plan spike in child abandonments and the physical abuse of youngsters during lockdown technical note on the protection of children during the covid-19 pandemic: children and alternative care. retrieved from: review, 97 & yerkes. m. 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macleod, catriona; böhmke, werner title: the conundrums of counselling women in violent intimate partner relationships in south africa: implications for practice date: 2019-06-08 journal: int j adv couns doi: 10.1007/s10447-019-09384-8 sha: doc_id: 11023 cord_uid: eahx37cy little research focuses on how counsellors experience counselling encounters concerning intimate partner violence. this study reports on narrative research conducted with eight south african non-governmental organisation counsellors. participants spoke of creating productive and caring counselling dynamics, and providing non-directive counselling. however, they also indicated providing moral guidance, particularly in cases where pregnancy or children were involved. success was viewed rather narrowly as the women leaving the relationship, setting up ‘all-or-nothing’ outcomes. such ‘success’ led to counsellor happiness, whilst failure in this regard led to counsellors experiencing anger and burn-out. we conclude that the conundrums evident in these data are grounded in patriarchal systems, limiting the efficacy of counselling based on a bondage and deliverance narrative. implications for practice and training are also outlined. local and international research has shown that counselling for women who have experienced relationships characterised by intimate partner violence (ipv) can have many positive effects. these include women gaining confidence to leave a violent/abusive relationship (hatcher et al. 2013; jewkes et al. 2002; rhodes and mckenzie 1998) , considering options for solving problems within the relationship, and increasing their emotional wellbeing (iverson et al. 2016; rhodes and mckenzie 1998) . counselling, however, may also be challenging. for example, research into a latino community in the usa revealed that counsellors sometimes did bnot consider some potentially important personal barriers to reporting^, such as the victim's shame (lewis et al. 2005, p. 81) . various models of conducting counselling in relation to ipv have been suggested in the literature. these include: viewing ipv relationships as developing in stages, and modelling therapy based on this perspective; a client-centred approach in which the counsellor facilitates the client in choosing solutions and actions that are compatible and appropriate for themselves (the client) (mchattie 2011); and a competency framework that focuses on counselling skills, specialist knowledge and specific personal characteristics needed for working with this client group (roddy and gabriel 2019) . research on the experiences of receiving counselling for ipv has been used to refine recommendations for the counselling encounter (roddy 2016) . little research has been conducted, however, on how counsellors themselves experience and describe their own positioning within the counselling encounter. given the high level of gender-based violence in many countries (including south africa, the site of this study), and that counsellors tend to be women, how the counsellors experience the counselling encounter in regard to ipv is an important aspect of understanding such counselling. in this paper, we report on a study in which we interviewed counsellors, using narrative interviews, about their understandings of relationships characterised by ipv and how they, as counsellors, worked with ipv in their practice. all of the counsellors interviewed were women. we report, in this paper, on these counsellors' experiences of providing counselling within the context of the study. south africa has one of the highest prevalence rates of ipv in the world (britton 2006; joyner and mash 2011; modiba et al. 2011, p. 872; ntaganira et al. 2008) . ipv cuts across all ethnic groups regardless of education or income level, or the victim's or perpetrator's line of employment (modiba et al. 2011) . south african research reveals that 19% of women have experienced a lifetime prevalence of domestic victimisation (seedat et al. 2009 ) and 27.5% of south african men reported abusing their current or most recent partner (gupta et al. 2008) . there are many barriers that women face in south africa when reporting ipv, related to resource constraints and social issues. the resource-related barriers include the relative lack of availability of healthcare or service provision facilities in the first place (mbokota and moodley 2004; modiba et al. 2011; njuho and davids 2012) . other reasons include lack of adequate assistance due to problematic interactions with counsellors (rasool bassadien and hochfeld 2005) . that is, counsellors may sometimes view ipv as a private matter, or that it is a normal phenomenon, possibly leading to lack of action or non-interference (rasool bassadien and hochfeld 2005); they may misdiagnose ipv (joyner and mash 2012) , be afraid to intervene on behalf of the community (lewis et al. 2005) , and may not have received adequate or appropriate primary care training (noted locally, mash et al. 2012, and globally, watts and mayhew 2004) . in terms of social issues, some women may not report abuse due to conservative gender roles; e.g., the belief that the man is the head of the household and that his authority, and manner in which he runs the household, should not be questioned (sugarman & frankel 1996 , cited in jewkes et al. 2002 . as a result of the relatively widespread acceptance of such conservative and traditional gender roles within south african society, ipv has, in many respects, become normalised within relationships. women may either accept such violence as an everyday feature of their intimate relationships, or may see themselves as deserving of violent treatment from their partners for failing to adhere to culturally-located gendered expectations regarding their relationship roles (kim and motsei 2002; wood et al. 2007) . as a result, many women who experience ipv may feel that their violent partners were justified in their actions or that they did not harm them intentionally (silverman et al. 2004) . women may also feel reluctant or ashamed about reporting ipv (lewis et al. 2005) due to the personal, and sometimes sexual nature of the assault (vogelman and eagle 1991) . cultural and contextually mediated understandings of violence in intimate relationships, as well as subjective interpretations of the relative harm sustained, may also play a role. for example, anthropological research in south africa has described violence in interpersonal relationships as being understood by those involved as a demonstration of love, depth of feeling, or emotional investment in the relationship, with women victims of ipv consequently downplaying the harm caused (wood et al. 2008) . as noted earlier, ipv is also often not recognized by primary care providers and when it has been identified, the treatment has often been badly coordinated, fragmented, missed important aspects and/or lacked continuity (joyner and mash 2012) . this may be due to the lack of appropriate or adequate training that healthcare workers receive, both globally (watts and mayhew 2004) and locally . the south african non-governmental organisation (ngo) sector has played a role in addressing ipv. there are a number of safe houses available for abused women within south africa (kaldine 2007 ) often linked to ngos. the south african ngo sector also has many organisations linked to women's movements, examples of which include family welfare society and living hope. these ngos offer various services including counselling for domestic violence, women's upliftment, empowerment programmes, interventions, legal support and shelter services. in essence, these organisations specifically aim to bengage masculinities within 'feminist' frameworks^due to bthe growing institutionalisation and ngo-isation of the south african women's movement^ (britton 2006, p. 145) . due to the various problems surrounding access to counselling for ipv as noted above, effective help from counsellors and healthcare professionals is vital when ipv is reported. indeed, b[a]chievement of an efficient healthcare system which enhances respect for women and children is likely to contribute to a reduction of violence in communities and [will] subsequently boost the quality of life in south africa^ (njuho and davids 2012, p. 280) . research shows that women who have utilised the services of counselling centres are able to consider options for solving problems within the relationship, increase their emotional wellbeing (iverson et al. 2016; rhodes and mckenzie 1998) and also develop an enhanced ability to physically remove themselves from the abuse (hatcher et al. 2013; jewkes et al. 2002) . a variety of models for conducting effective counselling for those experiencing ipv have been developed. for example, the care guidelines by miller et al. (2002) outline addressing decision-making, which clinical services should be considered, and timelines for when intervention and assessment should occur. feminist principles proposed by mwau (2000) include helping women to explore options, acknowledging their strengths, assisting them with coping with shame or guilt, educating them about ipv dynamics and validating women's feelings. research conducted on clients' experiences of counselling has been used to enhance counselling dynamics. for example, women have emphasised the need to share their stories with counsellors within a safe and trustworthy environment (mchattie 2011; roddy 2016) where there was sufficient time to explore issues (roddy 2013) . other important factors are clients having their agency supported, being able to complete certain tasks, learning skills, having access to information, the importance of empowerment (mchattie 2011), and counsellors recognising diversity (e.g., same-sex partnerships) and nuances within relationships (oswald et al. 2010) . overcoming shame in relation to ipv within a non-judgemental environment was also linked to feelings of acceptance and validation (roddy 2013 (roddy , 2016 . however, very little research has been conducted on the experiences of counsellors who work with ipv, with research of this kind being useful for enhancing the quality of counselling. exceptions include zust et al.'s (2017) study with evangelical pastors, who indicated that they were ill-prepared to deal with domestic violence, and that counselling focused mainly on keeping the children safe and helping victims/survivors to understand that the violence was not their fault. iliffe and steed (2000) found that counsellors in their study who were involved in ipv issues experienced vicarious trauma, reported changes in their views of safety and gender power issues, as well as feelings of isolation and powerlessness as a result of the involvement. this study used a narrative-oriented inquiry (hiles and čermák 2008) , based on the 'lightly-structured biographic-narrative interview structure' by wengraf (2001) see further details belowto investigate the micro-narratives elicited from counsellors when they spoke about their understandings of ipv and their practice in relation to it. narratives are bstories with words and meanings^that are linked to certain social groups and communities and provide information about the experiences and ways of life of these groups and communities (jovchelovitch and bauer 2000, p. 58) . micro-narratives can be defined as bshort bursts of narrative interactionally embedded in question-answer sequences: several stories produced often in intricate relations to one another^ (blommaert 2006, p. 181) . they often take the form of smaller, personal stories (fok 2011) and are bprovisional, contingent, temporary, and relative^ (barry 1995 , cited in o'donovan 2006 . although each person's narrative is idiosyncratic to their life experiences (hiles and čermák 2008) , narratives also benable human experiences to be seen as socially positioned and culturally grounded^ (hiles and čermák 2008, p. 149; young and collin 2004) . thus it is suggested that people construct narratives by drawing upon culturally-available social and discursive resources. data were collected by means of interviewing counsellors, using wengraf's (2001) method, who were based at two ngos, one located in an urban and the other in a peri-urban area in the eastern cape, south africa. these areas were chosen to ensure some diversity in the micronarratives. the clients who approach these ngos are from a lower socio-economic bracket. the agencies offer a variety of services including individual, couple and family counselling, women's empowerment initiatives and working in conjunction with the magistrates' court and the police to process safe house referrals and protection orders, as well as handling divorce and maintenance orders. the counsellors also intermittently enter the local communities to share knowledge and information on human rights. across the two sites, eight counsellors were interviewed for this research; owing to the relative size of the organisations, two were recruited at the peri-urban site and six at the urban site. the participants all had experience counselling people who had experienced ipv. seven of the counsellors were lay counsellors who had received in-house training and the other had a degree in social work. some of the counsellors themselves had been abused by their partners and thus could be seen as 'wounded healers'. counselling by 'wounded healers' may be beneficial as the counsellors are able to identify with the clients' traumatic experiences, and, through self-disclosure, can de-stigmatise the clients' experiences. on the negative side, however, counsellors may become too emotionally involved in their clients' situations, be unable to manage the countertransference set up in the encounter, and suffer from compassion fatigue (zerubavel and wright 2012) . at both sites, a client-centered, solution-based approach to counselling is adopted. after listening to the clients' stories, the counsellors, in a private, one-on-one setting, probe for more information, offer clients a variety of options for action, provide emotional support for the particular path chosen by the client, and offer to link the clients directly to places where they can get help. the study was granted ethical clearance by the rhodes university psychology department's research projects and ethics review committee. counsellors all provided their consent for the interviews to be conducted, including the fact that the interviews would be digitally recorded. the participants were assured that they would not be asked to divulge sensitive personal issues (e.g. their own histories in relation to ipv), as our research was focused on their experiences of their counselling. locations and names mentioned in the interviews were kept non-specific and the participants were asked to choose pseudonyms so as to ensure that the information could not be linked back to them. all of the participants were women; seven were black and spoke isixhosa as a home language; one was white with english as a home language. all were fluent in english. the first author and a co-researcher together conducted three separate interviews with each of the eight participants, using wengraf's (2001) method. this interview method allows the content of the narratives to guide further questions that the interviewers might ask. during the interviews, the co-researcher took notes, specifically focusing on topics that emerged during the elicitation of counsellors' micro-narratives. in the first interview, the counsellors were asked, using an open-ended narrative-inducing question, to share their understandings of ipv, and their experiences with conducting counselling sessions with clients who were in relationships characterised by ipv. in the second interview, held 15 min after the first one, the researcher asked questions based on topics that had emerged during the first interview. the third and final session was conducted two months later, once the data had been transcribed and after a preliminary analysis had been conducted on the data, so as to determine which topics would be suitable for follow-up questions in the final interview. the data were transcribed verbatim using parker's (1992) transcription conventions (see appendix). these conventions were selected as they provide details of the talk (pauses, interruptions, etc.) without being too technical. the data were analysed using aspects of taylor and littleton's (2006) narrative-discursive method in order to examine the micro-narratives that emerged during the interviews with the counsellors. taylor and littleton's (2006) approach focuses, inter alia, on how micro-narratives enable subject positioning (the depiction of people within particular roles and responsibilities) to take place. the interview recordings were listened to several times and the transcription read at the same time. the transcribed data were imported and coded using qsr nvivo 10, a qualitative data analysis software program. coding centred on the identification of micro-narratives. in the analysis, we examined common micro-narratives occurring across the interviews and at different times in the same interview, which allowed us to see patterns in the counsellors' micro-narratives. all three authors engaged with the analytical process, and the findings were presented to peers in order to refine the analysis. the following micro-narratives were identified across the interviewees' data: 'we develop good counselling dynamics', 'we use non-directive counselling', 'when things go well, we feel positive', 'counselling ipv victims is emotional labour' and 'we provide moral guidance and suggestions'. with regard to each of these, the subject positions enabled by the micronarratives, and the implications for counselling are discussed below. the counsellors shared that they utilised a variety of session management tools (praise for clients; listening deeply; building trust) in order to create a positive environment and appropriate counsellor-client session relationships/dynamics. in this way they positioned themselves as professional, and as following well-established counselling techniques. some of the counsellors indicated that they praised their clients for coming to see them. this, they explained, formed a positive relationship between the client and counsellor, as can be seen in the following extracts: extract 1: duvi (p5): ...so the woman straight away she's going to be straight and say that 'enough is enough /hmm/ ja 'when i am looking at myself … i see that i'm going nowhere' /hmm/ hmm …i even congratulate her /mmm/ saying that 'no-one forced you to come here' /mmm::/ meaning that you are ready to take any step. extract 2: lwando (p3): ...as for us at [name of ngo] (.) once a woman take[s] a step forward =/mmm/ (.) to look at herself =/mmm/ (.) we see that as a survivor person =/mmm/= because once you find that … you need i-advice =/yes/= you need i-solution /mmm/ you need to find out what will work for you /mmm/ so once you take a step (.) we take you … as a great survivor. in the above extracts, duvi spoke of attempting to build a positive relationship with her client by bcongratulat[ing]^her for coming to see her, and lwando by bsee[ing] that [person] as a survivor^. these affirmations are seen as important to the process of taking bsteps^in the right direction; i.e., the women moving towards solving the problem. across the dataset, interventions were viewed by the counsellors as something that should help the women leave their ipv situation. these extracts reveal how a story of bondage and then of deliverance (see haaken 2010) , or at least the possibility of deliverance (byou are ready to take any step^; bwe take you as a great survivor^), provided a positive framing that counsellors encouraged in the session. the client's movement from victim to survivor through extracting herself from the relationship was viewed by the participants as an essential element of successful counselling. counsellors acknowledged that the movement from victim to survivor requires counselling labour. some of the counsellors mentioned providing a space to listen empathetically and attentively to their clients as an important counselling management tool, seen in the extracts below. intervention. this is because trust and confidentiality are important aspects of effective intervention as they provide the safe space in which the client can share her stories. the counsellors mentioned that they educate their clients about their rights and available intervention options. within this micro-narrative, the participants saw the counsellor's job as being non-directive, simply assisting the client to make the best decision for her amongst the options presented, as exemplified in the extract below. however, this micro-narrative stands in contrast to the counsellors' stated orientation of working towards the client leaving the ipv relationship. certain examples of subject positioning, however, show the slippage from nondirective to directive counselling. shelly (p1): i always tell them (.) it's very good to talk =/mmm/= not to keep inside you mmm/= talk about it so that …when you are talking …you're also getting the answers …because the answer is not coming from people … that you are sharing with (.) it's also coming with from you =/mmm./… you started to do this by yourself =/mmm/= you have to be strong for that. in extract 7, despite indicating that she does not say bdo these things^, amandisa takes up the subject position of beducator^in relation to her clients, narrating how she informs them of their rights and the options open to them. in this way, she suggests that women are victims of ignorance: they are less knowledgeable than the counsellor or are un(der)educated and in need of information in order to best decide how to manage their ipv situation. as the counsellors are speaking from an institutional space of helping women with ipv situations, they are considered qualified to speak about interventions because of their skills, expertise and knowledge in the field. furthermore, being in an institutional 'space of helping' may reinforce counsellors' narrative of bondage/deliverance of which they see themselves as facilitators. they thus act as facilitators of deliverance by representing apparently neutral options to their clients. this might in turn obscure the contradiction between their stated neutrality and their practice of providing options that follow a restrictive narrative of successful counselling outcomes. nevertheless, these options are presented, according to shelly, in a neutral way, with the client having to make her own decisions, as seen in extract 8. in this extract, shelly outlines that an element of counselling is women providing their own answers through talking with the counsellor. shelly constructs her clients as having their own agency and responsibility for their futures. interestingly, amandisa initially indicates that she gives badvice^. this is quickly corrected to giving boptions^because telling clients what to do is viewed as problematic. work undertaken to promote the perception of neutrality seems to be a defining feature of the first micro-narrative of 'good practice'. we will take up the slippage between non-directive and directive counselling in a later analytical section. counsellors spoke of positive experiences when reflecting on successful outcomes. examples of these positive reflections can be seen in the following extracts: extract 10: lwando (p3): women … they (.) becoming brave to report these cases that makes me very happy =/mmm/= and even if the case has been taken to court and then the perpetrator is being sentenced =/yes/= that makes me very happy. shelly's extract above expresses emotional satisfaction (bfeel[ing] good^) at essentially helping clients (to leave relationships characterised by ipv). similarly, lwando expresses happiness at women being 'brave' and reporting cases as well as the outcome of a perpetrator being sentenced in court. importantly, lwando's extract emphasises the view that successful interventions, as mentioned earlier, are those where the women leave relationships characterised by ipv. clients are seen to change from the subject position of victim to survivor in the extracts as the women in these cases have been bbrave^: they have become survivors by taking the cases to court and having the perpetrator sentenced (extract 10). it is in these circumstances that the counsellors experience positive emotions and feel that they are successful in their work of helping their clients. a clear micro-narrative that emerged in the interviews concerned the emotional labour that goes into providing counselling for ipv clients. counsellors spoke about the sessions evoking strong emotions in them, the difficulty at times to remain objective as a result and thus the need to look after themselves. this can be seen in the extracts below: extract 11: shelly (p1): i got angry when … (.) a woman is staying … in an abusive relationship /mmm/ i got angry very angry =/okay/ … because … i stayed (.) but i don't want someone to stay there because i know (.) how it's pain … yho i know that in extract 11, shelly's struggle to remain objective can be seen in her revealing that she felt angry when her clients chose not to leave relationships characterised by ipv. in constructing this micro-narrative, shelly positioned herself as caring, as she is concerned for her clients and interested in their well-being. this can be seen in her remark that she understood and identified with the bpain^that the woman in this case was going through. the anger shelly felt at her client's inability to see the necessity of leaving the relationship links to work on wounded storytellers; frank (2003, p. xv) suggests that anger or bchaos [is] in the claustrophobia of confronting others' inability to see what [one] so clearly feel[s]^. shelly, as the wounded healer, managed, eventually, to accomplish the situation most desired by the counsellorsthat women leave abusive relationships. as such, she feels compelled to assist the client along the same path, and thus experiences the countertransference of anger when this does not occur. while confessing to anger, shelly also positioned herself as knowledgeable (through the experience of not leaving at first). in this way, the woman client is positioned as a victim with little agency. as a result of their work being emotionally taxing, the counsellors spoke about trying to look after themselves and one another in order to continually carry out their work effectively, as can be seen in the following extracts: extract 12: nomsa (p2): we still have the [weekly] supervision … so each week we bring … all those worrying cases /mmm/ and also we … get … advices from the:: other … colleagues /okay/ …we … present your [our] case [p claps] and all other … colleagues will intervene in your case /that's great/= [we] discuss discuss discuss (.). extract 13: amanda (p7): i have in the past (.) organised … (.) consultations with:: … a private person or someone =/mmm::/= … to deal with that =/yes/= … to make sure that it doesn't overwhelm [me] . nomsa indicates that she and her colleagues were interested in supporting one another and were concerned about one another's wellbeing in light of the emotionally taxing work that they do. they discuss ball those worrying cases^, providing input and advice. nomsa alluded to the idea that the helper needs help to navigate the bworry^, and suggested that the counsellors take on the burden of their clients' ipv experiences by feeling empathy for the clients. amanda expressed concern over the real possibility of the work overwhelming her emotionally, and pointed, therefore, to the need to consult a person outside of the ngo for professional supervision. as was noted earlier, the counsellors indicated that they provide non-directive counselling, in particular presenting their clients with options for resolving the problems they are facing. however, the counsellors also spoke at times about encouraging their clients to engage in certain practices/behaviours through providing moral guidance or suggestions. this occurred mostly when discussing matters involving pregnancy or children. these moral suggestions included encouraging women to look after themselves during pregnancy and to consider the children: not to leave them behind if the woman was thinking of leaving a relationship characterised by ipv. this stance is opposed to letting the woman freely choose their options without such suggestions. in relation to this, it is important to note that the moral suggestions and guidance offered by the counsellors were largely influenced by culturallylocated and socially-sanctioned constructions of gendered roles and subjectivities, especially those around the concept of motherhood. these ideas can be noted in the extracts below: extract 14: mrs. x (p8): i always remind them that it's only temporary that your tummy is big. you're going to have your baby in your arms no more in your:: tummy after nine months so for the nine months that the baby is depending on you for survival you need to take better care of yourself . mrs. x (participant's chosen pseudonym) is attempting to reassure her client that the pregnancy is temporary and that her client must btake better care of [her]self^. in this way, mrs. x was positioning the woman as a nurturer with a responsibility towards her children. while not problematic in and of itself, this positioning leads to the moral injunction of self-care. in providing this moral injunction, mrs. x was subtly implying that failure to attend to this self-care could result in damage to the children. preventing damage to the children thus becomes the sole responsibility of the woman; failure to engage in self-care results in the woman being positioned as wilfully refusing to prevent damage. shelly stated that if a woman was thinking of leaving a relationship characterised by ipv, she bmust think about [her] children^. as with mrs. x, shelly was placing herself in a superior subject position as she seemed to feel that she had the status, knowledge and expertise in order to provide this moral guidance. the micro-narratives the counsellors related of their experiences of counselling women in ipv relationships, and the associated subject positions, point to a number of conundrums or double binds. the counsellors positioned themselves as professionals who implement good counselling practices (praise, listening, confidentiality, trust); at the same time, they could not help but feel angry, burnt-out and overwhelmed. when counselling was successful, the counsellors felt positive, but there were often failures, which they reported led to anger. this anger could be viewed as the countertransference of wounded healers, who, having suffered similar abuses, simultaneously empathise with the client, feel righteous anger towards the perpetrator, and dismay at the lack of 'success' (zerubavel and wright 2012) . throughout the data, 'success' was described by the counsellors as the woman removing herself from the ipv relationship. as such, the classic narrative of women being delivered from bondage formed the foundation of counselling. within this narrative, women who remain are regarded as victims and women who leave are considered survivors. this creates a dichotomy or an 'all-or-nothing' position within the counselling dynamic. the counsellor's emotional investment in the client and relationship building (such as ensuring confidentiality and thus building trust, listening attentively, displaying empathy where possible, promoting strength) was seen as worthwhile when the woman leaves the relationship (see also lewis et al. 2005) . however, the counsellors indicated becoming discouraged when the woman remained within the relationship. counsellors indicated that they used non-directive counselling, informing women of their rights and options and assisting them in making decisions. in this, however, the counsellors positioned themselves as experts on the options open to women, and regarded the women as experts on their own lives. however, there were limits displayed to simply allowing women to make their own decisions. when it came to matters to do with pregnancy or children, the counsellors felt it imperative to provide moral guidance on the correct form of action; i.e., that women must engage in self-care and take their children with them if they were to leave the relationship characterised by ipv. the fact that these counsellors invested in a narrative of female survivorhood, that implied leaving violent intimate relationships, is perhaps not surprising, given the high rates of abuse in the country and that all counsellors interviewed were women. counsellors who have experienced abuse themselves (some voluntarily revealed this in the interviews, as can be seen in one or two extracts here) may create an emotional weight or responsibility if their female clients choose not to leave the relationship. we argue that the conundrums evident in the counsellors' talk stem from the fact that they counsel the women within already entrenched patriarchal and structural power relations. there is no guarantee that the women will be able to successfully leave their current relationship characterised by ipv, or avoid another one in the future, and the counsellors were painfully aware of this. they nevertheless held onto the narrative of bbondage to deliverance^or bvictimhood to survivorhood^as the only valid outcome of counselling. this singular narrative regarding what constitutes a 'successful' outcome of counselling women who have had experiences of ipv during pregnancy, does not take into account the sometimes very real structural and/or cultural obstacles that frequently prevent women from leaving relationships characterised by ipv (e.g., economic dependency on their partners for survival, or culturally-located customs and traditional practices regarding marriage bonds) (see fleischack et al. 2017 ). this 'narrow' view of counselling outcomes may, therefore, be more likely to fail than not. indeed counsellors' insistence on clients' adherence to patriarchal and culturally-entrenched forms of motherhood may unwittingly constitute a barrier to successfully leaving an ipv relationship, thereby undermining their own criterion for a successful outcome (that is, leaving the ipv relationship). the counsellors indicated that they felt overwhelmed, fatigued and disappointed if their clients did not leave the ipv relationship. this emotional cost suggests that the counsellors as well as the clients were victims, working against a patriarchal system. in this tough and challenging environment, the counsellors often turned to one another for help, support and guidance. our research illustrates the importance of studying not only clients' but also counsellors' experiences so as to improve counselling concerning ipv. the conundrums illustrated above point to a number of implications in terms of the counselling process. firstly, to obviate counsellors feeling that their emotional investment has not been worthwhile, a useful perspective would be to see clients as complex beings: somewhere between victim and survivor, slipping between the two depending on circumstances, or as neither. this may also allow the counsellors to see and value small gains in their counselling process. examples include: when the women come to counselling in the first place, because they feel hopeful that they can receive some assistance; valuing women having a comfortable space to share their stories to gain some insight (which also links to moon's 2006 idea that story telling is a means to healing); and the notion of women engaging in everyday practices that serve to increase their agency and reduce the ipv, even if it involves remaining in the relationship. thus, secondly, the narrative of bondage and delivery (i.e., being in an ipv relationship followed by leaving) needs to be nuanced to allow for other narratives of success, including changing dynamics within the household or simple mechanisms to reduce the possibility of abuse. this is particularly important in circumstances where, as mentioned earlier, some women feel unable, for a range of reasons (e.g., financial, childcare), to leave the relationship. research into ipv risk factors and reduction interventions have highlighted key risks and aspects that, if addressed, might lower the likelihood of ipv occurring. these include addressing, for example, poor relationship communication and conflict management skills (abrahams et al. 2006; hatcher et al. 2014) , as well as economic and social empowerment initiatives (jewkes et al. 2014; kim et al. 2007; pronyk et al. 2006) . these all aim to alter and/ or develop troubling dynamics within relationships to reduce ipv, rather than arguing that women should simply leave situations of ipv. thirdly, recognising that counsellors and clients are both steeped in patriarchal power relations that, in the first place, foster ipv and, in the second place, make resolving the situation very difficult is important. the kind of support received from colleagues that was spoken about by participants is essential. peer support as well as sensitive clinical supervision go a long way in developing growth and self-care in counsellors, as identified by friesema (2016) . equally, though, counselling needs to be supplemented with a focus on accountability or collective responsibility for ipv in communities. this, thus, suggests the need for widerscale interventions and advocacy. running these kinds of interventions alongside counselling may assist counsellors in feeling less burnt-out and despondent about what is and is not achievable in this context. finally, the conundrums evidenced in the 'wounded healer' position need to be taken up in training and clinical supervision. as noted above and in the literature (zerubavel and wright 2012) , 'wounded healers' have the potential to empathise with clients and to de-stigmatise being the victim of abuse. on the flip side, uncontained emotions such as anger may surface and may interfere with the sessions. this is particularly pertinent when, as in this case, the 'success' of the counselling is narrowly defined. training and supervision, thus, could concentrate on: (1) allowing the counsellors to reflect on and work through countertransference emotions, and (2) ensuring that the client's options and choices are taken seriously and supported without the implication that counsellor-led outcomes are better. ian parker's (1992) transcription conventions (adapted) round brackets ( ) indicates doubts arising about the accuracy of material ellipses … to show when material is omitted from the transcript square brackets [ ] to clarify something for the reader forward slashes / / indicates noises, words of assents and others equals sign = indicates the absence of a gap between one speaker and another at the end of one utterance and the beginning of the next utterance round brackets with number inserted, e.g. (2) indicates pauses in speech with the number of seconds in round brackets round brackets with full stop (.) indicates pauses in speech that last less than a second colon :: indicates an extended sound in the speech underlining ______ indicates emphasis in speech single inverted commas b indicates words or phrases which have been quoted; either the counsellor quoting themselves or quoting their clients, in this research intimate partner violence: prevalence and risk 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talk: a narrative-discursive research approach overcoming endemic violence against women in south africa reproductive health services and intimate partner violence: shaping a pragmatic response in sub-saharan africa qualitative research interviewing bshowing roughness in a beautiful way^: talk about love, coercion, and rape in south african youth sexual culture binjuries are beyond love^: physical violence in young south africans' sexual relationships introduction: constructivism and social constructionism in the career field the dilemma of the wounded healer evangelical christian pastors' lived experience of counseling victims/survivors of domestic violence publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations conflict of interest the authors declare that they have no conflict of interest. key: cord-011903-zqt6vu6d authors: duby, zoe; mcclinton appollis, tracy; jonas, kim; maruping, kealeboga; dietrich, janan; lovette, ashleigh; kuo, caroline; vanleeuw, lieve; mathews, catherine title: “as a young pregnant girl… the challenges you face”: exploring the intersection between mental health and sexual and reproductive health amongst adolescent girls and young women in south africa date: 2020-07-18 journal: aids behav doi: 10.1007/s10461-020-02974-3 sha: doc_id: 11903 cord_uid: zqt6vu6d in south africa, adolescent girls and young women (agyw) are at risk of poor mental health, hiv infection and early pregnancy. poor mental health in agyw is associated with increased sexual risk behaviours, and impeded hiv testing and care. using in-depth interviews and focus group discussions, we explored subjective experiences of mental health and sexual and reproductive health (srh) amongst 237 agyw aged 15–24 years in five south african districts. respondents shared narratives of stress, emotional isolation, feelings of depression, and suicidal ideation, interconnected with hiv, pregnancy and violence in relationships. findings show that agyw in south africa face a range of mental health stressors and lack sufficient support, which intersect with srh challenges to heighten their vulnerability. framed within the syndemic theory, our findings suggest that south african agyw’s vulnerability towards early pregnancy, hiv infection and poor mental health are bidirectional and interconnected. considering the overlaps and interactions between mental health and srh amongst agyw, it is critical that mental health components are integrated into srh interventions. poor mental health, including depressive disorders and stress, contributes significantly to the burden of disease in south africa, and other parts of sub-saharan africa, and is also associated with negative sexual and reproductive health (srh) outcomes for women, such as 'unintended' or early pregnancy, and increased risk behaviours for hiv [1] [2] [3] . researchers in the field of women's health have highlighted the need to further explore the syndemic interactions between psychosocial vulnerability, mental health, hiv infection, and poor srh outcomes [4] . in south africa's hiv epidemic, the largest in the world, a quarter of all new infections occur amongst adolescent girls and young women (agyw) aged 15-24, three times as high as their male counterparts [5] . as with hiv, south africa also has high rates of teenage pregnancy; in 2016, 16% of females aged 15-18 years had begun childbearing [6] . agyw in south africa are more susceptible to depressive symptoms than their male counterparts, and are likely to remain underdiagnosed and untreated [7] [8] [9] . thus, their vulnerability lies at a biological, social, and environmental nexus. the onset of depression in particular, but other mental health problems as well, can coincide with other developmental milestones such as sexual debut and escalated risks for hiv infection. estimates suggest that approximately three quarters of mental health comorbidities that affect adults across the life course emerge during adolescence and young adulthood [7] . adolescents' mental health status can have profound impacts on their future health, social, and economic circumstances as adults, particularly in contexts of poverty and vulnerability [10] . the development of poor mental health outcomes during this period is influenced by neurological, hormonal, and physical changes associated with puberty, combined with changes in adolescents' social environments [11] . evidence from south africa and other countries in the sub-saharan african region show that age-specific risk factors for depression and anxiety disorders include lower socio-economic status, lack of social capital and support, substance use, and exposure to violence and traumatic events [12] . adolescents growing up in the context of socio-economically adverse communities are faced with a range of additional psychosocial and health risks that may evoke stress and negatively affect their mental health; these risks include exposure to hiv, substance use, violence, and other stressors [13] . poverty has been shown to be associated with heightened vulnerability to experiencing poor mental health, including mood and anxiety disorders [13] . in addition to age-related factors and socio-economic factors, gender-related factors, including sexual and reproductive biology, also play a role in contributing to mental health risks. adolescent pregnancy poses a significant mental health burden, predisposing agyw to adverse mental health outcomes, with depression and anxiety being the most common [14] . in resource-deprived settings in sub-saharan africa, pregnancy amongst agyw is associated with adverse mental health outcomes and psychosocial stresses including stigma and discrimination [14] . in the south african context, pregnancy may exacerbate existing social and contextual stressors, adding additional stressors such as interpersonal relationship challenges, regret around 'unintended' pregnancies, and depression [15] . globally, suicide is the second leading cause of mortality among females aged 10-24 years; with low and middle income countries accounting for over 75% of global suicide deaths [11] . rates of suicidal ideation, defined as the thought of killing oneself, are highest among adolescents on the african continent, with hiv as a contributing factor [11] . the syndemic theory of health refers to the clustering of risk factors, or co-occurring and intersecting epidemics embedded in the particular social context in which an individual is situated, which combine and interact to create vulnerability to health outcomes that are worse than any one risk factor alone would cause [16, 17] . by focusing on the 'biosocial complex', the interconnected and cooccurring health issues, as well as the social and environmental factors that promote and enhance negative health outcomes, the syndemic theory can help to explain the way in which risk behaviours which lead to negative srh outcomes, namely hiv infection and 'unintended' pregnancy, are situated within co-occurring and interacting psychosocial health conditions, including psychological distress and poor mental health [9, 18, 19] . the immense physical, neurocognitive, mental, and social changes that occur during adolescence not only affect mental health, but also influence sexual behaviour; during this period of transitioning to adulthood, adolescents are at increased risk of hiv infection [18] . the association between depressive symptoms and decreased sexual agency and decision-making power in agyw are compounded by low self-esteem; in turn these are associated with increased risk behaviours, including increased susceptibility to pressure to have sex, comfort seeking, condomless sex, transactional sex, trans-generational sex, substance use, and 'unintended' pregnancy [7, 8, [19] [20] [21] . some of the mechanisms through which poor mental health symptoms influence sexual risk include substance use, maladaptive coping mechanisms to deal with stress, and impaired decision-making, indicating poor mental health as a prospective predictor of sexual risk [22] . depressive symptoms in agyw have also been correlated with a lack of ability to withstand social pressure, including peer pressure to engage in risky behaviours, a tendency to be more subservient and less assertive in sexual relationships, as well as with being more vulnerable to intimate partner violence and abuse [8, 19] . in addition to the links between depression and increased sexual risk taking, depression is also associated with impeded health seeking behaviour, including hiv testing [23] . considering the overlaps and interactions between mental health and srh amongst agyw is critical. greater insight into the lived subjective experience of depression and stress, and how these are linked to srh outcomes is needed. there appears to be a gap in the literature pertaining to the ways in which mental health and psychosocial risks, including depression and stress, intersect and overlap with srh related factors such as distress caused by 'unintended' pregnancy, material/emotional stressors of having a child, or social stigma [16] . various studies explore depression amongst hiv positive women, but there has been little exploration of mental health issues that arise due to, or co-occur with, srh outcomes. although mental health was not an initial focus of the research, upon qualitative enquiry, the significance of poor mental health outcomes impacting on sexual and reproductive health practices emerged as a salient theme, warranting closer examination. we examined agyw's narratives and conceptualizations of their own mental health, that of peers, and of the surrounding emotional and psychosocial support context in order to explore the ways in which these factors might interact with sexual health outcomes. this research formed part of the herstory study, which evaluated a comprehensive combination hiv prevention intervention for agyw implemented in ten priority districts in south africa from 2016 to 2019, funded by the global fund (https ://www.samrc .ac.za/intra mural -resea rch-units /healt hsyst ems-herst ory). included in the analysis for this paper are qualitative data from 63 in-depth interviews (idis) and 24 focus group discussions (fgds) conducted between august 2018 and march 2019 in five south african districts, with a total of 237 agyw aged 15-24 years. of the 237 agyw, 63 were from the western cape (wc), 50 from kwazulu-natal (kzn), 41 from mpumalanga (mpu), 35 from the north west (nw), and 48 from the eastern cape (ec). participant recruitment took place in selected schools and communities through liaising with school staff and/or intervention implementers in order to identify eligible participants, arrange interviews, and secure appropriate venues. a brief demographic questionnaire was also administered. idis (20-40 min) and fgds (40-90 min) were conducted in english, isizulu, isixhosa, setswana, or siswati, by one of two lead interviewers, accompanied by a research assistant, all female, and all of whom had received training on the study protocol, design, research tools, and human subject research ethics. semi-structured topic guides comprised of open-ended questions and probes guided discussions. included in the topic guides were questions relating to sources of social/emotional support; agyw were asked who they talk to or seek support from when experiencing emotional/relationship/school/health/srh concerns or challenges. mental health was not a specific focus of the study but arose in response to these. the research team engaged in an on-going reflective process of note-taking and debriefing discussions, which formed part of the collaborative interpretation discussions and analysis process. informed consent was obtained from all participants 18 years and older. written assent with written guardian consent was obtained for those younger than 18 years. participants were provided with a zar 50.00 (approximately us$ 3.00) supermarket voucher, transport reimbursement, and refreshments. the study protocol and research tools were approved by the south african medical research council research ethics committee, and by the associate director for science in the center for global health in the centers for disease control and prevention. the research team received training on the study protocol and procedures for reporting and managing social harms and adverse events, as outlined in human subject research ethical guidelines. during data collection, private-sector social workers were procured to assist with ensuring access to social support services for participants who needed psychosocial support. audio recordings of idis and fgds were transcribed verbatim into their original language, reviewed by the researcher who conducted the interviewer for accuracy, translated into english and re-reviewed by the interviewer. data analysis followed a thematic approach, in which a pre-determined deductive codebook underwent cyclical review and refinement [24] [25] [26] . collaborative interpretation by the research team, comprising the two interviewers who were also co-investigators, along with four other co-investigators, included individual data immersion and familiarisation, repeated deep readings of transcripts, documentation of reflective thoughts, and sharing growing insights about the research topic during regular team discussions. the codebook was entered into nvivo 12 software, which was used to organise and label relevant text from the transcripts. as concepts and themes emerged, the team collaboratively reviewed them, returning to the data, and refining themes. weekly research meetings were held throughout the data collection and analysis phases allowing for team debriefing and examination of how thoughts and ideas were evolving as they engaged with the data. three feedback workshops were held with 32 agyw aged 15-24 at three of the study sites, some of whom had previously participated in idis and fgds, and some who had not. the objective of these workshops was to review and discuss the preliminary analysis and interpretations, ensure accurate and appropriate interpretation of the data, clarify misunderstandings, and confirm findings and interpretations. during the workshops, the research team summarised and presented key themes and findings to the participants, who were then invited to give feedback, discuss their interpretation of the findings, and expand or elaborate on themes. facilitated discussions on each theme were captured through notes and audio recordings, transcribed and reviewed, and included in the overall analysis. amongst the 237 agyw respondents aged 15-24, the mean age was 17.4 years. of these, 99% (n = 235/237) selfreported to have been assigned female at birth. amongst the agyw respondents, 97% (n = 227/234) self-identified their gender as female, with two identifying as transgender, and three as gender-variant. most, 86% (n = 202/235) of agyw self-identified as heterosexual/straight, 4% (n = 9) as homosexual/gay/lesbian, and 7% (n = 17) as bisexual. for reporting of language spoken at home, the top three languages were isixhosa (39%, n = 92/237), isizulu (25%, n = 59/237), and siswati (15%, n = 35/237). overall, 18% (n = 41/232) of the agyw reported to have had a pregnancy. emergent themes in the qualitative data included agyw narratives and perceptions of depression, stress, and suicide. in the accounts of agyw, poor mental health, including depression and suicidal risk were linked to sexual/ romantic relationship challenges, early pregnancy and child-bearing, parenting responsibilities, experiences of violence/abuse, hiv status, and lack of emotional support. suicide risk emerged as a salient theme and was associated with discovery of pregnancy or an hiv positive status, low self-esteem, and a lack of anyone to trust or confide in. in general, agyw voiced a need for increased access to support, and additional information on mental health. the findings presented below are arranged into key thematic areas that emerged during analysis. illustrative quotations are excerpts from english transcripts or translations; in brackets are details of the respondents' site and sample group. in selected excerpts, original language terms/words have been included in italicised brackets for the purpose of illustrating the exact words/language used by participants relating to key concepts associated with mental health. the rationale for this is that often concepts such as "depression" have been framed in a universal/western way, without attention to contextual specificity. where qualitative research uses translations, there is a danger of the original meaning and concept getting lost in the translation process, as translators seek to find 'equivalent' terms [26] . suicidal ideation emerged as salient theme across provinces, despite there being no specific question probes relating to suicide. according to agyw, issues such as self-harm and having suicidal tendencies were common amongst their peers. one participant expressed hesitancy using the diagnosis of 'depression', but described self-harming and suicidal ideation: "there are girls, i don't want to say 'depressed', but who do things like self-harming, some attempt suicide" (15) (16) (17) (18) ec) . agyw made links between low self-esteem and self-worth, and lacking a sense of belonging, with suicidal ideation: "most girls… have a low self-esteem… feel as though they don't belong in this world. that's why people commit suicide. i used to have that… mentality… suicidal thoughts because of people" (19) (20) (21) (22) (23) (24) nw) . illustrating the link between srh and mental health, feelings of emotional isolation leading to suicidal ideation were exacerbated in the case of hiv positive or pregnant agyw who feel unable to access support: "this thing of suicide is becoming popular now, even here at school… especially when girls are pregnant or hiv positive, because they can't share it with anyone, they don't trust anyone" (15-18 years, wc). the sense of having no one to trust or confide in, and seek emotional support from, resulted in agyw feeling emotionally isolated, fostering suicidal ideation: "we don't share our sexual and personal life things… we keep it to ourselves, then some of us commit suicide (sizigcinia kuthi, abanye bethu ke baphela sebezibulala)" (15-18 years, wc, isixhosa). suicide was linked to feelings of isolation after an hiv positive diagnosis: "(when) the nurse told her that is she is hiv positive, she didn't know who to tell… so she took a rope and hanged herself because she had no one to talk to" (15-18 years, wc). the discovery of being pregnant was also described as a difficult emotional event. agyw in the older age group, 19-24 years, described personal experiences with suicidal ideation in this situation: "when i found out i was preg-nant… that was very difficult, i even thought about sui-cide… it was tough (kwabanzima kakhulu, ngangicabanga ngisho ukuyibulala, ya kwaku tough)" (19-24 years, kzn, isizulu). additional links between mental health and srh were apparent in the narratives of suicidal ideation in relation to the stress of teenage pregnancy, compounded by fear of hiv: "as a young pregnant girl… the challenges you face… maybe you will find out that he (baby's father) is hiv-positive… those are challenges that can be a problem and you end up committing suicide… a better solution is to kill yourself (yizona ngqinamba lezo ezingaba inkinga ugcine usu… usuzibula… i solutions kuncono ukuthi uzibulale)" (19-24 years, kzn, isizulu). respondents suggested that due to social stigma attached to teenage pregnancy, pregnant agyw fear being judged and gossiped about: "pregnant girls feel sad… some even contemplate suicide (azive efuna ukuzibulala)… because of hearing unpleasant things about their life being spoken by other people. (15-18 years, wc, isixhosa); "pregnant girls are teased, and then they drop out of school, they don't fin-ish… here at school… we gossip about each other in the toilets" (15-18 years, wc). parents' attitudes towards their daughters' romantic and sexual behaviour prevented agyw from accessing support: "like most girls, i got pregnant at an early age. some girls resort to committing suicide (ezibulala) or just run away from home because they cannot face their parents" (15-18 years, wc, isixhosa). getting involved in transactional relationships, compounded by a sense of shame and fear of social judgement, also led to depression and suicidal ideation: "most girls in the community, they get into those (transactional) relationships, to a point that it damages them… they end up being depressed… 'why are you doing this and that to me in front of people?'… they end up like that and they end up trying to commit suicide… 'he embarrassed me in front of people, tomorrow how will people look at me?'" (19-24 years, nw). the emotional 'burden' of teenage pregnancy was described as a key contributing factor to poor mental health: "they say having a child is a good thing, but as a teenager it is a burden, it's difficult to cope" (15-18 years, ec). financial, material and relationship insecurity added stress to pregnancy: "the baby's father has denied the baby, there will be stress of how you are going to support the baby, because the (social) grant is not enough" (19-24 years, kzn). those agyw who had experienced unexpected discovery of pregnancies described their stress related to being rejected by families, kicked out of school or from home. one participant described her concerns after finding out she was pregnant in grade 10: "i was confused and didn't know what to do… (i told my boyfriend) my dad is strict… i will be chased away from home" (19-24 years, kzn). those agyw who became pregnant with casual sex partners, or who were not in committed relationships described the stress and unhappiness they experienced. one young woman described how she wanted to terminate her pregnancy but was told it was already too late to do so, and how this unwanted pregnancy caused her stress: "i had stress… i only realised when i was 4 months 2 days that i was pregnant… if i had realised this earlier, i was going to do an abortion… then i asked the doctor 'is there any other way i can do an abortion?'… he then said 'it's either you die… i will not allow you to risk an abortion'…[sigh] i was not ready to have a child at that time… i knew how my situation was… the guy i was dating, i was just dating him for fun. i did not see myself having a child with him, or to have future with him… that was why i was going to abort this baby… i did not want the child… everything failed… i did not eat, i had stress… the one who impregnated me was staying in a shack" (19-24 years, nw). a lack of emotional support from partners/fathers of children also contributed to stress and depression amongst young mothers: "where does the stress go? …to me… i'm always watching this child, he cries the whole day and i don't know why… i'm holding him, gave him his bottle, he continues to cry, i don't know why he is crying… you call him (baby's father)… (but) he doesn't take any action… i become depressed and it affects the child" (19-24 years, nw). being a single parent was described as difficult and stressful: "if you are a single mother, there is nothing nice… (you) have love for your baby but that's it. everything else is not nice… it's difficult to raise the child" (19-24 years, nw). the feeling that former dreams and aspirations for the future were shattered by unexpected pregnancies heightened feelings of hopelessness and depression: "it's not going to be dark forever, things will be right… but what i can say? …to be pregnant unexpectedly is not good at all… life is not good… especially if… you had plans and maybe life does not go the way you had planned… i am speechless… for me now, life is not good… it's not good… tough times…" (19-24 years, nw). lacking a supportive social environment negatively impacted on mental health and self-esteem: "when people are discouraging me… i get very sad… i'm trying… i'm telling them that… and they say 'you cannot do that… you're weak'… it makes me angry, but… i don't defend myself" (19-24 years, nw). some agyw suggested that they tried to cope without sharing their problems with anyone: "i keep my problems to myself… i talk to no one… i keep to myself and own it, i don't make my problem someone else's… if ever i have something troubling me i will keep it to myself… eventually i will be fine (ndizade ndibe right)" (19-24 years, ec, isixhosa). the lack of emotional support for dealing with traumatic life events, including grief over the death of a loved one, was present in agyw narratives: "when i think about something that happened in the past my heart becomes sore (intliziyo yam ibabuhlungu)… (like) when i think about my mother… she passed away… there is nobody (i talk to at home)… i don't feel free talking to them… i don't speak to anyone at school (either)" (15-18 years, ec, isixhosa). a minority of agyw were vocal about receiving emotional support at home: "i know i am loved at home and they show me that they love me because they care for me and stuff" (19-24 years, ec). sexual and romantic relationships with violent and controlling partners were also described by some of the agyw, who ended up living in a state of fear: "if i have made friends… and we want to go out as girls, then he (boyfriend) will refuse and beat you. even when you make a minor mis-take… he will beat you, and you end up afraid… you now live in fear… when happy, it doesn't last for long… sometimes he will take out his anger on you even when you did nothing… but you continue to love him even when friends try to talk some sense to you, but you will continue staying and loving him because you are afraid of him and not at liberty to do your own things" (19-24 years, mpu). refusal to have sex with a partner also led to violence: "sometimes, it happens that he wants to sleep with you, and you don't want to, then he gets angry and he beats you" (19-24 years, kzn). those agyw who had experienced intimate partner violence explained their reluctance to disclose to her family and friends: "in most times, you keep quiet and when they ask you 'what happened, why are you hurt?' you just tell them that you got hurt, you turned and bumped into a wall" (19-24 years, kzn) . experiencing violence negatively impacted agyw self-esteem and self-worth: "it has to do with how you perceive yourself, he sees me as not good enough then maybe you will find that boyfriend that hits you, he is the one that you want to stay with because you think where else will you find another boyfriend? …when he hits you that means this person does not see any value on you he beats you, abuses you… physically you will be injured obviously because that will hurt you… and she will think that she is not good enough" (15-18 years, ec). pregnancy increased agyw dependence on partners, even when they are violent: "my friend is pregnant… (her boyfriend) beats her… in her pregnancy the guy did not care for her and he was beating her saying the child is not his" (19-24 years, ec). our study did not initially set out to examine mental health amongst agyw, but narratives around depression, stress and suicide became salient, as did evidence of their interconnection with sexual and reproductive health. feelings of stress, anxiety and not being able to cope, even to the point of suicide ideation, were associated with hiv status, unexpected discovery of pregnancy, and parenting responsibilities. violence in relationships, a lack of emotional support from family and partners, and financial insecurity interact to exacerbate agyw vulnerability to poor mental health and srh outcomes. agyw in our study who had been pregnant, shared narratives of negative emotions they had experienced on discovering their pregnancy, leading to depression and suicidal ideation. the social causation hypothesis theory posits that stressful circumstances or events increase an individual's susceptibility to manifesting or experiencing mental health problems [13] . it would therefore make sense that the emotional aspects related to the discovery of an unexpected pregnancy or an hiv positive status would act as a stressor and have potentially negative mental health outcomes [16] . it is likely that after encountering a stressor, adolescents will experience stress and symptoms of depression and anxiety [13] . the stress related to the discovery of an unexpected pregnancy is compounded by the shame and social stigmatisation of teenage pregnancy, and the ensuring social isolation from family and community increases the risk for psychological distress [7] . the framing of pregnancy during adolescence as a social problem means that pregnant teens receive limited social support, which in turn is linked to poor mental health outcomes [2] . the stress related to the discovery of an unexpected pregnancy is heightened further in the case of a dual discovery of being hiv positive [27] . the presence of depression, anxiety, and post-traumatic stress disorder in hiv-positive individuals is related to diagnosis and disclosure, and hiv-positive women experiencing 'unintended' pregnancy are at high risk for antenatal depression [27, 28] . agyw in our study described a worrying trend of suicidal ideation. thoughts about suicide narrated by agyw were related to unexpected discovery of pregnancy and its consequences, hiv diagnosis, and feelings of emotional isolation. suicide was described as "the best solution" to situations of stress created by the discovery of unexpected discovery of pregnancy or hiv positive status, lack of material/financial or emotional support for young mothers, and feelings of victimisation as a result of gossip or judgement. adolescents faced with multiple stressors may experience a sense of being overwhelmed and unable to cope, and view suicide as an escape [13] . agyw in our study associated low self-esteem and low self-worth with depression and suicidal ideation. negative self-cognitions and low self-worth are associated with depression, and positive self-esteem is a critical component of emotional well-being [29] . adolescents' ability to manage their stress symptoms or address the stressor they encounter may be pivotal to protecting their mental health state, as it may buffer the impact of experienced stress on mental health [13] . additionally, self-esteem and social support are amongst the 'protective assets' associated with improved srh outcomes [30] . in our study, agyw expressed feeling emotionally isolated, lacking people who they felt they could trust and confide in without fear of judgement or recrimination. emotional isolation and lack of support, especially when faced with stressors such as the discovery of an unexpected pregnancy or an hiv diagnosis, negatively impacts mental health. the emotionally distressing aspects of unexpected discovery of pregnancy, or an hiv diagnosis, combined with a lack of social support, contribute to the high rates of depression amongst agyw [16] . agyw in our study described additional stress related to teenage pregnancy and child-bearing relating to concern around the ability to support a baby financially, especially when there was a lack of material and/or emotional support from the father of the child. agyw in south africa, particularly those in resource-constrained or violent households, face a variety of personal and structural challenges, linked to disempowerment and psychological distress more broadly; an 'unintended' pregnancy can compound pre-existing social and economic vulnerabilities, and result in heightened feelings of stress and unhappiness [31] . socio-economic disadvantage compounds other stressors in an adolescents' life, and when co-occurring with pregnancy or hiv, can lead to poor mental health outcomes and a lack of utilisation of health care services [2, 13] . one limitation of this study was that the framing and concept of 'unintended' pregnancy was not investigated in more depth. for this reason, we avoid using the term 'unintended', and instead use the words of agyw respondents themselves when describing their unexpected discovery of a pregnancy, rather than objectively categorising the pregnancies as 'unintended'. in addition, social desirability bias relating to the stigma and shame around mental health may have resulted in a lack of disclosure from agyw regarding their own feelings of depression or suicide ideation. interpreting our findings within a syndemic theory framework is helpful, in order to describe the integration of sociocultural, psychological, and physiological factors that combine to shape agyw vulnerabilities and experiences [32] . our findings suggest that south african adolescent girls and young women's vulnerability towards early pregnancy, hiv infection and poor mental health are bidirectional and interconnected. the social context in which south african agyw are situated, as described by respondents in our study, is characterised by a lack of social support, economic insecurity, and stigma, and serves to exacerbate the gendered and age-related vulnerabilities of this population. this interaction of socio-cultural, economic, structural, gendered, age-related and biological factors increase south african agyw's heightened risk of negative srh outcomes, cooccurring with psychological distress and poor mental health [33] . in line with the syndemic theory suggesting synergistic interactions between epidemics, and the interconnectedness and clustering of psychosocial conditions such as 'unintended' pregnancies, psychosocial distress, and hiv infection in agyw, there is a need for comprehensive hiv prevention programming inclusive of mental health support [34] . it is clear that interventions aiming to reduce rates of teenage pregnancy and reduce hiv acquisition amongst agyw in south africa, need to incorporate mental health components [35] . recommendations have been made for integrating mental health care into care for patients with chronic non-communicable diseases, as well as communicable diseases such as hiv [10] , but few recommendations for integrating mental health into srh delivery exist [36] . the links between mental health, hiv status, and 'unintended' pregnancy, exacerbate the need to strengthen the integration of routine mental health screening in srh and hiv programming in order to enhance the health outcomes amongst agyw [12] . addressing underlying mental health risks may be an important additional strategy to promote sexual risk reduction, and behavioural interventions which are able to improve mental health are also more effective in preventing negative sexual health outcomes such as hiv infection [22] . the indication of a dual burden of psychological distress and sexual risk behaviours suggests that screening for mental health disorders should be integrated into srh services [22] . despite the evidence of intersecting epidemics, mental health screening is not standard in hiv prevention and care settings and has not been added to the hiv care cascade. combination interventions inclusive of psychological and behavioural components may be able to achieve greater reductions in sexual risk behaviour among adolescents, as incorporating psychological health interventions appears to be a critical part of any comprehensive strategy for mitigating hiv risk [21] . mental health services targeted at agyw, especially those that are hiv positive and/or pregnant, need to be integrated into srh services, especially those that aim to be "youth-friendly"; prevention, diagnosis and management of depressive symptoms should also be included in the package of comprehensive services [14, 19] . early mental health screening could help catch agyw who might not yet be diagnostically clinical depressed. given the evidence, it is likely that agyw have overlapping epidemics that are clinically significant. practical recommendations for improving mental health care delivery to agyw include improving mental health, advocacy, decentralization of services, taskshifting and on-the-job training [12, 37] . the way in which mental health issues, such as stress and depression, are defined and conceptualised differs across settings and socio-cultural contexts, and interventions needs to be contextually relevant [1] . in addition to contextual and conceptual equivalence, linguistic equivalence of terms related to mental health should be taken into account. the words "depression" and "anxiety" do not have direct equivalents in some south african languages, with psychological distress, including depression, described behaviourally rather than cognitively, and expressed and/or experienced somatically, or situated within the relational domain [29, 38] . in addition, the term "unintended pregnancy" is problematic, with traditional measurements dichotomously classifying pregnancies as intended or not, based on a woman's intentions before she became pregnant [39, 40] . "unplanned pregnancies" likewise have been defined as pregnancies which occur when a woman is using contraception or did not desire pregnancy as an outcome [39] . the key problem with these binary classifications of pregnancies as unintended/intended, planned/unplanned, is that they fail to consider the complexity of intention, motivation and desire [40] . the construct of 'pregnancy acceptability' may be a more useful way to taking into account the complexity of pregnancy intentions, in the context of women's lived experiences, emotions, relationships, and socio-economic circumstances [40] . a woman's emotions, levels of preparedness, and acceptance of a pregnancy are likely to change in reaction to external factors, which in turn influence health outcomes [40] . the biomedical/clinical understandings and definitions of "depression" and "unintended pregnancy" may not always capture an individual's subjective experiences and articulation of these states [41] , and in order for any intervention to be successful, there is a need to be sensitive and reflective of the reality of people's lives, with an understanding of the language that agyw use to describe their lived experiences of depression and pregnancy, which is why qualitative research such as the findings we present here, is much needed [40] . indeed, agyw in south africa construct "depression" and pregnancy is a complex phenomenon manifesting in a variety of emotions, thoughts, and behaviours; finding ways to surface contextually congruent understandings of sexual and reproductive health, and mental health can inform the development of interventions that are contextually and population relevant [29] . mental health and srh interventions and services need to be contextually appropriate and reflective of the reality of people's lives. screening tools need to take into account the diversity of understandings of emotional suffering and distress, using appropriate terms, language and concepts. it is evident that agyw in south africa face substantial social adversities and related mental health challenges due to a range of srh, social, economic, environmental, physiological and interpersonal factors. building on previous research that has found associations between depressive symptoms and psychological distress related to pregnancy, combined with a lack of social support amongst south african women [16] , our findings provide rich descriptive data on the lived reality of the interconnected psychosocial risks including stress, emotional isolation, feelings of depression and suicidal ideation, with 'unintended' pregnancy and hiv that agyw in south africa face, from their own perspectives. framing these interconnections within the syndemic framework can help to inform interventions that seek to address agyw risk. as psychological distress is associated with increased risk behaviours, it is critical that efforts to address early pregnancy and hiv infection amongst agyw incorporate mental health components. interventions to improve emotional wellbeing and coping mechanisms for agyw are needed in order to improve sexual and reproductive health outcomes; indeed, in a context where hiv, stis, early pregnancy are common, it is all the more important to have such interventions integrated into srh services and part of largescale programmes for agyw. understanding the context of mental health is crucial in order to design and implement effective mental health programming, and to provide appropriate psycho-social support to young women, and in turn, address sexual and reproductive health challenges. open access this article is licensed under a creative commons attribution 4.0 international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this licence, visit http://creat iveco mmons .org/licen ses/by/4.0/. building resilient families: developing family interventions for preventing adolescent depression and hiv in low resource settings social support among hiv-positive and hiv-negative adolescents in umlazi, south africa: changes in family and partner relationships during pregnancy and the postpartum period burden of non-communicable diseases in sub-saharan africa, 1990-2017: results from the global burden of disease study the intersection of hiv, social vulnerability, and reproductive health: analysis of women living with hiv in rio 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sub-saharan africa the measurement and meaning of unintended pregnancy it's not planned, but is it okay? the acceptability of unplanned pregnancy among young people. women's health issues a feminist phenomenological description of depression in low-income south african women we would like to acknowledge and thank the adolescent girls and young women, and other participants who agreed to make themselves available to take part in this research, and share their views, opinions and experiences with us. the combination hiv prevention interventions were funded by the global fund to fight aids, tb and malaria, and implemented in 10 districts in south africa by a range of government departments and civil society organisations that were appointed by the organisations responsible for the management of the agyw programme: western cape department of health, kwazulu-natal treasury, kheth'impilo, soul city institute for social justice, and the networking hiv and aids community of southern africa (nacosa). the programme was aligned with the she conquers campaign and was implemented with support from the south african national aids council (sanac) through the country coordinating mechanism (ccm) and the ccm secretariat. key: cord-292315-7vwybku8 authors: jung, gyuwon; lee, hyunsoo; kim, auk; lee, uichin title: too much information: assessing privacy risks of contact trace data disclosure on people with covid-19 in south korea date: 2020-06-18 journal: front public health doi: 10.3389/fpubh.2020.00305 sha: doc_id: 292315 cord_uid: 7vwybku8 introduction: with the covid-19 outbreak, south korea has been making contact trace data public to help people self-check if they have been in contact with a person infected with the coronavirus. despite its benefits in suppressing the spread of the virus, publicizing contact trace data raises concerns about individuals' privacy. in view of this tug-of-war between one's privacy and public safety, this work aims to deepen the understanding of privacy risks of contact trace data disclosure practices in south korea. method: in this study, publicly available contact trace data of 970 confirmed patients were collected from seven metropolitan cities in south korea (20th jan–20th apr 2020). then, an ordinal scale of relative privacy risk levels was introduced for evaluation, and the assessment was performed on the personal information included in the contact trace data, such as demographics, significant places, sensitive information, social relationships, and routine behaviors. in addition, variance of privacy risk levels was examined across regions and over time to check for differences in policy implementation. results: it was found that most of the contact trace data showed the gender and age of the patients. in addition, it disclosed significant places (home/work) ranging across different levels of privacy risks in over 70% of the cases. inference on sensitive information (hobby, religion) was made possible, and 48.7% of the cases exposed the patient's social relationships. in terms of regional differences, a considerable discrepancy was found in the privacy risk for each category. despite the recent release of government guidelines on data disclosure, its effects were still limited to a few factors (e.g., workplaces, routine behaviors). discussion: privacy risk assessment showed evidence of superfluous information disclosure in the current practice. this study discusses the role of “identifiability” in contact tracing to provide new directions for minimizing disclosure of privacy infringing information. analysis of real-world data can offer potential stakeholders, such as researchers, service developers, and government officials with practical protocols/guidelines in publicizing information of patients and design implications for future systems (e.g., automatic privacy sensitivity checking) to strike a balance between one's privacy and the public benefits with data disclosure. with covid-19 becoming a worldwide pandemic, each country is attempting various ways to stop or slow down the spread of the virus among people, such as social distancing, preventing events that bring many people together, detecting and isolating the confirmed cases, and so on (1) . in this situation, one of the effective measures is to conduct "contact tracing" (1, 2) . contact tracing is defined as "the identification and follow-up of persons who may have come into contact with an infected person, " and involves identifying, listing, and taking follow-up action with the contacts (3) . it plays an important role in quick isolation of infected persons to prevent potential contact with others. from a stochastic transmission model of the spread of covid-19, contact tracing was shown to be effective in controlling a new outbreak in most cases and reducing the effective reproduction number (2) . however, due to limited human resources for tracing, it could be very difficult to trace the contacts who might be potentially infected, particularly when the number of patients is skyrocketing. therefore, some countries began to proactively open the data of confirmed cases to the public or share it with medical institutions to find close contacts more efficiently. for instance, in singapore, the government discloses the places related to patients, such as residence, workplaces, and other places they had visited (4) . in taiwan, the authorities utilize the airport immigration database combined with the national medical database to quickly determine whether the patient has visited other countries (5) . other governments also are sharing the personal information of the patients with similar components of data, including age and gender, nationality, geographical breakdown of patients, and so on (6) . south korea also disclosed the patients' contact trace data to the public to prevent further spread of the coronavirus. each local government pseudonymizes the patient data, which contains demographics, infection information, and travel logs, and releases it to the public. this information helps the public to self-check whether they were co-located with the confirmed patient. however, there is a potential threat in publicizing the patient's data (7) . efficiently identifying potential contacts may be advantageous in terms of public safety but revealing personal data would infringe upon the patient's privacy. most of the information disclosed could be personal data and combining a set of data reveals additional information. privacy risks, along with online abuses or rumor-mongering based on somewhat uncertain information, may cause blame and social stigma (8, 9) and raise the risk of physical safety (10) . while it is important to find and isolate close contacts quickly for preventing the spread of infectious diseases, it is also critical to minimize breach of patients' privacy. recently, the national human rights commission of korea claimed that the publicized information is unnecessarily specific and may cause privacy violations (11) . in response to this, the korea centers for disease control & prevention (hereinafter "kcdc") announced two guidelines (12, 13) limiting the scope and the period of the data disclosure and recommended the deletion of outdated information (after 14 days from the table 1 | the korean government guidelines for the scope and detail of the information to be disclosed. mar. 14 • personal information: information that identifies a specific person should be excluded • period: information should be from 1 day before the symptoms occur to the date of quarantine • place and transportation: place and transportation should be disclosed where contacts have occurred with the confirmed cases. the detailed address of residence and workplace should not be disclosed. however, the address may be revealed if there is a risk that covid-19 has been spread to random people in the workplace. spatial and temporal information (e.g., building, place names, and transportation) should be specified as possible, except for that of identifying certain individuals. apr. 12 • disclosure period: the data should be only released for 14 days from the date that the patient had the last contact. last contact) on march 14 and april 12, respectively (see table 1 ). although a critical question about the cost-benefit tradeoffs between privacy and public safety still remains, existing studies on location and privacy have not fully reported insights from contact tracing and underlying privacy risks. past studies on location privacy primarily focused on an individual's privacy perceptions and potential risks of leaking current locations to diverse social media (14) (15) (16) . however, these prior works were more of a real-time location sharing of a single spot, rather than sharing one's full mobility data spanning several days to a week or more, as in contact tracing. another key difference to note is that privacy risks regarding contact tracing under special occasions, such as covid-19 are relatively unaddressed in the literature. it is timely to explore this issue as public disclosure of contact tracing data under covid-19 raises questions about data sovereignty and privacy of a patient. thus, the present study assessed privacy risks on the contact trace data disclosed in south korea. specifically, the study first examined what kind of personal information is contained in the data, and how much exposure or inference is made from that data. it then examined how much difference in privacy risk levels exists according to region and time when disclosing the data. while no study to the researchers' knowledge has assessed privacy risks on public disclosure of contact tracing data related to covid-19, the present study first analyzes the real-world data in south korea and provides possible directions for privacy-preserving data disclosure and presents several policy and technical implications that can possibly lower privacy risks. this section describes the data collection and analysis process used to evaluate privacy issues resulting from data disclosure. to assess potential privacy concerns through real-world examples, the contact trace data of 970 confirmed patients was collected. the data listing confirmed cases date-wise from january 20 to april 20 were released by seven major metropolitan cities in south korea. the contact trace data was collected from various publicly accessible online websites, such as the official website and social media sites of the local government, and its press releases and briefing information. since the data was released to the public by the government and any specific individual cannot be identified with it, there is no critical ethical concern for data analyses. as shown in table 2 , the released contact trace data included (1) the patient's demographics (i.e., nationality, gender, age, and residence), (2) infection information (i.e., infection route and confirmation date), and (3) travel log in time series (e.g., transport modes and visited places). the data is processed by the contact trace officer before it is released online (i.e., excluding places which the patient visited but no contact was made), hence the government may possess more information than the public can access. this study covered seven out of eight metropolitan cities in south korea, namely, seoul, incheon, sejong, daejeon, gwangju, ulsan, and busan. the city of daegu was excluded from the data collection process because it did not disclose patient information since the massive contagion outbreak prevented contact tracing. as the guidelines set by the kcdc recommend the deletion of the outdated information (after 14 days from the last contact), all the sample cases of disclosed patient data mentioned in this study were anonymized by the researchers. for instance, the address and name of a place (e.g., building name) were converted into four character long random strings (e.g., g3a5-gu, d12zdong, bqt3 building). similarly, the identification number of the patient was also anonymized (e.g., #w4p). in this study, a codebook was introduced to evaluate the level of privacy risks. the codebook has an ordinal scale of privacy risk levels and the scale quantifies relative risks from five major categories: demographics (nationality, gender, age), significant places (residence, workplace), sensitive information (hobby, religion, accommodation), social relationships, and routine behavior. the details of the codebook generation are as follows: the collected data were manually examined to evaluate the level of privacy risks. the following types of information were identified: demographics, location information (e.g., significant places and behavioral routines), and social relationships. affinity diagramming on contact trace data was performed to iteratively build a coding scheme (18) . as a result, the manual examination generated five categories with eight sub-categories, as described in table 3 . for each data category, an ordinal scale of privacy risk levels was introduced. the scale quantifies the relative privacy risks of the patient's trace data; for example, a high level means that detailed information was released. the following section describes the details of each category and its associated risk levels. this codebook was used to evaluate each patient's contact trace from seven metropolitan cities. the "demographics" category included three sub-categories: nationality, gender, and age. for nationality and gender, two scoring criteria were considered: (1) level 0 for not containing any information for each of the two categories and (2) level 1 for disclosing that information (e.g., patient #5sx is chinese, patient #8nw is a woman). in the case of "age, " three criteria were considered: (1) level 0 for no age information, (2) level 1 for rough description (e.g., the twenties), and (3) level 2 for accurate information (e.g., 30 years old, born in 1990). before describing the methods further, this study explains the administrative divisions in south korea since it could differ from country to country. the administrative divisions can be divided into four levels by their size: province ("do"; the whole country is composed of nine provinces), city ("si"; typically 100-1,000 km 2 ), sub-city ("gu"; typically 10-,100 km 2 ), and district ("dong"; typically 1-10 km 2 ) (19) . people in south korea often use this system when they look for a place or mention a certain location. in the address system of south korea, there are two more detailed steps in describing places: streets (i.e., "ro" or "gil") and the building number. the street is lower level than the "dong, " so a "dong" may contain several "ro"s and "gil"s. the lowest level is the building number and the address provided up to this step would point to the only building throughout the country. a person's home (residence) and workplace are considered significant places. to assess the detailed location information of these places, a two-stage approach was used: (1) direct location identification and (2) indirect location inference by combining the breadcrumbs of visited places and transport modes. the second stage was inferring the locations of personal life using nearby places whose full addresses or names were disclosed. even if the information is limited, reasonable inference based on a travel log is possible by examining the surrounding places and transport modes. for example, there was no explicit description of a patient's home, yet the travel log said "4 min in total to walk from his home to a convenience store, and come back again." and the full address of the store is known (i.e., 441-7, allakdong, dong-gu, ulsan). this log may indicate the approximate location of her house. considering a person's walking speed (e.g., 3 km/h), the area where her home is located could be determined as described in figure 1 . to estimate the time required to travel on foot, the average sizes of the sub-city ("gu"), district ("dong") and street ("ro" or "gil") were used. there were 68 gu, 1,033 dong, and 41,301 street included in the total for the seven cities. given that the total size of these cities was 4,000 km 2 , the average sizes of gu, dong, and street were calculated as 58.8, 3.9, and 0.1 km 2 , respectively. for the convenience of calculation, an assumption was made that the shape of each administrative area was circular. as a result, the radius of each division was 4.3, 1.1, and 0.2 km for gu, dong, and street, respectively. taking the average walking speed of a person this means it is reasonable to infer that a place is under dong level (i.e., privacy level 2) when it takes from 20 to 90 min on foot and street level (i.e., privacy level 3) if it takes 4-20 min. on the basis of these results, the details of a location were labeled where the address was not shown but could be inferred from a known place. for instance, in the case of patient #pr8 of bi1c-gu who went home from the q5eg branch of kjn1 convenience store (i.e., only one store of its kind in that region) on foot in 5 min, this case was scored as level 3 privacy risk. moreover, some places where it took <4 min on foot were labeled as 3.5. in this case, it is more specific than level 3, but it is still not possible to identify the exact place. in some buildings, there is a possibility of revealing sensitive personal information. for instance, if there is information on the travel log that the patient had attended a church service, and its name was disclosed, anyone who reads this could know her religion. this study mainly considered three place categories: (1) hobbies, such as fitness clubs, dance schools, pc cafes (playing games), and karaoke (singing); (2) religion, such as a church, cathedral, and temple; and (3) accommodation, such as hotel and motel. if any of these place categories were described in the travel log, that case was labeled as level 1; otherwise, level 0 was given. privacy issues might arise when information about how one person is related to another is revealed. if the travel log indicates that two people are found to have been together at a certain time or moved together to a place, there is privacy leakage of relationships. therefore, patients' travel logs were examined to check whether they included this relationship information. for not describing such information, level 0 was given. level 1 was rated in case of revealing the relationship only (e.g., patient #t52 in 4xal-gu is the mother-in-law of patient #rb4 in the "gu" of the building is disclosed 2 "dong" of the building is disclosed 20-90 min on foot taken from a known location 3 "ro" or "gil" of the building is disclosed 4-20 min on foot taken from a known location 3.5 <4 min on foot taken from a known location 4 the exact location of the building is disclosed only the relationship is disclosed 2 the location and the relationship are disclosed together routine behavior 0 no place that is visited repeatedly 1 includes places that are visited repeatedly same district). if the relationship was revealed with location (e.g., patient #90x in 8nuw-gu had lunch with her colleague patient #v8l in the same district, at a restaurant near their office), that case was rated as level 2. using information about places that are repeatedly visited in a specific time window (known as behavioral routines) could make it easier to identify a person. if it is revealed that there is a place where a confirmed patient repeatedly visits at a certain time, malicious people may use this information (e.g., robbery). for this reason, it was examined whether the travel log included routine behavior. if there was a place visited more than twice at a specific time, the case was labeled as a level 1 risk, otherwise, a level 0 risk (or no risk at all). this study analyzes 970 cases from seven metropolitan cities in south korea (see table 4 ) and reports (1) the descriptive statistics of privacy risk levels, and (2) their differences across regions and time. the five major categories and eight sub-categories of data types that might potentially reveal personal information (e.g., life cycle, social relationships, etc.) were coded in terms of privacy risk levels. here, a detailed description of the result as well as some noteworthy findings from the analysis of the privacy risk of the contact trace data is provided (see table 5 ). demographics included patients' nationality, gender, and age. in reporting nationality, 91.2% of the data do not contain patients' nationality (n = 885). these cases could be assumed to be koreans. all cases of confirmed foreign expatriates disclosed their nationality, which accounted for 8.8% (n = 85) of the patients. considering that legal foreign expatriates account for only 4% of south korea's total population (20) , and the number of confirmed foreign cases is a small proportion, there is a high chance of identifying an individual: it is easier to pinpoint an individual if cases from his/her nationality are relatively few. for example, there was only one confirmed case from gambia, while ∼260 gambians resided in south korea. this example shows the potential for easier identification of the suspect when the size of a community is small. all cases reported patients' gender, and 839 cases (86.5%) specified the exact age or birth year of a patient (e.g., age 30, born in 1990), whereas 131 cases (13.5%) only reported the age range of a patient (e.g., the twenties). one thing to note is that age and gender are personal details that make up one's social security numbers (3 digits) and collecting such data could be invasion of privacy. significant places refer to the residence and workplace of an individual. in identifying residence, over 70% (n = 759) of the disclosed data ranging from level 2 to level 4 provide highly granular data, such as the district, street, and name of an apartment. with additional data, such as activity type (e.g., walking) and the time taken, it could easily be deduced that an individual lives in that narrowly defined region. only 15 cases were labeled as level 0, which included the following two cases: (1) patients from abroad with no domestic residence, and (2) patients who had come from another city. of the disclosed data, 22.3% (n = 216) ranged from level 3 to 4 in the "workplace" category. one interesting fact to note was that collective infection at a workplace unavoidably revealed a patient's workplace location. for example, a collective infection case which caused about 118 related cases occurred at a call center located in guro-gu, seoul revealed the specific building and floor of the center (e.g., "korea" building, 11th floor). a large fraction of cases had a level 0 on workplace location (n = 703, 72.5%). this low risk of workplace location is possibly due to the confirmed patients being jobless (e.g., older adults, teenagers, patients from abroad). another noteworthy finding is that collective infection at a workplace inevitably exposes the location and the patient's job, which the patient wished to keep private (e.g., patient #u9m from 73tb-gu, seoul, works in the redlight district). other cases classified as "no information" usually had no related information of a workplace. some exceptional cases included the word "office, " but with no location specified (e.g., 9 a.m.-6 p.m., office). the data revealed several cases of patients' regular visits to a certain place, which makes it possible to infer one's personal details-hobby, religion, and accommodation information. in the hobby category, 69 cases (n = 69, 7.1%) were identified from patients' regular visits to the gym, golf club, and other places for amusement or leisure activities (see table 6 ). furthermore, religious orientations were revealed because of the collective infection that occurred through religious activities, such as group prayers (n = 111, 11.4%). after mass contagion, most religious services went online, and only a few infection cases revealed religious places. it was also found that information of a short stay (e.g., a few hours) at a specific accommodation, hotel, or motel, may infringe privacy-although this constituted only a small proportion (n = 15, 1.6%). along with location data, some of the patients' relationship information was also provided. with relationship data alone or combining location and relationship data, it might be possible to guess a patient's social boundaries and even infer more about personal life. thus, the category was divided into "relationship only" and "relationship and location." in "relationship only" (n = 215, 22.2%), family and social relations (e.g., colleagues, friends) of a patient were identified. from the analysis, the disclosure of family relations was shown to contain the following two categories: (1) disclosure of family information involving consecutive infection of family members (e.g., patient #8dj (seoul) mother from daegu visited patient #8dj's house, patient #t5v (seoul) patient #8dj's sister), and (2) disclosure of information on an uninfected family member (e.g., patient #sa3 (seoul) patient #sa3's husband had contact with patient #x6t at work and she was infected while under selfquarantine). in the first category, it was found that information about family relations was usually provided directly as family members' traces overlap and involve consecutive infections. the second category raises questions on the necessity of providing additional information about an uninfected family member. for example, information from the second case unnecessarily reveals that the patient's husband had contact with another patient who was assumed to be his colleague. considering that the patient's husband was not infected, it is difficult to say if his contact with a colleague was an essential piece of information. compared to family relations, social relations of confirmed cases generally provide activities shared together (e.g., carpool, late-night drinks at the bar). in the case of workplace relations, linkage information between patients was revealed largely through collective infection. some cases revealed additional information other than a colleague/friend relationship. for example, contact trace data of patient #9f5 (seoul) revealed his colleague is a member of d0l6 church, a church that was identified as the epicenter of the major outbreak in south korea after the infection of patient #f61, a "super-spreader" from daegu. the local government may have judged that providing this information was necessary considering the severity of the outbreak situation. however, the question still remains as to whether it was an appropriate decision to disclose information about religion along with social relationships. "relationship and location" (n = 257, 26.5%) provides information on visits to certain places that may reveal the presence of another person and lead to speculation and unwanted exposure of one's private relationship. for example, one patient's repeated visits to a motel at regular intervals may lead to speculation that he has an intimate relationship with someone. although excluded from our data analysis, patient #f24 from suwon (one of the cities in south korea) who had his traces overlapped with his sister-inlaw (patient #8if) was highly criticized by the media and social network for having an affair, which turned out to be a rumor (21) . less sensitive cases reported the location of home and workplace of a patient's family, friends, and other acquaintances. from the data, it was able to identify types of frequent activities of a patient (e.g., commuting, exercise), which extends to inference on a patient's routine behavior and lifestyle patterns (n = 234, 24.1%). for example, ∼55% of the contact trace data from seoul reported regular commuting time of the patients. these pieces of information are usually provided along with the type of transportation (e.g., on foot/by car/by bus/carpool with a colleague), which enables a detailed inference on one's time schedule. data of patient #t2n (seoul) showed repetitive commuting to a church and his later mobility patterns centered around the church. the patient also visited a nearby cafe several times at a similar time before the case was confirmed. this consistent pattern leads us to a plausible speculation that he is a christian who works at a church and often visits nearby places. the speculation in this study was confirmed through a news article that revealed his job, a missionary. as the high data granularity provided in this case leads to several assumptions on private information, it was found that inferred details of the patient (workplace, frequent visits, religion) could also belong to other categories, such as "significant places" and "sensitive information." key findings • demographics were observed in most cases (gender: 100%, age: 86.5%) and the data on significant places (residence/workplace) showed different levels of privacy risks in over 70% of the cases. • some places disclosed in the data indicated sensitive information about the patient due to the characteristics of the place (e.g., pc caf 'e -the patient's hobby is playing games, church-the patient is christian). in addition, nearly half of the cases (48.7%) exposed the patient's social relationships by describing information about relationships or by showing them visiting certain places with others. • around a quarter of the cases (24.1%) revealed the routine behavior of the patient from places that had been visited repeatedly and frequently. the patterns that appeared in routine behavior may be an important factor in inferring the patient's lifestyle. first, variation in privacy risk levels across different regions was analyzed by comparing their average privacy levels. the analyses revealed regional differences in privacy risks for the confirmed patients. in the demographics category, four cities, seoul, busan, incheon, and ulsan, often showed the exact age of patients (e.g., 27 years; i.e., level 2), while sejong, daejeon and gwangju showed the age range (e.g., the twenties; i.e., level 1). in terms of nationality, seoul disclosed the nationalities of the confirmed cases of all foreigners. despite its low proportion (∼7%) relative to the number of total cases, seoul reported a higher number of nationalities compared to other cities. it was posited that this was because of capital-specific effects, as the city has ∼400,000 foreigners. gwangju also reported a considerably high number of nationalities. out of the total 30 cases, gwangju revealed nationality information of all the cases (100% disclosure). unlike seoul, one interesting fact to note from gwangju is that the city also reported the nationality of korean patients. currently, no specific guidelines regarding nationality disclosure have been found. as shown earlier, all cities revealed gender information of the patients, and there was no difference in this regard. in addition, a comparison of the privacy level of significant places was conducted. as shown in table 5 , the average privacy level of residence is distributed between 1.21 (ulsan) and 3.00 (sejong). all the cities except sejong released only approximate information on a patient's residence such that more than half of the residential information released by each city was equal to or below level 2 ("dong" level). sejong revealed the most detailed information with level 3 on average (mostly at an apartment complex level), which is partly because of the unique characteristics of sejong, a new multifunctional administrative city with many high-rise apartment buildings. with regard to the workplace, the presence of a mass infection in the same building made the difference. important cases, such as the call center of an insurance company in guro-gu, seoul, influenced the high proportion of level 4 cases in seoul (15.1%) and incheon (27.2%); same was the case with a government building of the ministry of oceans and fisheries in sejong (76.1%). most of the patients in sejong work in government buildings, thereby resulting in a high ratio of level 4. daejeon showed a comparatively high ratio of level 4 (33.3%), despite having no case of mass infection, unlike other cities. in the "sensitive information" category, "hobby" showed a substantial proportion of cases that reported privacy level 0 across all cities. in level 1, sejong reported 17.4%, which is a markedly higher figure compared to other cities. this is interesting to note, as one patient who took a zumba class infected the other students. "religion" showed a moderately high percentage of level 0 in an overall sense, but busan showed 34.1% of cases that were level 1. collective infection occurred at a church that contributed to this relatively high level of disclosure. "accommodation" information appeared only in a small fraction of the dataset, but such visits were often suspected for cheating, as reported in the news articles (10) . from "hobby" and "religion, " it was found that a particular incident that involved collective infection unavoidably led to a disclosure of sensitive information. "routine behavior" showed a higher average level of disclosure than "sensitive information." in this category, sejong and daejeon showed relatively high percentages of 45.7 and 38.5%, respectively. in sejong (n = 46), confirmed cases showed very similar mobility patterns, as collective infection revealed that most of the patients worked at the same government and shared the same leisure activity (i.e., zumba class). it was assumed that the unique characteristics of this newly built administrative city have also contributed to this dense infection within the community, as the population is relatively small and a large proportion of residents are government officials. despite no occurrence of collective infection, daejeon (n = 39), as shown earlier, revealed the workplace of the confirmed patients. disclosed workplaces are usually research institutes or tech companies, as the city is a well-known mecca of science and technology in south korea. from the data, 84.6% of workplace revelations were particularly found in seo-gu and yuseong-gu, districts dense with research institutes. inferring the patients' routine behavior was relatively easier as their workplaces were revealed and they lived in the same area. cases from these two cities demonstrate that characteristics of a city can be reflected in contact trace data and enable an indication of one's routine behavior and daily patterns. in "social relationship, " ulsan showed the highest percentage of data disclosure (level 1 and level 2 combined: 72.4%), followed by gwangju (level 1 and level 2 combined: 63.3%). from ulsan, it was posited that mass influx from abroad and their traces with family members may have contributed to this high percentage of privacy disclosure. the korean government announced a guideline limiting the scope and detail of the information to be disclosed on march 14, 2020. as shown in table 7 , it was analyzed how the release of the government's official guidelines influenced privacy risk levels across different regions, by comparing the average privacy levels before and after the announcement. overall, average privacy risk levels decreased for the workplace, hobby, religion, and routine behavior, whereas other items remained somewhat similar. it is notable that while detailed demographic information (i.e., nationality, gender, and age) is generally considered as sensitive information, the average privacy levels for these remained unchanged even after the announcement. in privacy risk levels in general, every region showed a similar the change in trend. however, notable regional differences were found in accommodation and relationships; as an illustration, for relationships, the average levels decreased for seoul, daejeon, and gwangju, while the levels increased for busan and sejong. these findings indicate that the announcement of government guidelines can lower risk levels. however, the effects of the government guidelines could be limited to several factors, such as workplaces and routine behaviors, and vary across regions (or local governments). key findings • differences in privacy risk levels among the cities were observed. in particular, the data from sejong revealed the most detailed information on significant places (the average privacy risk levels for residence and workplace in sejong were over level 3), whereas ulsan showed a relatively high percentage of data disclosure on social relationships (i.e., 72.4% of the confirmed patients in ulsan). • the government guidelines on data disclosure have been released recently, and the effects were limited to a few factors, such as workplaces and routine behaviors. disclosed contact trace data (e.g., "where, when, and for how long") help people to self-identify potential close contacts with people confirmed to be infected. however, location trace disclosure may pose privacy risks because a person's significant places and routine behaviors can be inferred. privacy risks are largely dependent on a person's mobility patterns, which are affected by several regional and policy factors (e.g., residence type, nearby amenities, and social distancing orders). in addition, the results showed that disclosed contact trace data in south korea often include superfluous information, such as detailed demographic information (e.g., age, gender, nationality), social relationships (e.g., parents' house), and workplace information (e.g., company name). disclosing such personal data of already identified persons may not be useful for contact tracing whose goal is to locate unidentified persons who may be in close contact with confirmed people. in other words, for contact tracing purposes, it would be less useful to disclose the personal profile of the confirmed person and their social relationships, such as family or acquaintances. the detailed location of the workplace could be omitted because, in most cases, it is easy to reach employees through internal communication networks; an exceptional case would be when there is a concern of potential group infection with secondary contagions. likewise, it is not necessary to reveal detailed travel information of overseas entrants (which were not reported in the main results), such as the arrival flight number and purpose/duration of foreign travels. based on the results and discussions, this subsection presents policy and technical implications for contact tracing and data disclosure. detailed guidelines are required: the scope and details of patient data disclosure should be carefully considered in the official guidelines. as shown earlier, some of the information included in the patient data in south korea could be controversial because it is not clear whether it is essential to prevent further spread of covid-19. the current guidelines set by the kcdc, which are shown in table 1 , do not provide detailed recommendations. therefore, the guideline about "information that identifies a specific person" could be interpreted differently by different contact trace officers. at the time of contact tracing, it is difficult for officials to envision how a combination of different pieces of information provides an important clue the patient's identity. to reduce the possibility of subjective interpretation, current guidelines can be augmented with the patterns of problematic disclosure, which could be documented by carefully reviewing existing cases. in this case, the codebook of this study could serve as a starting point for analyzing the patterns of problematic disclosure. for instance, one's residence and workplaces can be generally considered sensitive information. the codebook allows the assessment of privacy risk level on a patient's residence and workplaces when disclosing the patients' visited places and transport modes. in addition, for location privacy protection, privacy protection rules, such as k-anonymity can be applied. the k-anonymity ensures that k people in that region cannot be distinguished (22) . due to public safety, however, its strict application is not feasible, yet a relaxed version of k-anonymity can be used: at least for a given region, when there are multiple confirmed cases with overlapping periods, removing identifiers (or confirmed case numbers) could be considered to further protect their location privacy. proper management of revealed data is required: given that some level of privacy risk is unavoidable due to public safety, it is important to manage the patients' data that have been opened to the public. official guidelines recommend that municipalities erase outdated data from their official websites. while scouring the dataset over several months for this research, it was noticed that contact trace data are replicated on multiple sources, ranging from official channels of municipalities (e.g., homepage, blogs, social media, and debriefing videos on youtube) to online news articles and personal sites. diversifying information access channels would be beneficial for public safety; however, the authorities should set a strict code of conduct or regulations on managing replicated contact trace data (e.g., "register before publish") to promote responsible use (e.g., removing outdated data). it's possible to automatically check privacy issues: contact tracers' subjective interpretation could be a source of privacy risks. one could consider an intelligent system that detects possible privacy issues from the patient data before disclosure. for example, personal data can be detected by utilizing supervised machine learning that analyzes semantic, structural, and lexical properties of the data (23) or by estimating privacy risks with visual analytic tools based on k-anonymity and l-diversity models (22). if a system utilizes a metric for quantifying the privacy threat and evaluation model as proposed in the previous study (24) , the system could not only detect potential issues but also obscure the data automatically until it meets a certain privacy level. however, these automatic approaches should be considered with care because they may hide essential contact trace information that needs to be released for public safety. unified management of contact tracing data could be introduced: decentralized management of contact trace data in each municipality makes it difficult to examine privacy risks and manage data replication. in addition, the quality of user interfaces varies widely across different regions. introducing a unified system that manages and visualizes the contact trace data across all regions would be beneficial. of course, there is a concern of a single point of failure, yet this issue can be overcome by introducing decentralized server systems with cloud computing. to promote responsible replication and management of patient data, one can implement a "register before publish" policy. moreover, an information system can help to manage the people who reprocess the patient data officially provided by the local government and deliver it to the public via news articles. this system should have the ability to (1) authorize data usage, (2) track in which article the data is being used, and (3) delete the data automatically when it is outdated. the system could also provide a built-in sharing feature as in youtube's video embedding. youtube allows users to add a video to their websites, social network sites, and blogs by embedding the video to the sites, while any modification or deletion of the original video on youtube is also reflected in the embedded video (25) . a similar mechanism can also be applied to the system. mobile technologies for contact tracing can be alternatively considered: mobile technologies could be utilized to avoid privacy concerns from public disclosure (26, 27) . short-range wireless communications (bluetooth) can be used to automatically detect close contacts by keeping periodic scanning results of nearby wireless devices [e.g., tracetogether (28) and apple/google's app (29, 30) ]. a confirmed user can now publish its anonymized bluetooth id, which helps other people to check whether they are in close contact with the patient. this approach certainly helps protect user privacy because location information is not explicitly shared. however, there are major concerns about its assumption: a majority of people voluntarily need to install mobile applications. there should be further studies on how to consider multiple contact tracing methods along with traditional methods of public disclosure. with the outbreak of covid-19, as mentioned in the introduction, several countries have been disclosing contact trace data. although this paper presents the privacy risks of contact tracing practices, the results should be carefully interpreted, given the limitations of the study. first, this work is focused on south korea and the results may not be generalizable to other nations due to policy differences. however, our methodologies and insights could still be applied in other nations that make contact trace data public. comparing the differences in disclosure policies and privacy risk levels would be an interesting direction for future work, as slight differences in disclosure exist. for instance, the hong kong government reveals the patient's information in an interactive map dashboard that showed not only the demographics but also the full address of both residential and non-residential places that the patient had visited (31) . the singapore government also released detailed patient information, such as nationality, visited sites, and infection sources (4). aggressive contact tracing and data disclosure were considered effective methods for suppressing the spread of a virus. while there is an ongoing dispute between promoting public safety and protecting personal privacy, there is a growing consensus that a reasonable level of personal privacy needs to be sacrificed for public safety, as shown in a recent survey (32) . for all these cases, our policy and technical implications could help lower privacy risks and yet allow governments to effectively conduct contract tracing. in future studies, researchers could compare the differences between governmental policies of open access to contact trace data and the opinions from the public among these countries to set international guidelines on data disclosure in pandemic situations. next, there are privacy issues that remain to be quantified; for example, revealing foreign travel logs, underlying medical conditions, and even part of a patient's name (i.e., the last name of the patient). place log information may include hospital visits that are not related to covid-19; this could reveal a patient's underlying health or personal conditions (e.g., urology, dermatology, and cosmetic surgery). therefore, this study should be expanded to evaluate diverse privacy-violating elements. it is also necessary to study the media's disclosure patterns of patient information. in some cases, the media provided more specific data than the government through an exclusive report. recently in south korea, new media publicized a patient's sexual orientation by investigating visited places (e.g., specific types of bars) or workplace/social information (e.g., infected healthcare workers). therefore, one could compare the disclosed data from the local government with that from the media to evaluate how much further privacy leakage would occur through the news media. this work mainly focused on analyzing the officially disclosed patient data, nevertheless, it is also important to find out what people (both patients and the public) really think about that data. opinions on sharing my data as opposed to someone else's may differ (33) , and the perception of risk of information disclosure could be influenced by the consequent results of both benefits and risks (34) . thus, researchers could possibly find an optimal level where personal privacy and public benefit are well-balanced. all datasets presented in this study are included in the article/ supplementary material. feasibility of controlling covid-19 outbreaks by isolation of cases and contacts contact tracing during an outbreak of ebola virus disease available online at response to covid-19 in taiwan: big data analytics, new technology, and proactive testing how coronavirus is eroding privacy south korea is reporting intimate details of covid-19 cases: has it helped? fear and stigma: the epidemic within the sars outbreak defect: issues in the anthropology of public health. stigma and global health: developing a research agenda privacy: are south korea's alerts too revealing? (2020) national human rights commission of korea. nhrck chairperson's statement on excessive disclosure of private information available online at division of risk assessment and international cooperation, kcdc. press release-updates on covid-19 in korea (as of 14 march) division of risk assessment and international cooperation, kcdc. press release-the updates on covid-19 in korea as of 21 may sharing location in online social networks location disclosure to social relations: why, when, & what people want to share rethinking location sharing: exploring the implications of social-driven vs. purpose-driven location sharing available online at using thematic analysis in psychology localness of location-based knowledge sharing: a study of naver kin ?here? yonhap news agency. no. of foreign rresidents in s. korea hits record 2.05 mln in 2018 south korea's tracking of covid-19 patients raises privacy concerns using data visualization technique to detect sensitive information re-identification problem of real open dataset private data discovery for privacy compliance in collaborative environments the metric model for personal information disclosure available online at: https:// support.google.com/youtube/answer/6301625?hl=en mobile phone data and covid-19: missing an opportunity? arxiv covid-19 contact tracing and data protection can go together singapore says it will make its contact tracing tech freely available to developers available online at available online at latest situation of coronavirus disease (covid-19) in hong kong americans rank halting covid-19 spread over medical privacy less than half in singapore willing to share covid-19 results with contact tracing tech teenagers' perceptions of online privacy and coping behaviors: a risk-benefit appraisal approach gj and hl collaboratively analyzed the dataset and wrote the main texts (i.e., introduction, results, discussion). ak actively guided the design of the study, helped data analyses/visualizations, and wrote the background and summary sections. ul supervised the overall research, provided detailed feedback for data analyses and paper organization, and reviewed the entire manuscript. all authors contributed to the article and approved the submitted version. the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.copyright © 2020 jung, lee, kim and lee. this is an open-access article distributed under the terms of the creative commons attribution license (cc by). the use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. no use, distribution or reproduction is permitted which does not comply with these terms. key: cord-031942-mfz313q0 authors: kim, hye kyung; ahn, jisoo; atkinson, lucy; kahlor, lee ann title: effects of covid-19 misinformation on information seeking, avoidance, and processing: a multicountry comparative study date: 2020-09-13 journal: sci commun doi: 10.1177/1075547020959670 sha: doc_id: 31942 cord_uid: mfz313q0 we examined the implications of exposure to misinformation about covid-19 in the united states, south korea, and singapore in the early stages of the global pandemic. the online survey results showed that misinformation exposure reduced information insufficiency, which subsequently led to greater information avoidance and heuristic processing, as well as less systematic processing of covid-19 information. indirect effects differ by country and were stronger in the u.s. sample than in the singapore sample. this study highlights negative consequences of misinformation during a global pandemic and addresses possible cultural and situational differences in how people interpret and respond to misinformation. the pandemic caused by the coronavirus disease 2019 (hereafter referred to as poses unprecedented threats to global human well-being. because of the high uncertainty associated with the novelty of covid-19, many people rely on online health information to learn more about how to protect themselves and their families from the imminent health threat (bento et al., 2020; garfin et al., 2020; hernández-garcía & giménez-júlvez, 2020) . while its prevention and treatment require practices based on scientific evidence, there are myriad sources of incorrect information circulating on the internet about what prevents and cures covid-19. this is critical because relying on such misinformation can bring about detrimental health outcomes by encouraging people to engage in ineffective-even harmful-remedies. for example, nearly 300 people have been killed by ingesting methanol based on harmful treatment recommendations that spread across social media in iran (associated press, 2020) . in south korea, 46 churchgoers were infected with covid-19 after church leaders sprayed saltwater into their mouths out of a misguided belief that the water would help prevent the spread of covid-19; the spray bottle became contaminated with the virus in the process and spread infection (park, 2020) . in the united states, rumors spread on social and national media that ingesting bleach might help kill the virus; research suggests that this misinformation contributed to individuals "engaging in non-recommended high-risk practices with the intent of preventing sars-cov-2 transmission, such as washing food products with bleach, applying household cleaning or disinfectant products to bare skin, and intentionally inhaling or ingesting these products" (gharpure et al., 2020, p. 705) . accordingly, the world health organization (who; 2020) has declared an "infodemic" related to covid-19 and actively sought to rectify the crisis levels of misinformation spreading online. despite the proliferation of online misinformation, the internet is an important source of information during a disease pandemic as it can be an efficient and expeditious channel for providing necessary information and for correcting misinformation. indeed, risk communication scholars have emphasized the importance of providing timely information in risk contexts to help aid decision making, especially when there is considerable uncertainty about the most effective course of action in a given situation (edgar et al., 2000; yang, aloe, & feeley, 2014) . therefore, scholars must find ways to better understand how the power of the internet to misinform is affecting its ability to inform. one important, still unanswered question is whether exposure to misinformation serves to motivate or deter subsequent information seeking, and/or changes the way encountered information is processed. prior theorizing on risk communication has often focused on immediate outcomes of information exposure; yet there is a lack of understanding about the subsequent information management that follows exposure to risk information (so et al., 2019) . the current study addresses these important gaps in the extant literature in its examination of exposure to misinformation on this study builds on previous research by offering two main contributions. first, guided by the risk information seeking and processing (risp) model (griffin et al., 1999) , we posit that a reduction in the perceived need for additional information (or information insufficiency) is an important mechanism that underlies adverse consequences of misinformation exposure on subsequent information seeking and processing. given that prior research has often focused on the spread of misinformation (guess et al., 2019; valenzuela et al., 2019) , addressing the implications of that spread on information seeking and processing helps to enrich our understanding of misinformation effects. second, this current study examines whether the effects of misinformation exposure are universal across cultures or specific to certain cultural contexts. studies on information seeking and processing have been conducted predominantly in western contexts, and cross-cultural studies, especially studies that involve multiple countries, are lacking in the extant literature. for theory building and refinement, it is important to examine the validity of a theoretical prediction across different cultural contexts and populations. misinformation is defined as objectively incorrect information that is not supported by scientific evidence and expert opinion (nyhan & reifler, 2010) . while misinformation can persist for a long time without contradiction (kata, 2010) , for scientific issues, what is true or false can be altered with newly emerging evidence and consensus among experts (vraga & bode, 2020) . researchers also differentiate misinformation from misperception and disinformation: misperception is holding a belief that is incorrect or false (southwell et al., 2018) , whereas disinformation is driven by the intention to deceive (wardle, 2017) . while misinformation is inadvertently false, its propagation or sharing can subsequently be either deliberative or accidental (southwell et al., 2018) . there is ample evidence on the pervasiveness of misinformation in the context of infectious disease outbreaks. for example, a study on the zika virus found that half of the top 10 news stories were based on misinformation or rumors, and those stories were 3 times more likely to be shared on social media than stories based on facts (sommariva et al., 2018) . studies on covid-19 similarly found that misinformation was more frequently tweeted than science-based evidence or public health recommendations (bridgman et al., 2020; pulido et al., 2020) . researchers have addressed the potential consequences of misinformation that could undermine the adoption of preventive measures (bridgman et al., 2020; dixon & clarke, 2012; tan et al., 2015) , which could exacerbate the spread of the epidemic. researchers have also suggested that exposure to misinformation can trigger individuals' additional information seeking to verify the information that they suspect to be false (tandoc et al., 2017) . for example, when individuals cannot verify information on social media based on their own judgment and knowledge, they seek out information from their social circle and other sources to authenticate (tandoc et al., 2017) . researchers, however, also point out that the motivation for subsequent information seeking may not always be related to accuracy (southwell, 2013) . as thorson (2016) addressed, misinformation exposure actually may prevent individuals from seeking new information and instead may trigger motivated processing to protect their preexisting attitudes or beliefs. such selective information exposure and motivated reasoning make it difficult to rectify misinformation once false beliefs are deeply held (bode & vraga, 2015; jerit & barabas, 2012) . as porter and wood (2019) argued, however, individuals can simultaneously pursue the accuracy on factual matters as well as the goals that serve their pre-extant beliefs. in the context of a novel disease pandemic, it is also important to consider the uncertainty regarding what is true and false about the disease and its prevention, given that the expert consensus and "best available evidence" are subject to change (vraga & bode, 2020, p. 138) . such information uncertainty may as well have implications on the public's information behaviors. in a recent study, perceived exposure to covid-19 misinformation was positively associated with seeking more information and complying with health advisories (hameleers et al., 2020) . because perceived misinformation exposure takes into account individuals' judgment on the veracity of information, its implications may differ from exposure to misinformation that is based on actual state of scientific evidence (vraga & bode, 2020) . we thus take the latter conceptualization in the current study to understand the effects of misinformation exposure. guided by the risp model (griffin et al., 1999) , the current study examines whether and how exposure to misinformation about covid-19 prevention motivates or deters effortful seeking and processing of relevant information. the risp model is one of the most comprehensive models that seeks to understand social psychological motivators of seeking and processing risk information (yang, aloe, & feeley, 2014 ). in the model, various concepts drawn from the theory of planned behavior (ajzen, 1991) and other works are depicted as having an indirect impact on information seeking and processing through the model's central concept of information insufficiency. however, the risp model does not theorize individuals' prior exposure to risk information within the model, despite the possible implications of prior exposure on information seeking and processing. in risk contexts, information seeking and processing are driven by the motivation to reduce uncertainty. information insufficiency refers to one's subjective assessment of the gap between their perceived current knowledge about a risk and what they feels is sufficient knowledge for adequately coping with the risk (sufficiency threshold). information insufficiency is at the heart of the risp model because uncertainty reduction occurs only when individuals are sufficiently motivated to engage in the tasks needed to achieve the desired judgmental confidence (eagly & chaiken, 1993) . while little is known about how exposure to misinformation influences individuals' perceived (needed) knowledge, misinformation on covid-19 can potentially make individuals feel overwhelmed with different and inconsistent recommendations on what prevents and cures the disease (pentina & tarafdar, 2014) . in turn, this sense of being overloaded with information may manifest as having sufficient information on a given issue (i.e., a lower information insufficiency). indeed, pentina and tarafdar (2014) have argued that the amount and variety of unverified information circulating online can make individuals feel overloaded with information, given individuals' limited capacity to process. researchers have also suggested that the ambiguity, low quality, and novelty of information can trigger the feeling of overload as these attributes make it more difficult for individuals to process information (keller & staelin, 1987; schneider, 1987) . thus, we posit our first hypothesis on information insufficiency as follows: hypothesis 1 (h1): exposure to misinformation will be negatively associated with information insufficiency. the risp model theorizes information insufficiency as the primary component that predicts subsequent information seeking and avoidance as well as how the information will be processed. information seeking is defined as a volitional process of acquiring desired information from relevant sources, whereas information avoidance refers to deliberately shunning or delaying the acquisition of available information. we treated information seeking and avoidance as two orthogonal constructs, instead of the opposites on a continuum, as they can coexist under some circumstances that involve uncertainty (yang & kahlor, 2013) . informed by the heuristic-systematic model (eagly & chaiken, 1993) , the risp model posits a dual system of information processing. the dual system includes one that requires more effortful and deeper processing (systematic processing) and another that involves more superficial processing and poses fewer cognitive demands on individuals (heuristic processing). griffin et al. (1999) predicted that the drive to overcome information insufficiency motivates individuals to seek more riskrelated information and to systematically process the information, while making it less likely for them to heuristically process. some empirical work has supported the insufficiency principle in this role (griffin et al., 2002; kahlor, 2007) , while a meta-analysis of the risp model found limited evidence (yang, aloe, & feeley, 2014) . the conflicting evidence points to the possibility of information insufficiency serving as a mediator between misinformation exposure and information seeking and processing. prior exposure also may have direct associations with information seeking and processing. past information exposure and related attitudes have been related to other information behaviors, including information avoidance and information sharing (kahlor et al., 2016; yang & kahlor, 2013; yang, kahlor, & griffin, 2014) . furthermore, a study by kalichman et al. (2006) suggested a positive relationship between exposure to misinformation about aids/hiv and information avoidance behaviors. thus, we posit the following direct and indirect effects of misinformation exposure on information seeking and avoidance, as well as systematic and heuristic processing. hypothesis 2 (h2): exposure to misinformation will be associated with (a) reduced information seeking, (b) increased information avoidance, (c) reduced systematic processing, and (d) increased heuristic processing. hypothesis 3 (h3): informational insufficiency will mediate the effect of misinformation on (a) information seeking, (b) information avoidance, (c) systematic processing and (d) heuristic processing. the risp model also addresses several psychosocial factors that predict information insufficiency. the most powerful predictor of risk information seeking to emerge from the risp research is informational subjective norms, that is, perceived pressure from others to engage in a given information behavior (kahlor, 2010; yang, aloe, & feeley, 2014) . these norms also constitute an important predictor of information insufficiency (kahlor, 2010; yang, aloe, & feeley, 2014) . another important risp concept is risk perception, which comprises subjective probability and perceived severity of harm and is the most commonly examined cognitive component of how individuals assess a given risk (yang, aloe, & feeley, 2014 ). the risp model also takes into account affective responses to risk, such as anxiety and fear, which serve as important heuristic cues in making risk decisions (finucane et al., 2000) . affective responses, which result from risk perceptions, increase an individual's desire for information (griffin et al., 2008; so et al., 2019; yang & kahlor, 2013) . one interesting question is whether misinformation exposure influences these psychosocial factors, which would subsequently affect information insufficiency as well as information seeking and processing. there are two different possibilities. if misinformation exposure increases perceived risk, affective response to risk, and informational subjective norms, then this also would increase information insufficiency, thus counterbalancing the negative implications of misinformation hypothesized in h1. in contrast, if misinformation decreases these psychosocial factors, this would further explain h1. to examine these possibilities, we pose the following research question: what is the role of risk perception, affective response, and informational subjective norms in the relationship between misinformation exposure and information insufficiency? there is limited understanding of why certain individuals or societies are more or less vulnerable to misinformation (wang et al., 2019) . researchers suggest that older adults (mitchell et al., 2003) , those with lower cognitive ability (de keersmaecker & roets, 2017), and those who are less educated (kalichman et al., 2006) are more likely to be misinformed than those who are younger, have higher cognitive ability, or are more educated. prior research also points to ideological asymmetries in sharing and believing misinformation. the research suggests that people who prioritize conformity and tradition (i.e., conservatives) also tend to emphasize uncertainty reduction, and thus exaggerate within-group consensus and maintenance of homogenous social relationships, both of which contribute to the spread of misinformation (jost et al., 2018) . beyond these individual-level characteristics, we lack data comparing the relative susceptibility to misinformation between populations and societies based on cultural differences. research on cultural differences suggests that uncertainty avoidance, which refers to the "extent to which the members of a culture feel threatened by uncertain or unknown situations" (hofstede, 1991, p. 113) , is a cultural dimension related to anxiety, security needs, and rule orientation. high-uncertainty avoidance cultures tend to be less tolerant about ambiguity and diversity than low-uncertainty avoidance cultures. because misinformation on covid-19 prevention is characterized by scientific uncertainty, we suggest that cultural differences in uncertainty avoidance may moderate the effect of misinformation exposure on information seeking and processing. moreover, cultural differences in uncertainty avoidance also may change the relative strength of the relationship between information insufficiency and information seeking and processing. that is, those in high-uncertainty avoidance cultures may be more likely to act on their information insufficiency to seek out and effortfully process relevant information in order to reduce their uncertainty, than those in low-uncertainty avoidance cultures. consistent with this prediction, in the context of climate change, one crosscultural study based on the risp model found the information insufficiencyinformation seeking intention association to be stronger in the u.s. sample (a relatively higher uncertainty avoidance culture) compared to the china sample (a low-uncertainty avoidance culture; yang, kahlor, & li, 2014) . given the conceptual importance of information insufficiency in the risp model, we extend prior work by comparing the relative strength of the effect of information insufficiency between the u.s. sample and two other countries, one with a higher uncertainty avoidance culture (south korea, index score = 85) and the other with a lower uncertainty avoidance culture (singapore, index score = 8) compared to the united states (index score = 46; hofstede, 1983; hofstede et al., 2010) . research question 2 (rq2): do the direct and indirect effects of misinformation exposure on information seeking, avoidance, and processing differ between the united states and south korea or singapore? an online survey was conducted in the early stages of the covid-19 pandemic 1 in three countries, the united states (march 16-23, 2020), south korea (february 24-march 3, 2020) and singapore (february 25-march 10, 2020). panel members were recruited from online panel companies: global research in south korea (n = 1,500) and qualtrics in singapore (n = 1,023) and the united states (n = 419). we employed quota sampling in terms of age, gender, and ethnicity to match with the national profile of singapore, south korea, and the united states. the survey took about 15 minutes to complete and was administered in english in singapore and united states and in korean in south korea. the english survey questionnaire was translated into korean by two bilingual researchers. for the combined samples, respondents ranged in age from 18 to 90 (m = 42.29, sd = 12.62) and consisted of 48.8 % females. the median educational attainment was "some college or an associate's (2-year) degree." the majority of the singapore sample was ethnic chinese (80.4%), followed by 10.5% malay. in the u.s. sample, 74.9% self-identified as white and 15.4% identified as black or african american. south korea is a monoethnic country. table 1 presents the sample profile and descriptive statistics by country. information seeking and avoidance. information seeking was measured by five items derived from j.-n. kim et al. (2012) and j.-n. kim and grunig (2011) . sample items, on a 5-point likert-type scale (1 = strongly disagree, 5 = strongly agree), included "i regularly check to see if there is any new information about this problem" and "i spend a lot of time learning about this issue" (m = 3.36, sd = .81, α = .82). information avoidance was measured by five items adapted from howell and shepperd (2016) and miles et al. (2008) . on the same likert-type scale, items included "i don't want any more information about covid-19" and "i avoid learning about covid-19" (m = 2.06, sd = 0.87, α = .88). systematic and heuristic processing. systematic processing was assessed by three items derived from yang et al. (2010) and yang et al. (2019) . on a 5-point scale (1 = not at all, 5 = very much), sample items included "after i encounter information about covid-19, i stop and think about it" and "for me to understand about covid-19, the more viewpoints i get the better" (m = 3.61, sd =0 .74, α = .73). heuristic processing was assessed by three items from yang et al. (2010) and kahlor et al. (2003) . using the same 5-point scale, items included, for example, "when i come across information about covid-19, i focus on only a few key points" (m = 3.07, sd = .75, α = .64). although cronbach's alphas for these scales are relatively weak, they are comparable to the one used by yang et al. (2010) , who suggest that these processing scales are still under development and thus have room for improvement (also see deng & chan, 2017 , as yang et al., 2010 , reported omega rather than alpha). information insufficiency. to calculate information insufficiency, we separately assessed perceived current knowledge and sufficiency threshold (griffin et al., 2008; yang et al., 2019) . to assess perceived current knowledge, participants rated to what extent they currently know about covid-19 on a scale of 0 (knowing nothing) to 100 (knowing everything; m = 65.24, sd = 19.39). for sufficiency threshold, participants estimated how much knowledge they would need in order to deal adequately with the risk of covid-19 on a scale of 0 (need to know nothing) to 100 (need to know everything you could possibly know; m = 73.00, sd = 20.03). we employed the analysis of partial variance (cohen & cohen, 1983) to compute information insufficiency 2 (m = 40.38, sd = 17.55) that contains the residual variance of information threshold accounting for the variance of perceived current knowledge (rosenthal, 2013) . this approach helps to address the limitations of using a raw difference score (e.g., sensitive to floor and ceiling effects) and the regressed change approach (e.g., the inflated explained variance in information insufficiency). exposure to covid-19 information. exposure to misinformation was assessed with five claims on covid-19 prevention measures that were identified as false at the time of data collection 3 (who, 2020): (a) gargling with mouthwash, (b) eating garlic, (c) avoiding pets, (d) vaccination against pneumonia, and (e) regularly rinsing the nose with saline. on a 4-point scale (1 = not at all, 4 = a lot of times), participants reported how often they had heard that each of the five claims from eight different information sources (e.g., news app or website, social media app or website, medical or health websites, television and radio news; tan et al., 2015) . cronbach's α for the exposure scales across the five claims ranged from .96 to .97, and items were averaged to create composite scores. the composite scores were further averaged into an index of exposure to misinformation (m = 1.43, sd = 0.68, α = .95). for comparison purpose, we also examined exposure to general covid-19 information without specifying the information content. on a 5-point scale (1 = never, 5 = very often), participants reported how often they learned about covid-19 using 10 different information sources (rains, 2007; e.g., websites or social networking site [sns] of governmental health agencies, print or online newspapers, sns of newspapers, individual sns, television). responses were averaged into a score of exposure to general covid-19 information (m = 3.13, sd = .73, α = .95). exposure to misinformation and exposure to general covid-19 information were moderately correlated (r = .43, p < .001). risk perception. two components of risk perception were assessed: perceived susceptibility and severity. to assess perceived susceptibility (brewer et al., 2004) , participants estimated their chances of contracting covid-19 in several weeks if they do not take any preventive actions on a given slider between 0% and 100% at 10% intervals (m = 52.25, sd = 28.24). on a 5-point likert-type scale (1 = strongly disagree, 5 = strongly agree), we used three items derived from weinstein (2000) to measure perceived severity (e.g., "i think that covid-19 is a very dangerous disease"; m = 3.50, sd = 0.98, α = .86). based on convention (griffin et al., 2008; weinstein, 2000) , we multiplied perceived susceptibility and severity to create an index of risk perception (m = 189.51, sd = 125.34). affective responses. we assessed negative affective responses experienced during the covid-19 pandemic such fear, anger, sadness, and anxiety derived from prior work (yang, 2016; yang et al., 2019) . these emotions have been reported to be frequently experienced in crises and pandemic situations (jin et al., 2012; h. k. kim & niederdeppe, 2013) . on a 5-point scale (1 = not at all, 5 = very much), participants rated their feelings toward the covid-19 situation on the following emotions themed under fear (afraid, fearful, scared), anger (angry, mad, irritated), sadness (sad, downhearted, unhappy), and anxiety (anxious, worried, concerned). responses were averaged to create a scale of affective responses (m = 3.49, sd = 0.98, α = .95). informational subjective norms. derived from yang and kahlor (2013) , we used four items asking participants' perception of other's expectations about their seeking covid-19-related information on a 5-point scale (1 = not at all, 5 = very much; e.g., "most people who are important to me think that i should seek information about covid-19"). responses were averaged to create a scale of informational subjective norms (m = 3.33, sd = 0.91, α = .88). to examine our hypotheses and research questions (summarized in figure 1 ), we used hierarchical ordinary least squares regression, which allowed us to enter variables in separate blocks to test the incremental assessment of r 2 in each step as well as the relative effects of variables while accounting for those entered together or in earlier steps (cohen et al., 2003) . all the analyses controlled for demographic factors (i.e., age, gender, education, country), having a respiratory disease in the past few weeks (yes/no), and presence of local cases of covid-19 in the subject's city (yes/no). multicollinearity tests showed tolerance values above zero and variance inflation factor values below the conventional cutoff value of 10 for all variables entered in the models (cohen et al., 2003) . we entered exposure to misinformation and general information on covid-19 in the first block along with other control factors (testing h1 and h2), and risp model components (risk perception, affective response, informational subjective norms, and information insufficiency) in the second block. addressing h3 and rq1, we tested a serial mediation model (model 80) with process macro (hayes, 2017) to investigate the indirect effects of misinformation on information seeking, avoidance, and processing, separately mediated through risk perception, affective responses, and information subjective norms, as well as serially via information insufficiency. addressing rq2, the conditional indirect effects via information insufficiency by country were analyzed with process macro model 15. the u.s. sample served as a reference group given its middle position in regard to the level of uncertainty avoidance (hofstede, 1983) . we estimated confidence intervals (cis) with 5,000 bootstrap samples. we hypothesized that exposure to misinformation would be negatively associated with information insufficiency (h1). as shown in table 2 , h1 was supported. information insufficiency was negatively correlated with misinformation exposure (β = -0.12, p < .001) and positively with general information on covid-19 (β = 0.11, p < .001). risk perception (β = 0.13), affective response (β = 0.14), and information subjective norms (β = 0.09) were also positively associated with information insufficiency (all p < .001). we also predicted that exposure to misinformation would be negatively associated with information seeking and systematic processing, and positively associated with information avoidance and heuristic processing (h2a-d). as shown in table 3 , h2a was not supported, as misinformation was positively associated with information seeking (β = 0.045, p = .006). however, h2b and h2d were supported, as misinformation was positively associated with information avoidance (β = 0.373, p < .001) and with heuristic processing (β = 0.273, p < .001). as predicted, h2c also was supported, as systematic processing was negatively associated with misinformation exposure (β = −0.048, p = .012). at step 2, controlling for other risp components, information insufficiency was negatively associated with information avoidance (β = −0.104, p < .001) and heuristic processing (β = −0.067, p = .002), whereas it was positively associated with systematic processing (β = 0.104, p < .001). no association was found with information seeking (β = 0.022, p = .096). we predicted indirect effects of misinformation on information seeking, avoidance, and processing via informational insufficiency (h3). in light of the predictions of the risp model, we also included risk perception, affective responses, and informational subjective norms in a serial mediation model using process macro (model 80; finally, we sought to explore whether the direct and indirect effects of misinformation are further moderated by country (rq2). we used process macro (model 15; table 5 ) to examine the moderated mediation via information insufficiency by country (u.s. sample served as a reference group) on information seeking, avoidance, and processing. figure 2 presents the effects of misinformation exposure by country, and figure 3 presents the effects of information insufficiency by country. in a model predicting information seeking, the direct effect of misinformation differed between singapore and united states (p = .015; south korea-united states comparison, p = .07) such that it was significant only in the singapore sample (β = .085, p = .013; β us = −.022, p = .47; β kr = .044, p = .06). in contrast, the effect of information insufficiency on information seeking was significant only in the us sample (β = .003, p = .005), which was significantly different from that of the singapore sample (p < .001; β sg = −.002, p = .06) but not from the south korea sample (p = .32; β kr = .002, p = .054). the conditional indirect effect was significant only in the us sample (95% ci [−.020, −.003]) and this effect statistically differed only from the singapore sample (index of moderated mediation = .019, ci [.006, .034]). in predicting information avoidance, the direct effect of misinformation was significant across all three countries (β us = .399, β sg = .370, β kr = .538, all p < .001), but the effect size significantly differed only between the u.s. and south korea samples (p = .006; united states-singapore comparison, p = .63). the effect of information insufficiency on information avoidance was significant in the u.s. and south korea samples (β us = −.008, β kr = −.007, all p < .001) but not in the singapore sample (β sg = −.002, p = .13); thus, only the contrast between the united states and singapore was significant (p = .011). the conditional indirect effect was significant only in the u.s. (95% ci [.014, .046]) and south korea samples (ci [.013, .37]); there was a significant moderated mediation for the united states-singapore contrast (index = −.020, ci [−.040, −.003]). as for systematic processing, the direct effect of misinformation was significant only for the u.s. sample (β us = −.118, p < .001; β sg = −.004, p = .91; β kr = −.050, p = .053), and it contrasted significantly with the effect in the singapore sample (p = .02) but not the south korea sample (p = .09). the effect of information insufficiency did not differ by country (united states-south korea comparison, p = .49; united states-singapore comparison, p = .54) and all conditional indirect effects were significant on systematic processing regardless of country (95% ci in predicting heuristic processing, the direct effect of misinformation was significant across all countries (β us = .408, β sg = .265, β kr = .256, all p < .001), while the effect size being stronger in the u.s. sample than in the singapore (p = .012) or south korea samples (p = .001). the effect of information insufficiency was significant only in the u.s. sample (β us = −.006, p < .001; β sg = −.001, p = .71; β kr = −.002, p = .09), and its coefficient was significantly different from that of the singapore (p = .006) and south korea samples (p = .023). accordingly, the conditional indirect effect was significant only in the u.s. sample (95% ci [.010, .037]) and the moderated mediation was significant for both united states-singapore ( the covid-19 pandemic represents one of the biggest challenges to global human well-being to date. an epidemic of misinformation makes this formidable challenge even more so by impeding people from getting correct information on how to prevent and curb the spread of the disease. based on a multicountry survey conducted in the early stages of the global pandemic, this study documents that exposure to misinformation demotivates individuals from seeking out and thoughtfully processing information on covid-19. our intercountry comparisons suggest, however, that the influence of misinformation exposure may not be equivalent across different populations and cultures. thus, we provide important insights for theory building, as well as for the mitigation of misinformation effects across populations as they all face a common goal-to prevent and curb the spread of disease. this study found that exposure to misinformation was negatively associated with information insufficiency. that is, when people encounter misinformation, they perceived less informational need for adequately preventing and treating covid-19. it is noteworthy that exposure to misinformation reduced both sufficiency threshold and current knowledge, when these variables were analyzed separately. yet the decrease in sufficiency threshold was greater than that of current knowledge, which resulted in lower information insufficiency. unlike the association of misinformation, exposure to general information was positively associated with information insufficiency. this suggests that the influence of misinformation is distinguished from that of general information on covid-19. in the early stages of a novel disease pandemic, exposure to general information on the unknown risk at hand may make individuals realize that they need more information, whereas the opposite is true for misinformation. information insufficiency served as a significant mediator of the relationship between misinformation exposure and information avoidance, systematic processing, and heuristic processing. that is, when individuals perceived that they know enough about covid-19 as a result of misinformation exposure, they were more likely to avoid information and heuristically process (rather than systematically process) relevant information. this counters the findings from a study that assessed perceived misinformation exposure (hameleers et al., 2020) . as vraga and bode (2020) addressed, the public may have different perceptions than what is agreed upon among experts (e.g., who) on misinformation, thus having differential implications on information behaviors. on the other hand, when other mediators suggested in the risp model are taken into account, the total indirect effects were not significant on these information outcomes. notably, affective response and informational subjective norms, both of which could be triggered by exposure to misinformation, appear to counterbalance the mediating role of information insufficiency. while information insufficiency was not directly linked to information seeking, misinformation exposure was indirectly associated with information seeking when mediated by affective response and informational subjective norms. across all three countries, exposure to misinformation had a significant direct association with information avoidance and heuristic processing. this relationship was stronger in the south korea sample for information avoidance (vs. united states) and in the u.s. sample for heuristic processing (vs. south korea and singapore). it is also noteworthy that exposure to misinformation had a direct relationship with information seeking only in the singapore sample, and with systematic processing only in the u.s. sample. these results suggest that exposure to misinformation may have different implications on information seeking or processing depending on culture or population. that is, misinformation exposure may have more implications on how americans process information, whereas for south koreans or singaporeans it will be reflected in their information seeking or avoidance. these may reflect cultural differences in how people manage uncertainties or contextual factors such as partisanship and information sources. in particular, the stronger relationship between misinformation and information avoidance in the south korea sample (vs. united states) may reflect the high-uncertainty avoidance culture of south korea (hofstede et al., 2010) . in light of the direct positive association with both seeking and avoidance in the singapore sample, singaporeans may be uniquely motivated to deal with misinformation having ambivalent responses toward such information. interestingly, only in the u.s. sample, information insufficiency served as a constant predictor across all information outcomes. in the south korea sample, information insufficiency was significantly associated only with information avoidance and systematic processing. in the singapore sample, only systematic processing was associated with information insufficiency. similar to our findings, yang, kahlor, and li (2014) also found a stronger relationship between information insufficiency and information seeking intention in the u.s. sample than the china sample. collectively, western populations may be more likely to be influenced by epistemic motivation than eastern populations, regardless of uncertainty avoidance tendencies. instead, cultural differences in perceptions of personal control or ability to seek, process, and retain information may be closely related to the differential effects of information insufficiency. alternatively, given that the risp model was developed in the western context, the model and its measurements may better reflect westerners' seeking and processing tendencies. future work should examine these possibilities in cross-cultural contexts. this study has several limitations to note. first, the sample sizes were not balanced among the three countries examined and these countries were differently affected by covid-19 at the time when the surveys were conducted. while we controlled for risk characteristics and relevant experience, it was not possible to account for all contextual factors that could confound the results. nonetheless, we believe that it is imperative to document public sentiment and responses during an actual pandemic, and thus this work could have unique value in studying misinformation effects. second, this study cannot confirm causal orderings proposed in the conceptual model due to the cross-sectional nature of the data. future work should consider employing a longitudinal or experimental design to support causal statements about the proposed relationships here. last, while there are multiple types of covid-19-related misinformation circulating on the internet, we focused on five false claims relevant to the prevention of covid-19 that reflect the state of scientific evidence at the time of data collection. it would be beneficial for future studies to investigate additional types of misinformation to better understand misinformation effects. despite these limitations, this study makes important contributions to the extant literature on misinformation and information seeking and processing. first, this is the first study that examined implications of misinformation exposure on information seeking and processing. because information seeking and processing constitute important components in managing uncertainty and risk situations (griffin et al., 1999) , understanding the mechanisms of how misinformation affects these informational behaviors offers crucial insights into human tendencies under uncertainty. second, this is one of just a few studies to make comparisons across multiple countries that are simultaneously affected by a common risk in studying information seeking and processing. studies in these areas have often focused on one cultural, mostly western, context, and intercultural comparisons have been scarce. comparing the relative predictive utility of a theoretical framework across different cultural contexts and populations is important for theory development. on the practical front, critical assessment of information as well as active seeking of quality information are crucial for mitigating the false beliefs that could be formed based on misinformation. given that misinformation demotivates individuals from these important information activities during a disease pandemic, it is necessary to minimize exposure to such incorrect information and to deliver evidence-based health advisories. to this end, risk communicators and government authorities should continuously monitor and clarify emerging misinformation on various online platforms to prevent the public's misperception and engagement in fake remedies or scientifically unproven measures. in light of the counterbalancing role of informational subjective norm we found, it would be beneficial to emphasize the social expectation on keeping up with health advisories to minimize the adverse effects of misinformation exposure. in dealing with global pandemics, like covid-19, it would be essential for international and local health agencies to take into account differences in culture in communicating risk. for example, compared to lowuncertainty avoidance cultures (e.g., singapore, sweden), high-uncertainty avoidance cultures (e.g., south korea, japan, germany) may be less tolerant about information uncertainty (misinformation) as well as changes in health advisories, which are inevitable in most pandemic situations. in high-uncertainty avoidance culture, clear and consistent risk communications as well as implementation of formal governing structures (e.g., laws) could be particularly beneficial for mitigating uncertainty. the author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. the author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: this work was supported by the ministry of education of the republic of korea, the national research foundation of korea (nrf-2018s1a3a2074932), and singapore ministry of education academic research fund tier 1. hye kyung kim https://orcid.org/0000-0003-0870-147x notes 1. during data collection, local cases of covid-19 increased from 4,604 to 44,189 in the united states (out of 328.2 million total population), from 833 to 5,186 in south korea (out of 51.6 million), and from 96 to 166 in singapore (out of 5.6 million). 2. in keeping with cohen and cohen (1983) , we used perceived knowledge to predict sufficiency threshold, and noted the unstandardized regression slope (β). then, information insufficiency was computed by subtracting perceived knowledge * β from sufficiency threshold. 3. in march 2020, who removed avoiding pets and gargling with mouthwash from myth busters in response to the emerging evidence on these measures. there is no evidence that pets have infected humans with covid-19, but an infected dog was found in hong kong. as well, there is no proof that gargling prevents respiratory infections caused by covid-19, but health experts note that there is little downside in gargling. the theory of planned behavior evidence from internet search data shows information-seeking responses to news of local covid-19 cases in related news, that was wrong: the 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with multicollinearity in three methods information overload: causes and consequences information seeking upon exposure to risk messages: predictors, outcomes, and mediating roles of health information seeking spreading the (fake) news: exploring health messages on social media and the implications for health professionals using a case study social networks and popular understanding of science and health: sharing disparities misinformation among mass audiences as a focus for inquiry exposure to health (mis)information: lagged effects on young adults' health behaviors and potential pathways audiences' acts of authentication in the age of fake news: a conceptual framework belief echoes: the persistent effects of corrected misinformation the paradox of participation versus misinformation: social media, political engagement, and the spread of misinformation defining misinformation and understanding its bounded nature: using expertise and evidence for describing misinformation systematic literature review on the spread of health-related misinformation on social media fake news. it's complicated perceived probability, perceived severity, and health-protective behavior coronavirus disease (covid-19) advice for the public: myth busters altruism during ebola: risk perception, issue salience, cultural cognition, and information processing risk information seeking and processing model: a meta-analysis fearful conservatives, angry liberals: information processing related to the 2016 presidential election and climate change what, me worry? the role of affect in information seeking and avoidance i share, therefore i am: a us−china comparison of college students' motivations to share information about climate change a united states-china comparison of risk information-seeking intentions from information processing to behavioral intentions: exploring cancer patients' motivations for clinical trial enrollment hye kyung kim (phd, cornell university) is an assistant professor in the wee kim wee school of communication and information at nanyang technological university in singapore. her research applies communication and social psychological theories to understand the processing and effects of communicative interactions in health and risk. her research ultimately seeks to develop theory-driven communication strategies that improve persuasion.jisoo ahn (phd, the university of texas at austin) is a research professor at health and new media research institute at hallym university. her research studies health and environmental and disaster communication and seeks effective ways to deliver information to the public by using interactive media technologies. austin. her research looks at communication in the context of sustainability and the environment. she focuses on the ways message components in environmental communication campaigns influence environmental attitudes, beliefs, and behaviors.lee ann kahlor (phd, university of wisconsin-madison) is an associate professor at stan richards school of advertising & public relations in the university of texas at austin. her primary research interest is in health and environmental risk communication with an emphasis on information seeking, avoiding, and sharing. key: cord-021224-dqfmrm6m authors: cooke, philip title: a ground-up “quaternary” innovation strategy for south korea using entrepreneurial ecosystem platforms date: 2017-07-12 journal: nan doi: 10.1186/s40852-017-0061-4 sha: doc_id: 21224 cord_uid: dqfmrm6m this paper offers an account of the recent economic slowdown in the growth trajectory formerly enjoyed by south korea as one of the first “asian tigers”. indicators are provided that, unlike the others, hong kong, singapore and taiwan that have continued their upward profile, south korea has stagnated. it is argued that the others and some more recent asian growth economies have moved upwards to higher value, high skill and high profitability levels and deindustrialising as they did so. this even applies to recent breakthrough economies like china and vietnam. in each case, “financialization” has been an important element in the growth of the quaternary economy, even in such relative newcomers as vietnam, where privatization of services has attracted private equity and other foreign direct investment financiers. thus manufacturing is less pronounced than it was. meanwhile, south korea has a weak international presence of banks and other financial sectors because of the domestic focus in its indigenous growth model. other weaknesses of closed versus open innovation and “cronyism” at the behest of the chaebol system can be laid at the door of south korea’s traditional conglomerates. a different model of “thin globalisation” led by knowledge-intensive high-tech, biotech and cleantech with prodigious financialization is characteristic of the new fast-growth regions and countries elsewhere, notably israel, silicon valley and cambridge. here flattened hierarchies, reliable networking, and “crossover” innovation are pronounced and from which south korean industrialists and policymakers could usefully learn to recover past growth performance. the reason for this paper is that south korea's economy has stagnated in the secondary and tertiary developmental paradigms, similar to japan, while the other "asian tigers" have forged ahead into the "quaternary". in this contribution, the plan is to reconsider the importance of "embeddedness" to regional economic development. one reason for this is that recent research in economic sociology has raised questions about its contemporary usefulness given critique of two elements: one intrinsic to the perspective; the other being a feature of evolutionary tendencies in the political economy of today and the near future. in brief, the critique draws attention to a recent questioning of "embeddedness" thinking treating the "economy" and specifically the "market" a good record on public administration of, for example, "export subsidies" by south korea (rodrik, 2011) . for a time government policy on heavy investment in fossil fuel and exceptional reliance on nuclear energy contributed to rapid post-war growth. but more recently, a hitherto prevailing "anti-green" policy perspective persisted in south korea while elsewhere pollution and sustainability concerns were already being addressed in other oecd economies. suddenly attention was paid regarding south korea's "fossil & nuclear" legacy energy policy when change occurred by presidential decree in 2010. this was recently re-prioritised as a leading intervention by new president, moon jae-in in 2017. it can be stated that south korea retained its "embedded autonomy" leadership profile but that it had become outdated. latterly, some of the leading developmental large firms have revealed problems, e.g. hanjin, bankrupted in 2017, samsung (sdi -"closed innovation and battery fires" internal supplier) and evidence of "cronyism" and corruption. thus the hitherto harmonious implementation of "investment guarantees" had begotten the problem of "cronyism". this took the form of a presidential indictment in relation to a $38 billion "transfer" from samsung. subsequently, evidence of expensive gifts to former president park from lotte inc. for $17million and smaller cosmetic surgery infractions involving 17 blue house visits were added to the indictment. so the model of post-war economic growth became shaky shortly after the local variant of the killer disease sars (meirs) was also found to have origins in south korea's leading samsung medical clinic. however, because of its emphasis on "imitating" the japanese "developmental state" model of rapid industrialisation by major investment in heavy industry, notably steel and shipbuilding, followed by light engineering in consumer goods (automotives and electronics) south korea experienced a somewhat asymmetrical "financialization" if indeed that is a correct descriptor. because the chaebols contained their own banks, each supplying preferential investment to its industrial "family" south korea never developed the kind of international banking system that other "asian tigers", notably hong kong and singapore did at the centre of their developmental strategies. this was for good reasons given that those two island economies had already developed as trade, commerce and financial centres before independence and they had little option but to do so, although both later developed profitable "quaternary" economic activities like ict and biotechnology to accompany their financialization. significantly, south korea's gdp per person (purchasing-power parity; ppp) has long lagged somewhat compared to the three "tiger island" economies. but, it is also noteworthy that japan's relative economic stagnation since 1990 means that south korea was expected (by imf) to by-pass japan in 2017 as did singapore in 1993, hong kong in 1997 and taiwan in 2010 (fig. 1) . but the most startling re-ranking will be when south korea becomes richer than japan, since in 1980 south korea's gdp per person was barely a quarter the level of japan's. however, our key indicator for the future is the trajectory of the "quaternary" measured by profitability. while the trend in profitability had been upward, 2013 saw a decline in bank profitability. south korean banks reported $8.2bn in combined net profits in 2012, a drop of 23.2% from 2011, as their net interest margina key measure of banks' profitabilityfell to 2.1%, its lowest level of the past decade apart from the crisis years of 2007-9. the country's banks face squeezing margins due to their heavy reliance on interest income, while their non-interest income remains small. to compensate, they are under increasing pressure to expand into non-banking activities like insurance (kb financial group) and derivatives (e.g. woori finance) rather unsuccessfully. south korean banks remain weak in investment banking, which requires thorough risk control. consumer credit offers little room for growth, given the already high levels of debt among korean households. also, penetrating foreign markets has been a difficult, due to their lack of brand value and international networks (jung-a, 2013). moreover, the profitability of the four main seoul-based companies, shinhan financial group co. ltd., hana financial group inc., kb financial group inc. and woori bank dropped for two consecutive years from 2013. their combined profit declined by half, to 4.78 trillion won (us$4 billion) at the end of 2013 from 9.19 trillion won (us$8 billion) 2 years earlier. if we move to other knowledge activities, we find profitability down there too. south korea's 30 largest business groups saw their profitability plunge to the lowest level since the global financial crisis in 2008. the combined operating profit of the nation's 30 largest conglomerates by assets came to 57.56 trillion won (us$49.34 although the business profit rates of samsung group and hyundai motor group were higher than those of 2008, the figures of both companies were showing a downward trend after hitting peaks in 2010 and 2011, respectively. samsung's operating profit rate reached 11% in 2010, then kept decreasing from 9.7% in 2012 and 8.9% in 2013 to 6.4% last year. for hyundai motor group, the figure also dropped from 8. 7% in 2011 , 7.8% in 2012 , and 7.2% in 2013 to 6.9% last year (jung suk-yee, 2015 . hsbc, europe's biggest bank, further scaled down its south korean operations by closing its retail business, following the sale of its insurance business in 2013. thus outlook for consumer banking in south korea remained a concern to firms there. standard chartered said earlier in 2013 that it had seen a decline in asset quality in the country and would reassess the value of its goodwill. so in respect of the hypothesis of "financialization" -meaning the share of profits going to interest and dividends is growing, and the rate of profit considering nonfinancial corporates converges to the real rate of profitability -does not appear to be the case for south korea. the reverse is the case, where the rate of financial outflowthat is, the sum of interest, dividends and rents relative to those of nonfinancial corporateshas remained relatively stable at 50% since the 1980s (hart-landsberg et al., 2017) exporters are creating fewer jobs in south korea as the chaebol move production offshore to look for cheaper labour. that has left the domestic economy hurting: small and medium-sized businesses are still failing and the high-value services sector is lagging well behind other countries. according to the oecd: "this has raised concerns about korea's traditional catch-up strategy led by exports produced by large chaebol companies", the oecd report on south korea said in its recent study (oecd, 2016) . there has also been increasing economic polarisation in the post 2008 downturn. economic inequality increased noticeably during and after the 1997 crisis and the great recession of 2008-9. south korea's average gini coefficienta measure of inequalityfor 1990-1995 was 0.258, but with rising inequality its coefficient increased to 0.298 in 1999. it continued to increase, reaching 0.315 in 2010. the same trend can be seen in income distribution: the share held by the top 10% of income holders divided by that of the bottom 10% has increased from 3.30 in 1990 to 4.90 in 2010. the income share of the top 1% was 16.6% of national income in 2012, not far short of the extremes in the us and much worse than in japan (roberts, 2017) . however, it is noteworthy that singapore's profitability has also recently been downgraded. thus third quarter 2016 profitability of singapore's big three banks declined in asset quality because of their exposures to loans and investment in the oil and gas service companies. this goes against rodrik's (1995) revisionist but plausible explanation for the economic take-off of singapore and taiwan, which was the sharp increase in investment demand that took place in the early 1960s. the reason for this investment boomunlike the accounts of such agencies as the imf and world bank that stress export orientationis the efforts of the respective governments massively to enhance government coordination and fashioning of innovative measures to promote profitability. profitability from export growth at the time was modest by comparison. a much more plausible explanation for the economic take-off is thus the sharp increase in investment demand that took place in the early 1960s. rodrik's (1995) heterodox argument is that in the early 1960s and thereafter the korean and taiwanese governments managed to engineer and enhance a significant increase in the private return to capital which increased profitability. space does not allow further analysis of these differences between the comparatively low "quaternary" economic development of the recent decade or two in south korea's growth trajectory. we simply assert from the limited evidence mobilised, that two important deductions can be made from the comparative data and analysis proposed by economic growth theorists such as rodrik (1995 rodrik ( , 2011 the first of these is that manufacturing employment and gdp share remain high in south korea. meanwhile some even later industrialising countries have already begun de-industrializing, notably china and vietnam. conversely, the "tiger" economies, notably singapore and hong kong, and their asian successors have "financialized" their economies more than south korea (e.g. also vietnam) and have augmented such quaternary activity with other knowledge-intensive, high value, high skill and high profitability quaternary activities as in taiwan. these include activities such as innovative ict, software, systems design, medical biotechnology and r&d. in this respect their economic profiles are closer to those of regions like silicon valley, greater cambridgeshire and israel, which are among the most knowledge-intensive "quaternary" regions in the world. in this section of the paper, we propose to utilise the information so far displayed alongside some key insights about the mechanisms that may help understanding of the differential trajectories of south korea in comparison with some other asian growth economies. we shall begin with outlining some key features of "innovation governance" in the advanced regional innovation systems listed at the end of the previous section before comparing and contrasting such governance with what has typified or diverged from that emergent new "innovation governance" mode. first, we may say that hightech platform ecosystems or complexes like silicon valley, cambridge and israel do not display strong top-down governmental modes of economic decision-making in policy or strategy. in other words there is seldom, if ever, a peak committee in which economic deliberations that directly affect specific platform industries by producing detailed action-lines that favour or disfavour specific technologies. that is not to say that in a general way, certain bundles of "cross-cutting" new technology capabilities or problems that may indeed occur in the form of "technology pathologies" may be fashioned. these may evolve as broad frameworks for alerting or sensitising "actors of consequence" of a clearer priority of recognition by "policy champions". a good example is "homeland security" which consists of many diverse but technologically interlocking targets, problems and opportunities. in the us as many as 17 different information and intelligence agencies engage directly with intelligence gathering at home and abroad. these involve mobilising "big data" gathering and analysis, algorithm writing, cybersecurity, cyberwarfare, including cyberforensics, drone design and applications and multiple kinds of tracking, verifying, intercepting and, if necessary, arresting or otherwise preventing "technology pathologies" from threatening individual lives and communities. without labouring the point, such "crossover" innovation opportunities also occur, in different combinations but including overlaps across the boundaries of "big platforms" such as biomedicine, elderly healthcare, artificial intelligence, renewable energy and sustainable mobility, sometimes "fuzzily" designed to meet "societal grand challenges". such often "post-political" activity bundles are moulded by "policy champions" of various kinds. for example, artificial intelligence, with its close linkages to robotics and nanotechnology has a few "protean" influential champions in the us such as ray kurzweil, an apologist for ai for decades (ford, 2015; barrat, 2013) . kurzweil himself is widely seen as an attention-seeking entrepreneur and proselytiser for only the positive implications of ai. he is influential, having his pedagogical efforts sponsored by, amongst other californian businesses, google, genentech and cisco systems. his inventive effort has touched such technologies as optical character recognition, computer-generated speech and music synthesis, all of which relate to augmentation of human senses. he was awarded 20 doctoral degrees from the likes of babson college, bloomfield college, clarkson university, depaul university, hofstra university, michigan state university, rensselaer polytechnic institute and worcester polytechnic institute, and been honoured by us presidents johnson, reagan and clinton. among his awards to the technological, humanities and musical communities are the following: 2000 the lemelson-mit prize. this $500,000 award is the largest in the u.s. in invention and innovation. 1999 the national medal of technology, the nation's highest honor in technology. 1998 the stevie wonder / sap "vision award" for product of the year a $150,000 prize (being used by the kurzweil foundation to provide scholarships to blind students), and the 2008 american creativity association lifetime achievement award. it can obviously be agreed that the optimist kurzweil is widely seen as a "crossover" innovator and an ai "champion" despite his cultist association with silicon valley's "singularity university" (reminiscent in some ways of l. ron hubbard and "scientology") which kurzweil founded in 2008. without contemplating the "cultist" evangelizing of kurzweil's obsession with a fictitious fake version of the astrophysical phenomenon of the "singularity" when even light can no longer escape from a black hole in space, three things that follow are pertinent to our utilisation of his curriculum vita in support of the function of "champions" as arbiters of post-political action framing. first, it is noteworthy the extent to which kurzweil's innovative career expresses crossover innovativeness with respect to: the invention of a classical music synthesizing computer involving designing computer technologies such as machine reading to assist the disabled and to enrich the arts, including winning awards for film production. second, the institutional nodes with which kurzweil's interaction occurs are solid entities in the worlds of academic research entrepreneurship, government and large corporations. after long advisory roles with firms listed above, he was in 2013 appointed head of engineering at google. he had worked with google's co-founder larry page on special projects over several years. his executive appointment occurred as google began assembling the largest artificial intelligence (ai) laboratory in existence. acquisitions involved military robotics firm boston dynamics, thermostat maker nest and cutting-edge cambridge (uk) ai firm deepmind. these were added to smaller purchases of bot & dolly, meka robotics, holomni, redwood robotics and schaft, and another ai startup, dnnresearch. it also hired geoffrey hinton, a british computer scientist who is rated the world's leading expert on neural networks (cadwallader, 2014) . finally, kurzweil is an avid publicist for his serious and more questionable analyses and predictions having published seven books translated into 11 languages. no other technologyspecifically ai (with robotics [ford, 2015] and nanotechnologies)has anywhere near as "protean" the influence on key decision actors ranging from darpa to google as the aforementioned ray kurzweil but others take on relevant roles from other more sceptical viewpoints. three of these, cited in barrat (2013) include i. j. good, eliezer yudkowski, and stephen omohundro. good, who died at 92 in 2009, was a british expatriate mathematician and former bletchley park codebreaker colleague of alan turing. good was responsible for coining the term "information explosion" to describe the impact of ai on human intelligence when it could be anticipated. stanley kubrick turned to good as the adviser on the 1968 film 2001: a space odyssey. it was jack good with his insights on intelligent machines, who helped create the infamous character of hal, the ai computer in the film. in good's seminal paper "speculations concerning the first ultra-intelligent machine" he defined thisa forerunner to "singularity" thinking -as follows: let an ultra-intelligent machine be defined as a machine that can far surpass all the intellectual activities of any man (sic) however clever. since the design of machines is one of these intellectual activities, an ultra-intelligent machine could design even better machines; there would then unquestionably be an 'intelligence explosion, ' and the intelligence of man would be left far behind. thus the first ultra-intelligent machine is the last invention that man need ever make, provided that the machine is docile enough to tell us how to keep it under control. (good, 1965) accordingly, good was a "champion" and influential at the highest governmental, academic and corporate levels with crossover theoretical interests from bayesian mathematics to computer programming design and manufacturing to film consultancy. moreover, he was careful not to take an over-optimistic line on the controllability of ai unless -as he wrote -"docility" could be built into the resulting technology. other more sceptical ai "champions" who take a more practical but still pessimistically inclined view regarding the difficulty of ensuring "docility" from future ai or "artificial general intelligence" (agi) as they term it, include gurus such as eliezer yudkowski, and stephen omohundro, noted earlier and as profiled extensively in barrat (2013) . omohundro is optimistic, but this is based on his underlying notion that all ai is lethal because of the well-known software engineering problem that much programming is bad work, i.e. sloppy and incompetent, as microsoft word users have known for decades for its almost constant de-bugging upgrades. bad programming is estimated to cost the us economy $60 billion per year. this implies a vast need for "self-improving software" a variety of "evolutionary programming" that may evolve from currently practised "machine learning". article space disallows fuller explication of such potentially influential views, save to say that yudkowskiwho invented the ai boxa kind of turing machine that led some players of its "game" to believe that a "thinking engine" had been invented, insists agi would be catastrophic for humanity unless it is designed to be "friendly ai", but as barrat (2013) observes critics argue that progressing towards agi is necessitated by the even greater dangers of "artificial specialised intelligence" (asi) falling into the hands of: " so many reckless and dangerous nations on the planet -north korea and iran for exampleand organised crime in russia and state-sponsored criminals in china launching.....cyberattacks, relinquishment would simply cede the future to crackpots and gangsters" (barrat, 2013, 200-01) . hence we see the origins of the engineer's linear determinist thinking enlarged prodigiously and apocalyptically. the initial "mindlessness" of contemporary incremental innovators is captured in the following statement from uber founder and chief technical officer (cto) oscar salazar who admitted: "we are adding technology to a society without thinking about the consequences. i think government, industry and society need to work more together, because it is going to get crazier and crazier." (fairchild, 2017) . herebelatedly -is recognition that as governments fail adequately to regulate technological experiments, good champions are also hard to find when their infantile aspirations are mainly "disruptive" (christensen, 1997) and informed by the likes of facebook's mark zuckerberg's earlier mission statement to "move fast and break things" (the origin of bad programming; taplin, 2017) . it has finally dawned on the ubernauts that, as fairchild (2017) also notes: "advances in artificial intelligence and automation could mean as many as 50% of today's us jobs will go away, according to some estimates. joined on stage by other high-profile members of the tech community, (chair kara) swisher forced her panelists to defend silicon valley's seeming incapability to take responsibility for the downstream effects of its innovation. (ibid) most governments and tech entrepreneurs excuse their mindlessness regarding the effects of ai automation upon workforces by stressing the importance of retooling and reskilling the workforce for tech jobs in the future. as engineers, in the main, they completely fail to see the paradox that they are responsible for the future absence of positions that it will be futile to train anyone for (streeck, 2016). we shall return to this conundrum of engineering's linear model of non-reflective obtuseness later, but for the moment we cite frey & osborne's (2013) estimate of 64 million us jobs (47% of the total) having the potential to be automated and thus disappear within "perhaps a decade or two" (frey & osborne, 2013) . this narrative demonstrates that technological policy innovation needs "champions" although they do not have to be evangelical or cultist in their behaviour along the lines of ray kurzweil, even though he clearly fits in with a particular strand of american science fiction "envisioning" that suits the vacuous purposelessness of the careless engineering and software programming that clearly often characterises high-tech innovation processes. even when there is some degree of "adult supervision" of highly sensitive explorative and purposeful algorithm design, other mistakes can be thoughtlessly committed. thus the story of the "cyberecosystem" and its often dystopian as distinct from cyberutopian outcomes is often prefaced by reference to and discussion of the work of disaster sociologist charles perrow. in his oft-cited book "normal accidents" (perrow, 1999) and in particular his critique of "tight coupling" describes a system whose parts have immediate and severe impact upon each other. a case in point is the so-called "smart grid", another is the financial system (mackenzie, 2008) or food refrigeration system, healthcare system, defence system and so on. all of these and many other such systems are potentially vulnerable regarding "department of homeland security" (dhs) issues. in 2007 dhs tested the robustness of the grid at the idaho national laboratory by selecting a typical online turbine generator, "hacking" it and altering its settings. accordingly, it malfunctioned as the turbine self-destructed from inside. its "supervisory control and data acquisition" system (scada) the "global controller" encrypted security programming of the type used in many systems critical settings noted above failed. on the bass of this, a new kind of malicious software (malware) to cause such destruction to hostile systems was conceived. it was called stuxware. it was specifically designed for the us (nsa) and israeli intelligence services to destroy a siemens logic controller used in a gas centrifuge nuclear fuel enrichment plant in natanz, iran by subverting its virus-prone ms windows pc operating system. spies carried flash drives releasing the stuxnet virus throughout the plant's local area networks (lan) to identify undiscovered security holes in the operating system. stuxnet worked and, as noted, it was likely sponsored by us and israeli intelligence agencies but the private equation group has been identified as advising in the us and mossad's agents activating the israeli contribution. un-named private consultants in tel aviv were also interviewed in website reports and testing is asserted to have been conducted at the idaho national laboratory nuclear research facility in the us (the same one where dhs conducted its stress-test) and at dimona's negev nuclear research center, israel's nuclear weapons facility. but, even so, stuxnet, which was supposed to self-destruct after multiple malware operations, escaped, allowing thousands of copies to be accidentally distributed. experts conclude that this fate is typical of the lack of thinking beyond the short-term that characterises "act fast and break things" thinking about the likelihood of "normal accidents" occurring. in 2017 variants of stuxnet were implemented as wannacry and (not)petya malware attacks by "ransomware" cyberfraudsters. while this narrative does not seek to present platform ecosystems of the quaternary kind under discussion as paragons of virtue, it is clear that even the tightest hierarchical control assumed to be typical of military hierarchies is not immune to major failures of administration predicted in perrow's (1999) "normal accidents" analysis. although we have yet to turn to the implications of this narrative for the prodigious hierarchical control of chaebols like samsung in the south korean context it should nevertheless give pause for concern during that national economy's period of relative stagnation compared to the past. one reason is that a tradition of neo-confucianist hierarchy, obedience and control associated with chaebol tradition is no longer the administrative power in industrial organization that it once was. more recently, notions of "flattened hierarchies", "intrapreneurship" and "open innovation" have affected learning in some large corporate entities as they have struggled to compete with more flexible, nimble and agile regional and global supply and knowledge networks. typically, this way of operating has characterised the sme platform ecosystems of the quaternary activities pronounced in the silicon valley, cambridge and israeli set-ups and in the global financial "superhubs, "biomedical megacentres" that are nowadays the leading "frame" for learning innovative organizational "(non)governance" (nadivi, 2017) . accordingly a highly "networked" collaborative enterprise complex characterises, for example the "complex adaptive super-systems" that manage global financial systems. these elements of "superhub globalisation" with numerous nodes distributed across the planet contrast with the "thin globalisation" networks more typical of the other knowledge-intensive quaternary activities associated with "big data", cybersecurity, systems design, software algorithms, biopharmaceuticals and cleantech. as noted earlier, these have high rate of networking among technology entrepreneurs, university researchers and government or military representatives and clients. such platform ecosystems are thus not top-down hierarchical administrative or bureaucratic systems in any meaningful way. it is thus a decentralised, associational "innovation advocacy" model of industry organization. there is usually no formal strategy; the main driver has been incremental, evolutionary, sometimes rapid, change. "superhubs" for financial services and *biotech megacentres" particularly in the uk and us tend to be open not managed economies and there has been little or no recognisable industrial strategy the uk's recent attempt at an industrial strategy in 2017 was disparagingly referred to as a political "toyshop" finally, we now see, typically new innovation models emerging in the likes of cambridge where "crossover" mutations from microelectronics to advanced combustion engines and healthcare are being fashioned (eason & dean, 2016) . in cambridge the "soft infrastructure" of entrepreneurship and innovation marketing support has the following intermediaries active at one or other time assisting the ict, biotech, software and systems and cleantech sectors. the cambridge network, which links together members and provides services for academic entrepreneurship. st. john's innovation centre incubation environment accelerated the growth of ambitious innovative start-up businesses. cambridge science park, established in 1970 was the new setting on which the ict cluster began to grow rapidly. there were some 39 new companies from 1960 to 1969. in the 1970s, 137 were formed. by 1990, there were 100 per year. these initiatives are now supported by knowledge-intensive intermediaries such as idea-space, which is a community of people in cambridge starting high impact new ventures. hence ideaspace members are creating new business models (kirk et al., 2016) . what we might term examples of "soft infrastructure, soft power" includes institutions like cambridge enterprise which helps cambridge university students and academics to commercialise innovative ideas by establishing a business. in the field of biotechnology, one nucleus is a not-for profit biotechnology membership organisation which aims to maximise the global competitiveness of its members. supporting this is cambridge biotechnology campus, which houses 7000 professionals and scientists. of significance also is the wellcome genome campus is home to some of the world's foremost institutes and organisations in genomics (sanger institute) and computational biology at hinxton tech park. this facility is a long-established and highly valued support infrastructure also for biotechnology -babraham biosciences incubator & research campus. a newer are a of cluster ecosystem evolution involves clean technology, represented by cambridge cleantech. this is also a member organisation for cleantech start-ups and evolved firms, replicating the "associational" or collaborative mode of start-up industry organisation. bestriding this associational infrastructure are cluster-platform "champions", notably hermann hauser, co-founder of acorn with christopher curry, who was part of a cambridge ii initiative. hauser's venture capital company amadeus (with funding from the likes of software transplant microsoft) was a leading actor in helping start-up companies. thereafter, in collaborative efforts to access support for growth in cambridge, which by 2017 had grown to the status of a city-regional mayoralty consolidated as the cambridge-peterborough, built partly on the growth insights of the past partnership among alec broers (vice-chancellor of cambridge university), spatial planner marcial echenique (cambridge university school of architecture and a transport planning specialist and david cleevely (analysys telecom consultant founder) who, collectively, decided to assist thesubsequently successful -attempt to develop cambridge's high-tech future. this marked the evolution of "cambridge phenomenon 2", (segal et al., 2011) which in 1997-8 looked at various issues such as land use, transport systems and telephony. the aim was to seek to accommodate growth through new science park development to link the university and industry. the university saw need for seedcorn finance and participated in seed capital funds, including the quantum fund, and cambridge research and innovation ltd. entrepreneurs also became venture capitalists: amadeus capital (hermann hauser); merlin ventures, a biotechnology fund (chris evans founded chiroscience) and the gateway fund founded by local financier nigel brown. thus the "champions" were able to envision how future growth rests on continued acquisition of research funding, understood as the key knowledge core ofespecially -ict and biotechnology innovation excellence. a future key is the identification of flexible research funding that furthers and fosters "knowledge at interfaces" ("crossover") types of interdisciplinary research profile to evolve along multiple inter-dependent research pathways. departure by the uk from the european union presages major uncertainty about science and technology "framework funding" as represented by the eu's horizon 2020 research programming. this has meant a novel financing development bolstering research at cambridge university has occurred as follows. because of uk (and eu) financial weakness, so-called "quantitative easing" more commonly known as "printing money" is practised by the bank of england (and in the eurozone, the european central bank). in the uk the bank of england currently buys bonds issued by some universities, including cambridge. the largest university bond was a £350 million issue from cambridge in 2012 with a maturity date of 2052. such bonds are sold to finance university research and teachingdeemed officially to make a material contribution to the uk economy. accordingly, the bank of england now also has a contributory role in funding long-term cambridge university research (wilson, 2016) . as a final and recent indication of the financing prowess of the uk's leading seats of academic entrepreneurship in the country's changing circumstances, the following is indicative. a comparison of university venture funds shows the uk at the global top of the league (table 1) . within the kaust (king abdullah university of science & technology of saudi arabia) university venture fund data for the uk, cambridge innovation capital (a private fund) was a key investor in intellectual property, raising £75 million. from 2011 to 2016 university of cambridge enterprise (public knowledge transfer office of the university) administered deals involving 11 companies that were sold or stock exchange listed with a combined value of £1.3 billion. these spinouts own their own ip and were incubated in the university with regular peerreview of progress before coming to market. as hinted earlier, much of this initial investment capital comes from the gulf and asia (frean, 2016) . many of the implications of the global financial crisis, and some or all these listed key priorities, will as already noted, be affected by the uk exit from the eu with its negative and positive effects upon the cluster-platform. thus access to high skilled migrant labour from the eu is directly affected by migration policy from the uk state. it is less a driver of negative effects than non-eu technological talent recruitment which, as we saw, is seen as often more modern in its curriculum than eu labour. thus labour shortages may in different ways occur to eu and non-eu talent recruitment. as segal et al. (2011) say, the cluster: "...must recruit workers they need, recognising a particular shortage of top quality management and marketing skills but also the imperative to attract internationally excellent professionals from all spheres" (segal et al., 2011, vi) . this means eu-start-ups, management and research leaders may continue to be sought while non-eu trained medical diagnosticians and analysts or technologists in medical and ict fields will remain in demand. finance will remain an imperative if high-tech growth occurs while the uk's declining currency makes acquisitions from abroad more likely and attractive. finally, although cambridge foreign acquisitions still occur as noted with cambridge consultants ltd's (ccl) acquisition of us firm synapse, but such acquisitions became 20% dearer directly after the brexit plebiscite (with assets 20% cheaper to outsiders). until then this was part of ccl's strategy to evolve a track record of creating highvalue organisations built around disruptive technology, an exemplar of "thin" globalisation. thus four of cambridge's $15 billion capitalisation firms -cambridge silicon radio (csr), xaar, vectura and domino printing sciences -were among those spun off by ccl. other spin-offs include alphamosaic and inca, who were subsequently acquired by broadcom for $123 m and japan's dainippon screen for $60 m. with the expansion of its us presence, ccl would also be bringing its venturing activity to the extensively "financialized" us capital markets. now there is greater uncertainty about basic and applied research funding that hitherto came to cambridge research from programmes such as horizon 2020. the uk government has given some reassurance that substitution of such funding will occur short-term, but the final arrangement awaits the results of brexit negotiations. by contrast as shown, long-term uncertainty is in part insured against by the issuing of cambridge university bonds that are currently available for purchase by the uk central bank's quantitative easing policy, as long as it lasts. with inflation on the rise in 2017 monetary policy will remain constrained and interest rates straining but likely to be kept at historic lows during the uk's "resilience-free" economic era, likely to last 10 years or more since the 2007-8 global financial crisis. so, to return to south korea's current evolutionary arrest in its upward growth trajectory, south korea is like an island, surrounded by sea and cut-off from the land-mass immediately to its north by an extremely hostile political power in north korea, aided somewhat reluctantly in its political posture of local and global aggression by its globally prodigious geopolitical ally, china. not surprisingly, south korea, while globally competitive in consumer goods markets is quite locked-in to a manufacturing paradigm. it has become somewhat isolated regarding global good practice in industrial organization despite its success in the past in succeeding in rapid industrialisation. the chaebol system by which industrial groups divide along sectoral boundaries, supported by an in-house domestic banking system, managed by an extremely hierarchical and rather bureaucratic administrative system, now seems rather outdated and lacking in forward impetus. the problems of "cronyism" towards the disgraced former south korean leader park geun-hye with claims of enormous gifts to presidential charitable interests and worse are testimony to the weakening of the traditional elite system of industry management. the scandal of the burning battery was one caused ultimately by a mentality that favoured "closed innovation" in a world that had generally become happier with market transactions involving "open innovation". the in-house supplier chosen by samsung was not expert in battery technology but sdi won the in-house supplier contract anyway. sdi stands for samsung digital imaging which is actually an optoelectronics (or photonics) subsidiary of samsung spun-off from samsung optoelectronics in 2009. the burning battery in the galaxy 7 smartphone cost samsung some $5billion in 2016-7. half the faulty batteries were produced by sdi while the other half were produced by affiliate amperex technology without fault. in a different field of samsung operations where global networks with other major corporates are pronounced, samsung biologics is jointly owned by samsung electronics co. and samsung everland inc. each owning a 40% stake in the venture, with samsung c&t corp. and durham, north carolina-based quintiles each holding 10%. samsung biologics will contract-make medicines comprising living cells. samsung group plans to expand into producing copies of biologics including rituxan leukaemia and lymphoma treatments sold by roche ag and biogen idec inc. of boston, ma. the samsung medical centre is south korea's leading clinic. however, it transpired in 2015 that the national outbreak of a mutated form of severe acute respiratory syndrome (sars) or (middle eastern irs) originated in the samsung medical centre. these, in different ways point to a worrying degree of "corporate overreach" by south korea's leading conglomerate. as a small-scale yet traditionally high-grade university research centre, cambridge learnt the lesson of intellectual property in 1975 when local research launched a new industrybiotechnologythe commercial returns from which were exploited by academics and risk capitalists based across the world in the university of california's san francisco medical school. thereafter, a relatively liberal intellectual property regime prevailed with the discoverers or academic inventors evolving into innovators as they were encouraged to exploit their own ipr alongside that of the university by agreement. this meant that the growth trajectory self-guided towards an "open innovation" model of knowledge exploitation relatively unhindered by corporate requirements or interests except insofar as market-based contracts were fulfilled between global customers and local suppliers of commercialised knowledge-intensive output. surrounding this research exploration/exploitation kernel, a facilitative bottom-up innovative and entrepreneurial infrastructure of "associative" intermediaries and "champions" evolved towards an economic governance form known in development studies as "embedded autonomy". this is the opposite of a "developmental state" model of economic growth once practised in early fast-growth asian economies like south korea, singapore and taiwan. as we saw earlier the last two of these, alongside hong kong, have largely moderated their "developmental state" models in favour of the "thin globalisation" of a knowledge-intensive "quaternary" trajectory, deindustrialising away from manufacturing-led growth as they proceed. however, due to its deep path dependence on chaebol-led state development thinking, south korea has been unable or unwilling to join them, resulting in deteriorating economic indicators in consequence. the self-sustaining ambition of he "asian tiger" pioneers has generally been to overcome the developmental blockage identified by rodrik (2011) , which has been to stimulate demand for innovation by stimulating the supply to meet demanding customers' requirements for creating technology (not sector) entrepreneurs. such technologies are then capable of becoming "general purpose technologies" not simply sector-limited technologies. crossover innovations in leading quaternary clusterplatform complexes like silicon valley, cambridge and israel naturally find applications among cluster ecosystems, especially where they co-exist in proximity with ready applications in new economic activities occurring outside their original technology base. rather than relying upon corporate or state hierarchies to "pick winners" the local "platform champions" conduct local and national lobbying through their shared interest in promoting "innovation advocacy". in the case of cambridge anatomised above it began with the first champions for the nascent ict cluster, and then evolved as a group of inter-related, albeit diverse clusters that subsequently grew into, currently, four pillars of a set of complementary, advanced technology knowledge-intensive or quaternary cluster-platforms. from this, local-global marketing of "crossover" excellence leads to high employment, skills and profitability growth, something which all development experts hope to deliver. our final invention are the robots about to rise? google's new director of engineering thinks so, the guardian the innovator' s dilemma apple weighs up £1billion mclaren bid to kick-start driverless cars, the times embedded autonomy: states and industrial transformation will ai's impact on jobs finally force silicon valley to grow up? linked-in rise of the robots: technology and the threat of a jobless future why the smart money is being invested in university research, the times, december the future of employment: how susceptible are jobs to computerisation? oxford martin school, programme on the impacts of future technology speculations concerning the first ultra-intelligent machine capitalizing on crisis: the political origins of the rise of finance south korean banks seeking profitability but not finding it, financial times profitability of korea's top 30 business groups tumbled in 2014 the cambridge phenomenon: global impact an engine, not a camera: how financial models shape markets superhubs how the financial elite and their networks rule our world normal accidents: living with high-risk technologies korea: corruption, cults and chaebols getting interventions right: how south korea and taiwan grew rich, columbia university working paper industrial policy for the twenty-first century the globalization paradox: democracy and the future of the world economy cambridge cluster at 50 -the cambridge economy: retrospect & prospect move fast and break things bank takes an interest in historic seats of earning. the times finally, i have few acknowledgements as i wrote the paper entirely dependent on my own effort. however i was inspired by my hosts at the graduate school of public administration, seoul national university, prof. kwangho jung, dr. sabinne lee and dr sungman jun and prof samyoul lee at the graduate program in public administration of yonsei university, seoul. authors' contribution i am the sole author. the author declares that he has no competing interests. springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord-027859-citynr6c authors: p. shetty, nandini; s. shetty, prakash title: epidemiology of disease in the tropics date: 2020-06-22 journal: manson's tropical diseases doi: 10.1016/b978-1-4160-4470-3.50007-0 sha: doc_id: 27859 cord_uid: citynr6c nan the study of epidemiology in the tropics has undergone major changes since its infancy when it was largely a documentation of epidemics. it has now evolved into a dynamic phenomenon involving the ecology of the infectious agent, the host, reservoirs and vectors as well as the complex mechanisms concerned in the spread of infection and the extent to which this spread occurs. 1 similar concepts in the study of epidemiology apply to communicable as well as non-communicable diseases. the understanding of epidemiological principles has its origins in the study of the great epidemics. arguably, the most powerful example of this is the study of that ancient scourge of mankind, the so-called black death or plague. a study of any of the plague epidemics throughout history has all the factors that govern current epidemiological analysis: infectious agent, host, vector, reservoir, complex population dynamics including migration, famine, fi re and war; resulting in spread followed by quarantine and control. the world health report 1996: 'fighting disease, fostering development', states that infectious diseases are the world's leading cause of premature death. 2 infectious diseases account for 45% of deaths in low-income countries (figure 3 .1) and up to 63% of deaths in children under 4 years of age worldwide. africa and south-east asia carry the highest mortality due to infectious diseases (figure 3 .2). in addition, new and emerging infections pose a rising global threat (table 3 .1). no more than six deadly infectious diseases: pneumonia, tuberculosis, diarrhoeal diseases, malaria, measles and more recently, hiv/aids, account for half of all premature deaths, killing mostly children and young adults (figure 3 .3). acute respiratory infections (aris) are the leading cause of death of infectious aetiology, killing more than 4 million people a year, 1.9 million of which constitute children under the age of fi ve. 3 among the 42 countries of the world that carry 90% of the child mortality burden, 14-24% of the under-5 mortality is due to pneumonia and nearly 70% of this pneumonia mortality occurs in the africa and south and south-east asia regions. the majority of this burden is borne during early childhood, with the greatest risk from mortality occurring during the neonatal period. the global incidence of ari in children is estimated to be 154 million cases per year. 3 this range of infections, which includes pneumonia in its most serious form, accounts for more than 8% of the global burden of disease. pneumonia often affects children with low birth weight or those whose immune systems are weakened by malnutrition or other diseases. caused by different viruses or bacteria, ari is closely associated with poverty, overcrowding and unsanitary household conditions. several other factors seem to exacerbate the disease. exposure to tobacco smoke increases the risk of contracting these infections, and many studies implicate both indoor and outdoor air pollution. indoor air pollution has been the focus of particular concern: specifi cally, the soot and smoke associated with the burning of biomass fuels such as wood, coal, or dung. many people in the developing world, mostly in rural areas, rely on biomass fuels for heating or cooking. a cause-and-effect relationship between indoor air pollution and ari has been diffi cult to prove. even so, the world bank estimated in 1992 that switching to better fuels could halve the number of pneumonia deaths. 4 approaches to the management of childhood pneumonia in the tropics are hampered by lack of diagnostic facilities to identify the aetiological agent. the who has devised a simple algorithm for use in fi eld situations, by primary healthcare workers, using clinical criteria such as respiratory rate and indrawing of ribs to decide whether a child needs hospitalization. proper implementation of this strategy has been shown to reduce the mortality from childhood pneumonias by 25-50%. 5 however, implementation of community ari treatment programmes remains patchy and current rates of children with ari being taken to a health provider are ~40% in africa and south asia. in nearly half of the 81 countries with available data, less than 50% of the children with ari were taken to an appropriate healthcare provider. 5 the aids pandemic has emerged as the single most defi ning occurrence in the history of infectious diseases of the late twentieth and early twenty-fi rst centuries. according to the aids epidemic update of december 2005 (unaids and who), 6 the epidemiology of hiv in the tropics varies enormously from place to place (figure 3 latest estimates show some 8.3 million people (2 million adult women) were living with hiv in 2005, including the 1.1 million people who became newly infected in the past year. aids claimed some 520 000 lives in 2005. these estimates are in line with known risk behaviour in this region, where men account for the majority of injecting drug users, and are responsible for sexual transmission of hiv, largely through commercial sex. commercial sex accounts for a large part of the estimated 20% of hiv infections in china that are due to unprotected heterosexual contact. it also features in the transmission of the virus among men who have sex with men: a recent survey among male sex workers in the southern city of shenzhen found that 5% of them were hivpositive. however, it is the potential overlap between commercial sex and injecting drug use that is likely to become the main driver of china's epidemic. diverse epidemics are underway in india, where, in 2003, an estimated 5.1 million indians were living with hiv. although levels of hiv infection prevalence appear to have stabilized in some states (such as tamil nadu, andhra pradesh, karnataka and maharashtra), it is still increasing in at-risk population groups in several other states. as a result, overall hiv prevalence has continued to rise. a signifi cant proportion of new infections is occurring in women who are married and who have been infected by husbands who (either currently or in the past) frequented sex workers. commercial sex (along with injecting drug use, in the states of nagaland and tamil nadu) serves as a major driver of the epidemics in most parts of india. hiv surveillance in 2003 found 14% of commercial sex workers in karnataka (26% in the city of mysore) and 19% in andhra pradesh were infected with hiv. the wellknown achievements among sex workers of kolkata's sonagachi red-light area (in west bengal, india) have shown that safe sex programmes that empower sex workers can curb the spread of hiv. condom use in sonagachi has risen as high as 85% and hiv prevalence among commercial sex workers declined to fewer than the combination of high levels of risk behaviour and limited knowledge about aids among drug injectors and sex workers in pakistan favours the rapid spread of hiv, and new data suggest that the country could be on the verge of serious hiv epidemics. most countries in asia still have the opportunity to prevent major epidemics. bangladesh, where national adult hiv prevalence is well below 1%, began initiating hiv prevention programmes early in its epidemic. indonesia is on the brink of a rapidly worsening aids epidemic. with risk behaviour among injecting drug users common, a mainly drug-injection epidemic is already spreading into remote parts of this archipelago. in malaysia, approximately 52 000 people were living with hiv in 2004, the vast majority of them young men (aged 20-29 years), of whom approximately 75% were injecting drug users. after peaking at 3% in 1997, national adult hiv prevalence in cambodia fell by one-third, to 1.9% in 2003. the reasons for this are two-fold: increasing mortality and a decline in hiv incidence due to changes in risk behaviour. thailand has been widely hailed as one of the success stories in the response to aids. by 2003, estimated national adult hiv prevalence had dropped to its lowest level ever, approximately 1.5%. however, thailand's epidemic is far from over; infection levels in the most at-risk populations are much higher: just over 10% of brothel-based female sex workers were hiv-infected in 2003, as were 45% of injecting drug users who attended treatment clinics. while cambodia and thailand in the 1990s were planning and introducing strategies to reverse the spread of hiv, another serious epidemic was gaining ground in neighbouring myanmar. there, limited prevention efforts led to hiv spreading freely. consequently, myanmar has one of the most serious aids epidemics in the region, with hiv prevalence among pregnant women estimated at 1.8% in 2004. the main hiv-related risk for many of the women now living with the virus was to have had unprotected sex with husbands or boyfriends who had been infected while injecting drugs or buying sex. in japan, the number of reported annual hiv cases has more than doubled since 1994-1995, and reached 780 in 2004; the highest number to date. much of this trend is due to increasing infections among men who have sex with men. prevalence of hiv remains low in the philippines and lao pdr. the advance of aids in the middle east and north africa has continued, with latest estimates showing that 67 000 people became infected with hiv in 2005. approximately 510 000 people are living with hiv in this region. an estimated 58 000 adults and children died of aids-related conditions in 2005. although hiv surveillance remains weak in this region, more comprehensive information is available in some countries (including algeria, libya, morocco, somalia and sudan). available evidence reveals trends of increasing hiv infections (especially in younger age groups) in such countries as algeria, libya, morocco and somalia. the main mode of hiv transmission in this region is unprotected sexual contact, although injecting drug use is becoming an increasingly important factor (and is the predominant mode of infection in at least two countries: iran and libya). infections as a result of contaminated blood products, blood transfusions or a lack of infection control measures in healthcare settings are generally on the decline. by far the worst-affected country in this region is sudan. in a country with a long history of civil confl ict and forced displacement, internally displaced persons face higher rates of hiv infection. for instance, among displaced pregnant women seeking antenatal care in khartoum in 2004, hiv prevalence of 1.6% was found compared with under 0.3% for other pregnant women. the epidemic in latin america is a complex mosaic of transmission patterns in which hiv continues to spread through male-tomale sex, sex between men and women, and injecting drug use. sub-saharan africa has just over 10% of the world's population, but is home to more than 60% of all people living with hiv -25. the rights and status of women and young girls deserve special attention. around the world -from south of the sahara in africa and asia to europe, latin america and the pacifi c -an increasing number of women are being infected with hiv. it is often women with little or no income who are most at risk. widespread inequalities including political, social, cultural and human security factors also exacerbate the situation for women and girls. in several southern african countries, more than three quarters of all young people living with hiv are women, while in sub-saharan africa overall, young women between 15 and 24 years old are at least three times more likely to be hiv-positive than young men (figure 3 .5). 6 in many countries, marriage and women's own fi delity are not enough to protect them against hiv infection. among women surveyed in harare (zimbabwe), durban and soweto (south africa), 66% reported having one lifetime partner, 79% had abstained from sex at least until the age of 17 (roughly the average age of fi rst sexual encounter in most countries in the world). yet, 40% of the young women were hiv-positive. many had been infected despite staying faithful to one partner. diarrhoea remains one of the most common diseases affl icting children under 5 years of age and accounts for considerable mortality in childhood. estimates from studies published between 1992 and 2000 show that there was a median of 3.2 episodes of diarrhoea per child-year in developing countries. this indicates little change from previously described incidences. estimates of mortality revealed that 4.9 children per 1000/year in these countries died as a result of diarrhoeal illness in the fi rst 5 years of life, a decline from the previous estimates of 5.6-3.6 per 1000/year. the decrease was most pronounced in children aged under one year. despite improving trends in mortality rates, diarrhoea accounted for a median of 21% of all deaths of children aged under 5 years in developing countries, being responsible for 2.5 million deaths per year. there has not been a concurrent decrease in morbidity rates attributable to diarrhoea. as population growth is focused in the poorest areas, the total morbidity component of the disease burden is greater than previously. 7 diarrhoea remains a disease of poverty affl icting malnourished children in crowded and contaminated environments. efforts to immunize children against measles, provide safe water and adequate sanitation facilities, and to encourage mothers to exclusively breast-feed infants through to 6 months of age can blunt an increase in diarrhoea morbidity and mortality. preventive strategies to limit the transmission of diarrhoeal disease need to go hand in hand with national diarrhoea disease control programmes that concentrate on effective diarrhoea case management and the prevention of dehydration. 8 the factors contributing to childhood mortality and morbidity due to diarrhoea are described in table 3 .2. 8 studies in asia and africa have clearly shown that establishment of an oral rehydration therapy (ort) unit with training of hospital staff can signifi cantly reduce diarrhoea case fatality rates. for instance, at mama yemo hospital in kinshasa, zaire, there was a 69% decline in diarrhoea deaths after creation of an ort unit. 9 in may 2002, the world health organization and the united nations children's fund recommended that the formulation of oral rehydration solution (ors) for treatment of patients with diarrhoea be changed to one with a reduced osmolarity and that safety of the new formulation, particularly development of symptomatic hyponatremia, be monitored. 10 a total of 53 280 patients, including 22 536 children younger than 60 months, were monitored at the dhaka and matlab hospitals, bangladesh. the risk of symptoms associated with hyponatraemia in patients diarrhoeal disease treated with the reduced osmolarity ors was found to be minimal and did not increase with the change in formulation. 10 changing patterns in the epidemiology of diarrhoea have been noted in many studies. in matlab, bangladesh, acute watery diarrhoea accounted for 34% of diarrhoea deaths in under-fi ves, while the remaining 66% were related to dysentery or persistent diarrhoea and malnutrition. this pattern was age dependent, with acute watery deaths being more important in infancy, being associated with 40% of deaths, and less important in later childhood, being associated with 10% of deaths. 11 rotavirus is the most common cause of severe diarrhoeal disease in infants and young children all over the world, and an important public health problem, particularly in developing countries where 600 000 deaths each year are associated with this infection. more than 125 million cases of diarrhoea each year are attributed to rotavirus. in tropical developing countries, rotavirus disease occurs either throughout the year or in the cold dry season. almost all children are already infected by the age of 3-5 years. although the infection is usually mild, severe disease may rapidly result in life-threatening dehydration if not appropriately treated. natural infection protects children against subsequent severe disease. globally, four serotypes are responsible for the majority of rotaviral disease, but additional serotypes are prevalent in some countries. the only control measure likely to have a signifi cant impact on the incidence of severe disease is vaccination. since the withdrawal from the market of the tetravalent rhesus-human reassortant vaccine (rotashield, wyeth laboratories) because of an association with intussusception, ruling out such a risk has become critical for the licensure and universal use of any new rotavirus vaccine. recent studies have shown that two oral doses of the live attenuated g1p [8] human rotavirus vaccine were highly effi cacious in protecting infants against severe rotavirus gastroenteritis, signifi cantly reduced the rate of severe gastroenteritis from any cause, and were not associated with the increased risk of intussusception linked with the previous vaccine. 12 man is both the reservoir and natural host of shigella, the commonest cause of dysentery in the tropics. the most severe infections are caused by the s. dysenteriae type 1 (also known as shiga's bacillus); it is also the only serotype implicated in epidemics. infection is by the faecal-oral route and is usually spread by personto-person transmission. it takes only 10-100 shigella organisms to produce dysentery, a low infectious dose, whereas 1 million to 10 million organisms may need to be swallowed to cause cholera. during the late 1960s, shiga's bacillus was responsible for a series of devastating epidemics of dysentery in latin america, asia and africa. in 1967, it was detected in the mexican-guatemalan border area and spread into much of central america. an estimated half a million cases, with 20 000 deaths, were reported in the region between 1967 and 1971. in some villages the case fatality rate was as high as 15%; delayed diagnosis and incorrect treatment may have been responsible for this high death rate. one particularly disturbing feature was the resistance of the bacteria to the most commonly used antibacterial drugs: sulfonamides, tetracycline and chloramphenicol. 13 serious epidemics due to the multiple-drug resistant s. dysenteriae type 1 have occurred recently in bangladesh, somalia, south india, burma, sri lanka, nepal, bhutan, rwanda and zaire. west bengal in india has always been an endemic area for bacillary dysentery. preventive measures include boiling or chlorination of drinking water, covering faeces with soil, protecting food from fl ies, avoiding eating exposed raw vegetables and cut fruits, and washing hands with soap and water before eating and after using the latrine. however, such measures are not easy to implement in most areas. consequently epidemics take their own course and subside only gradually. 13 tuberculosis tuberculosis (tb) is the leading cause of death associated with infectious diseases globally. the incidence of tb will continue to increase substantially worldwide because of the interaction between the tb and hiv epidemics. 14 in many developing countries, tb is mainly a disease of young adults affecting carers and wage-earners in a household, thus placing a huge economic burden on society as a whole. chemotherapy, if properly used, can reduce the burden of tb in the community, but because of the fragile structure of treatment programmes in many countries tb cases are not completely cured and patients remain infectious for a much longer time. another important consequence of poor treatment compliance is development of drug resistance in many developing countries. resistance to tuberculosis drugs is probably present everywhere in the world. 15 worldwide attention was focused on south africa, when in october 2006 a research project publicized a deadly outbreak of xdr-tb in the small town of tugela ferry in kwazulu-natal. xdr-tb is the abbreviation for extensively drug-resistant tuberculosis (tb). this strain of mycobacterium tuberculosis is resistant to fi rstand second-line drugs, and treatment options are seriously limited. of 536 tb patients at the church of scotland hospital, which serves a rural area with high hiv rates, some 221 were found to have multi-drug resistance and of these, 53 were diagnosed with xdr-tb. some 52 of these patients died, most within 25 days of diagnosis. of the 53 patients, 44 had been tested for hiv and all 44 were found to be hiv-positive. the patients were receiving antiretrovirals and responding well to hiv-related treatment, but they died of xdr-tb. since the study, 10 more patients have been diagnosed with xdr-tb in kwazulu-natal. only three of them are still alive (see: http://www.who.int/tb/xdr/xdr_jan.pdf). directly observed treatment, short course (dots), is the most effective strategy available for controlling the tb epidemic today. dots uses sound technology and packages it with good management practices for widespread use through the existing primary healthcare network. it has proven to be a successful, innovative approach to tb control in countries such as china, bangladesh, vietnam, peru and countries of west africa. however, new challenges to the implementation of dots include health sector reforms, the worsening hiv epidemic, and the emergence of drugresistant strains of tb. the technical, logistical, operational and political aspects of dots work together to ensure its success and applicability in a wide variety of contexts. 14 million africans who die from malaria each year, most are children under 5 years of age. in addition to acute disease episodes and deaths in africa, malaria also contributes signifi cantly to anaemia in children and pregnant women, adverse birth outcomes such as spontaneous abortion, stillbirth, premature delivery and low birth weight, and overall child mortality. the disease is estimated to be responsible for an estimated average annual reduction of 1.3% in economic growth for those countries with the highest burden. 16 of the four species of plasmodium that infect humans: p. falciparum, p. vivax, p. malariae and p. ovale, p. falciparum causes most of the severe disease and deaths attributable to malaria and is most prevalent in africa south of the sahara and in certain areas of south-east asia and the western pacifi c (figure 3.7) . the second most common malaria species, p. vivax, is rarely fatal and is commonly found in most of asia, and in parts of the americas, europe and north africa. there are over 40 species of anopheline mosquitoes that transmit human malaria, which differ in their transmission potential. the most competent and effi cient malaria vector, anopheles gambiae, occurs exclusively in africa and is also one of the most diffi cult to control. climatic conditions determine the presence or absence of anopheline vectors. tropical areas of the world have the best combination of adequate rainfall, temperature and humidity allowing for breeding and survival of anophelines. in areas of malaria transmission where sustained vector control is required, insecticide treated nets are the principal strategy for malaria prevention. all countries in africa south of the sahara, the majority of asian malaria-endemic countries and some american countries have adopted insecticide treated nets as a key malaria control strategy. 16 one of the greatest challenges facing malaria control worldwide is the spread and intensifi cation of parasite resistance to antimalarial drugs. the limited number of such drugs has led to increasing diffi culties in the development of antimalarial drug policies and adequate disease management. 16 resistance of p. falciparum to chloroquine is now common in practically all malariaendemic countries of africa (figure 3.7) , especially in east africa. resistance to sulfadoxine/pyrimethamine, the main alternative to chloroquine, is widespread in south-east asia and south america. mefl oquine resistance is now common in the border areas of thailand with cambodia and myanmar. parasite sensitivity to quinine is declining in several other countries of south-east asia and in the amazon region, where it has been used in combination with tetracycline for the treatment of uncomplicated malaria. 16 in response to widespread resistance of p. falciparum to monotherapy with conventional antimalarial drugs such as chloroquine and sulfadoxine-pyrimethamine, who now recommends combination therapies as the treatment policy for falciparum malaria in all countries experiencing such resistance. the preferred combinations contain a derivative of the plant artemisia annua, which is presently cultivated mainly in china and vietnam. artemisininbased combination therapies (acts) are the most highly effi cacious treatment regimens now available. resistance of p. vivax to chloroquine has now been reported from indonesia (irian jaya), myanmar, papua new guinea and vanuatu. 17 urban and periurban malaria are on the increase in south asia and in many areas of africa. military confl icts and civil unrest, along with unfavourable ecological changes, have greatly contributed to malaria epidemics, as large numbers of unprotected, nonimmune and physically weakened refugees move into malarious areas. such population movements contribute to new malaria outbreaks and make epidemic-prone situations more explosive. 16 another disquieting factor is the re-emergence of malaria in areas where it had been eradicated (e.g. democratic people's republic of korea, republic of korea and tadjikistan), or its increase in countries where it was nearly eradicated (e.g. azerbaijan, northern iraq and turkey). current malaria epidemics in a majority of these countries are the result of a rapid deterioration of malaria prevention and control operations. climatic changes have also been implicated in the re-emergence of malaria. in the past 5 years, the worldwide incidence of malaria has quadrupled, infl uenced by changes in both land development and regional climate. in brazil, satellite images depict a 'fi sh bone' pattern where roads have opened the tropical forest to localized development. in these 'edge' areas malaria has resurged. temperature changes have encouraged a redistribution of the disease; malaria is now found at higher elevations in central africa and could threaten cities such as nairobi, kenya. this threat has been hypothesized to extend to temperate regions of the world that are now experiencing hotter summers year on year. 18 although substantial progress has been made in reducing measles deaths globally, in 2000 measles was estimated to be the fi fth leading cause of mortality worldwide for children aged <5 years. measles deaths occur disproportionately in africa and south-east asia. in 2000, the african region of who, with 10% of the world's population, accounted for 41% of estimated measles cases and 58% of measles deaths; the south-east asia region, with 25% of the world's population and 28% of measles cases, accounted for 26% of measles deaths. the burden of mortality in africa refl ects low routine vaccination coverage and high case-fatality ratios. in south-east asia, where vaccination coverage is slightly below average worldwide levels, the large population amplifi es the number of cases and deaths resulting from ongoing measles transmission. the overwhelming majority of measles deaths in 2000 occurred in countries eligible to receive fi nancial support from the global alliance for vaccines and immunization's vaccine fund (who, unpublished data 2003). the majority of measles deaths occur among young children living in poor countries with inadequate vaccination services. like human immunodefi ciency virus, malaria, and tuberculosis, measles can be considered a disease of poverty. however, unlike these diseases, measles can be prevented through vaccination. 19, 20 in much of the world, particularly sub-saharan africa, south-east asia, china and the pacifi c basin, infection with hepatitis b virus (hbv) is very widespread. the carrier rate in some of these populations may be as high as 10-20%. in developing countries most hepatitis b transmission occurs during the perinatal period. infection between children is another common route of infection; it is not uncommon to fi nd up to 90% of 15-year-olds have serological evidence of infection with hbv. intermediate levels of infection (2-7%) are seen in parts of the former soviet union, south asia, central america and the northern zones of south america. these high rates of infection lead to a high burden of disease, mainly from the clinical consequences of long-term carriage of the virus, which may include chronic hepatitis, cirrhosis and liver cancer. it has been estimated that hbv infection is the second most common cause of cancer deaths in the world (after tobacco consumption). in india hepatitis b is linked to 60% of cases of hepatocellular carcinoma and 80% of cases of cirrhosis of the liver. 21 on the basis of disease burden and the availability of safe and effective vaccines, the who recommended that by the end of the twentieth century, hepatitis b vaccine be incorporated into routine infant and childhood immunization programmes for all countries. the effi cacy of universal immunization has been shown in different countries, with striking reductions of the prevalence of hbv carriage in children. most important, hepatitis b vaccination can protect children against hepatocellular carcinoma and fulminant hepatitis, as has been shown in taiwan. nevertheless, the implementation of worldwide vaccination against hbv requires greater effort to overcome the social and economic hurdles. safe and effective antiviral treatments are available but are still far from ideal, a situation that, hopefully, will be improved soon. with hepatitis b immunization, the global control of hbv infection is possible by the end of the fi rst half of twenty-fi rst century. 22 tetanus is a vaccine-preventable disease that causes a total of 309 000 deaths annually. of particular concern is maternal and neonatal tetanus (mnt), which can be prevented through immunization of the mother in pregnancy. in 2000, neonatal tetanus alone was responsible for an estimated 200 000 deaths. in addition, an estimated 15 000-30 000 non-immunized women worldwide die each year from maternal tetanus that results from postpartum, postabortal or postsurgical wound infection with clostridium tetani. while the focus is on 57 priority countries, 90% of the neonatal tetanus deaths occur in 27 countries. unicef spearheaded the effort to eliminate mnt by the year 2005, with the support of numerous partners. mnt elimination is defi ned as less than one case of neonatal tetanus per 1000 live births at district level. the main strategies consist of promotion of clean delivery practices, immunization of women with a tetanus toxoid (tt) containing vaccine, and surveillance. maternal tetanus immunization is, in most developing countries, implemented as part of the routine immunization programme. however, large areas remain underserved, due to logistical, cultural, economical or other reasons. in order to achieve the target of mnt elimination by 2005, and to offer protection to women and children otherwise deprived from regular immunization services, countries are encouraged to adopt the high risk approach. this approach implies that, in addition to routine immunization of pregnant women, all women of child-bearing age living in high risk areas are targeted for immunization with three doses of a tetanus toxoid containing vaccine (tt or td). 23 by the end of 2007 vaccination against a range of bacterial and viral diseases is an integral part of communicable disease control worldwide. vaccination against a specifi c disease not only reduces the incidence of that disease, but it also reduces the social and economic burden of the disease on communities. very high immunization coverage can lead to complete blocking of transmission for many vaccinepreventable diseases. the worldwide eradication of smallpox and the near-eradication of polio from many countries provide excellent examples of the role of immunization in disease control. despite these advances many of the world's poorest countries do not have access to vaccines and these infections remain among the leading global causes of death. the special programme for research and training in tropical diseases (tdr) of the world health organization has designated several infectious diseases as 'neglected tropical diseases' (ntds) that disproportionately affl ict the poor and marginalized populations in the developing regions of sub-saharan africa, asia and the americas. 24 infectious diseases are considered as 'neglected' or 'orphan' diseases when there is a lack of effective, affordable, or easy to use drug treatments. as most patients with such diseases live in developing countries and are too poor to pay for drugs, the pharmaceutical industry has traditionally ignored these diseases. ntds cause an estimated 500 000 to 1 million deaths annually and cause a global disease burden equivalent to that of hiv-aids. who estimates that at least 1 billion people, i.e. onesixth of the world's population suffers from one or more neglected tropical diseases, while other estimates suggest the number to be much higher. some diseases affect individuals throughout their lives, causing a high degree of morbidity and physical disability and, in certain cases, gross disfi gurement. others are acute infections, with transient, severe and sometimes fatal outcomes. patients can face social stigmatization and abuse, which only add to the already heavy health burden. neglected tropical diseases are contrasted with the 'big three' diseases (hiv/aids, tuberculosis and malaria) which receive much more attention and funding. the current neglected diseases portfolio includes parasitic diseases of protozoan origin like kala-azar (leishmaniasis), african sleeping sickness (african trypanosomiasis) and chagas' disease (american trypanosomiasis) as well as those caused by helminths such as schistosomiasis, lymphatic fi lariasis, onchocerciasis (river blindness) and dracunculiasis (guinea worm). infestations due to soil transmitted helminths such as ascariasis, trichuriais and hookworm also belong to the latter category. other neglected diseases include those of bacterial origin such as leprosy, buruli ulcer and trachoma as well as those of viral origin like dengue fever which are vector-borne. even cholera and yellow fever are considered by some as ntds, while some include cysticercosis, hydatidosis and food-borne trematode infections. it is now believed that ramped up efforts against the 'big three', will yield far bigger dividends if they are coupled with concerted attack on ntds 25 . evidence now points to substantial geographical overlap between the neglected tropical diseases and the 'big three', suggesting that control of the neglected tropical diseases could become a powerful tool for effectively combating hiv/aids, tuberculosis, and malaria. 25 since 1991, resurgent and emerging infectious disease outbreaks have occurred worldwide. in addition, many diseases widely believed to be under control, such as cholera, dengue and diphtheria, have re-emerged in many areas or spread to new regions or populations throughout the world (figure 3.8) . 26 a growing population and increasing urbanization contribute to emerging infectious disease problems. in many parts of the world, urban population growth has been accompanied by overcrowding, poor hygiene, inadequate sanitation and unclean drinking water. urban development has also caused ecological damage. in these circumstances, certain disease-causing organisms and some of the vectors that transmit them have thrived, making it more likely that people will be infected with new or re-emerging pathogens. the existing public health infrastructure is already overtaxed and ill prepared to deal with new health threats. breakdown of public health measures due to civil unrest, war and the movement of refugees has also contributed to the re-emergence of infectious diseases (table 3. 3). 26 international travel and commerce have made it possible for pathogens to be quickly transported from one side of the globe to the other (figure 3.9) . 26 examples of new and resurgent infections include ebola, dengue fever, rift valley fever, diphtheria, cholera, nipah virus infection, west nile virus infection, severe acute respiratory syndrome (sars) and avian infl uenza. in 1976 ebola (named after the ebola river in zaire) fi rst emerged in sudan and the democratic republic of the congo (formerly zaire). ebola virus occurs as four distinct subtypes: zaã¯re, sudan, cã´te d'ivoire and reston. three subtypes, occurring in the democratic republic of the congo, sudan and cã´te d'ivoire, have been identifi ed as causing illness in humans. ebola haemorrhagic fever (ehf) is a febrile haemorrhagic illness which causes death in 50-90% of all clinically ill cases. the natural reservoir of the ebola virus is unknown despite extensive studies, but seems to reside in the rain forests on the african continent and in the western pacifi c. through the global prevalence of dengue and dengue haemorrhagic fever (dhf) has grown dramatically in recent decades. the disease is now endemic in more than 100 countries in africa, the americas, the eastern mediterranean, south-east asia and the western pacifi c. south-east asia and the western pacifi c are most seriously affected. some 2500 million people -two-fi fths of the world's population -are now at risk from dengue. who currently estimates there may be 50 million cases of dengue infection worldwide every year. in 2001 alone, there were more than 609 000 reported cases of dengue in the americas, of which 15 000 cases were dhf. this is greater than double the number of dengue cases which were recorded in the same region in 1995. not only is the number of cases increasing as the disease is spreading to new areas, but explosive outbreaks are occurring. in 2001, brazil reported over 390 000 cases including more than 670 cases of dhf. during epidemics of dengue, attack rates among the susceptible are often 40-50%, but may reach 80-90%. an estimated 500 000 cases of dhf require hospitalization each year, microbial adaptation changes in virulence and toxin production; development and change of drug resistance; microbes as co-factors in chronic diseases of whom a very large proportion are children. without proper treatment, dhf case fatality rates can exceed 20%. with modern intensive supportive therapy, such rates can be reduced to less than 1%. the spread of dengue is attributed to expanding geographical distribution of the four dengue viruses and of their mosquito vectors, the most important of which is the predominantly urban species aedes aegypti. a rapid rise in urban populations is bringing ever greater numbers of people into contact with this vector, especially in areas that are favourable for mosquito breeding, e.g. where household water storage is common and where solid waste disposal services are inadequate. 28 rift valley fever (rvf) is a zoonotic disease typically affecting sheep and cattle in africa. mosquitoes are the principal means by which rvf virus is transmitted among animals and to humans. following abnormally heavy rainfall in kenya and somalia in late 1997 and early 1998, rvf occurred over vast areas, producing disease in livestock and causing haemorrhagic fever and death among the human population. as of december 2006, who fi gures indicate that the outbreak continues to affect the north western provinces of kenya. in september 2000 who documented the fi rst ever rvf outbreak outside africa, in yemen and the kingdom of saudi arabia (ksa). rna sequencing of the virus from ksa indicated that it was similar to the rvf viruses isolated from east africa in 1998. a total of 1087 suspected cases were identifi ed, of which 121 (11%) persons died. of the 1087, 815 (75%) cases reported exposure to sick animals, handling an abortus or slaughtering animals in the week before onset of illness. 29 the vibrio responsible for the seventh pandemic, now in progress, is known as v. cholerae o1, biotype el tor. according to the who, it continues to spread in angola and sudan; more than 40 000 cases have been documented with over 1500 deaths: a case fatality rate of 3.5-4%. cholera (biotype el tor) broke out explosively in peru in 1991, after an absence of 100 years, and spread rapidly in central and south america, with recurrent epidemics in 1992 and 1993. from the onset of the epidemic in january 1991 to 1 september 1994, a total of 1 041 422 cases and 9642 deaths (overall case fatality rate 0.9%) were reported from countries in the western hemisphere to the pan american health organization. in december 1992, a large epidemic of a new strain of cholera v. cholerae 0139 began in south india, and spread rapidly through the subcontinent (figure 3.10) . this strain has changed its antigenic structure such that there is no existing immunity and all ages, even in endemic areas, are susceptible. the epidemic has continued to spread and v. cholerae o139 has been reported from 11 countries in south asia. because humans are the only reservoirs, survival of the cholera vibrios during interepidemic periods probably depends on low-level undiagnosed cases and transiently infected, asymptomatic individuals. recent studies have suggested that cholera vibrios can persist for some time in shellfi sh, algae or plankton in coastal regions of emerging and resurgent infectious diseases infected areas and it has been claimed that they can exist in a viable but non-culturable state. 30 in early 1999, health offi cials in malaysia and singapore investigated reports of febrile encephalitis and respiratory illnesses among workers who had been exposed to pigs. a previously unrecognized paramyxovirus (formerly known as hendra-like virus), now called nipah virus, was implicated by laboratory testing in many of these cases. as of april 1999, 257 cases of febrile encephalitis were reported to the malaysian ministry of health, including 100 deaths. laboratory results from 65 patients who died suggested recent nipah virus infection. the apparent source of infection among most human cases continues to be exposure to pigs. human-tohuman transmission of nipah virus has not been documented. outbreak control in malaysia has focused on culling pigs; approximately 890 000 pigs have been killed. other measures include a ban on transporting pigs within the country, education about contact with pigs, use of personal protective equipment among persons exposed to pigs, and a national surveillance and control system to detect and cull additional infected herds. 31 nipah virus cases and deaths have also been reported from bangladesh. since then, no more human cases have been reported. sars is due to infection with a newly identifi ed coronavirus named as sars-associated coronavirus (sars-cov). 32 the source of infection is likely to be a direct cross-species transmission from an animal reservoir. this is supported by the fact that the early sars cases in guangdong province had some history of exposure to live wild animals in markets serving the restaurant trade. animal traders working with animals in these markets had higher seroprevalence for sars coronavirus, though they did not report any illness compatible with sars. more importantly, sars-cov-like virus detected from some animal species had more than a 99% homology with human sars-cov. 32 the clinical course of sars varies from a mild upper respiratory tract illness, usually seen in young children, to respiratory failure which occurred in around 20-25% of mainly adult patients. as the disease progresses, patients start to develop shortness of breath. from the second week onwards, patients progress to respiratory failure and acute respiratory distress syndrome, often requiring intensive care. 32 in may 1997, a 3-year-old boy in hong kong contracted an infl uenza-like illness, was treated with salicylates, and died 12 days later with complications consistent with reye's syndrome. laboratory diagnosis included the isolation in cell culture of a virus that was identifi ed locally as infl uenza type a but could not be further characterized with reagents distributed for diagnosis of human infl uenza viruses. by august, further investigation with serological and molecular techniques in the netherlands and in the usa had confi rmed that the isolate was a/hong kong/156/97 (h5n1), which was very closely related to isolate a/chicken/hong kong/258/97 (h5n1). the latter virus was considered representative of those responsible for severe outbreaks of disease on three rural chicken farms in hong kong during march 1997, during which several thousand chickens had died. molecular analysis of the viral haemagglutinins showed a proteolytic cleavage site of the type found in highly pathogenic avian infl uenza viruses. by late december, the total number of confi rmed new human cases had climbed to 17, of which fi ve were fatal; the case fatality rates were 18% in children and 57% in adults older than 17 years. almost all laboratory evidence of infection was in patients who had been near live chickens (e.g. in marketplaces) in the days before onset of illness, which suggested direct transmission of virus from chicken to human rather than person-to-person spread. in december 1997, veterinary authorities began to slaughter all (1.6 million) chickens present in wholesale facilities or with vendors within hong kong, and importation of chickens from neighbouring areas was stopped. knowledge of how humans are infected, the real level of humanto-human transmission, the spectrum of disease presentation and the effectiveness of treatment remains scanty. human-to human transmission is known to have occurred, but there is no evidence that transmission has become more effi cient. all the human-tohuman infections with h5n1 to date seem not to have transmitted on further. therefore, although the case fatality rate for human infection remains high (around 57% for cases reported to who), it seems that h5n1 avian viruses remain poorly adapted to humans. 33 global prevalence studies (figure 3 .11) indicate that indonesia is currently the most active site of bird to human h5n1 transmission in the asia pacifi c region, and a large number of human cases have been detected here in 2005-06. china and cambodia have also reported human cases in 2006. in south asia (india and pakistan), there have only been sporadic reports of infection in poultry to date. in vietnam and thailand there have been offi cial reports of poultry outbreaks; these show a decline since 2006. surveillance in africa is especially weak, and there is evidence of widespread infection in domestic poultry in parts of north, west and central africa. prospects of control are bleak here because of weaknesses in veterinary services, and a number of competing animal and human health problems. the outbreaks in egypt have been well described. these involved both commercial and backyard fl ocks, with considerable impact on economic life and food security. it is probable that large numbers of people in african countries are at risk of h5n1 infection. if that virus had pandemic potential then a pandemic arising from africa must be considered a possibility. 33 non-infectious diseases take an enormous toll on lives and health worldwide. non-communicable diseases (ncds) account for nearly 60% of deaths globally, mostly due to heart disease, stroke, cancer, diabetes and lung diseases. the rapid rise of ncds represents one of the major health challenges to global development in the twenty-fi rst century and threatens the economic and social development of nations as well as the lives and health of millions of their subjects. in 1998 alone, ncds were estimated to have contributed to 31.7 million deaths globally and 43% of the global burden of disease. 34 until recently, it was believed that ncds were a minor or even non-existent problem in developing countries in the tropics. a recent analysis of mortality trends from ncds suggests that large increases in ncds have occurred in developing countries, 35 particularly those in rapid transition like china and india (table 3 .4). according to these estimates at least 40% of all deaths in the tropical developing countries are attributable to ncds, while in industrialized countries ncds account for 75% of all deaths. low-and middle-income countries suffer the greatest impact of ncds. the rapid increase in these diseases is seen disproportionately in poor and disadvantaged populations and is contributing to widening health gaps between and within countries. in 1998, of the total number of deaths attributable to ncds 77% occurred in developing countries, and of the disease burden they represent 85% was borne by low-and middle-income countries. 34 it has now been projected that, by 2020, ncds will account for almost three-quarters of all deaths worldwide, and that 71% of deaths due to ischaemic heart disease (ihd), 75% of deaths due to stroke, and 70% of deaths due to diabetes will occur in developing countries 36 and the number of people in the developing world with diabetes is expected to increase by more than 2.5-fold, from 84 million in 1995 to 228 million in 2025. 37 on a global basis, 60% of the burden of ncds will occur in developing countries and the rate at which it is increasing annually is unprecedented. the public health and economic implications of this phenomenon are staggering, and are already becoming apparent. it is important to recognize that these trends, indicative of an increase in ncds, may be partly confounded by factors such as an increase in life expectancy, a progressive reduction in deaths due to communicable diseases in adulthood, and improvements in case detection and reporting in the tropics. however, increase in the incidence of these chronic degenerative diseases is real. the complex range of determinants (below) that interact to determine the nature and course of this epidemic 38 needs to be understood in order to adopt preventive strategies to help developing societies in the tropics to deal with this burgeoning problem. the determinants of non-communicable diseases in developing societies are as follows: 1 â�¢ demographic changes in population â�¢ epidemiological transition â�¢ urbanization and internal migration â�¢ changes in dietary and food consumption patterns â�¢ lifestyle changes (changes in physical activity patterns, sociocultural milieu and stress as well as increased tobacco consumption) â�¢ adult-onset effects of low birth weight and the effects of early life programming â�¢ infections and their associations with chronic disease risk â�¢ effect of malnutrition and nutrient defi ciencies â�¢ poverty, inequalities and social exclusion â�¢ deleterious effects of environmental degradation â�¢ impacts of globalization. four of the most prominent ncds: cardiovascular disease, cancer, chronic obstructive pulmonary disease and diabetes, are linked to common preventable risk factors related to diet and lifestyle. these factors are tobacco use, unhealthy diet and lack of physical activity. interventions to prevent these diseases should focus on controlling these risk factors in an integrated manner and at the family and community level since the causal risk factors are deeply entrenched in the social and cultural framework of society. developing countries in the tropics have to recognize that the emerging accelerated epidemic of ncds is a cause for concern and that it needs to be dealt with as a national priority. they have to learn from the experience of industrialized and affl uent countries to tackle the emerging crisis of chronic diseases that they are likely to face in the near future. the emerging health burden of chronic disease affecting mainly the economically productive adult population will consume scarce resources. it is important, however, to realize that the poorer countries will be burdened even more in the long run, if attempts are not made to evolve and implement interventions to address these emerging health issues on an urgent basis. ensuring that health policies are aimed at tackling the 'double burden' of the continued existence of the huge burden of infectious/communicable diseases alongside the emerging epidemic of non-communicable diseases in developing countries of the tropics becomes a priority. 39 the world we live in is constantly changing. in the past 25 years, we have witnessed signifi cant progress in sustainable and technological development. however, increases in mass population movements, continuing civil unrest and deforestation have helped carry diseases into areas where they have never been seen before. this has been aided by the massive growth in international travel. effective medicines and control strategies are available to dra-matically reduce the deaths and suffering caused by communicable and non-communicable diseases. despite reduced global military spending many governments are failing to ensure that these strategies receive enough funding to succeed. who priorities for the control of infectious diseases in developing countries include childhood immunization, integrated management of childhood illnesses, use of the dots strategy to control tb, a package of interventions to control malaria, a package of interventions to prevent hiv/aids, access to essential drugs, and the overall strengthening of surveillance and health service delivery systems. over 10% of all preventable ill-health today is due to poor environmental quality-conditions such as bad housing, overcrowding, indoor air pollution, poor sanitation and unsafe water. the challenge of disease in the tropics has continued into the new millennium -never before have we been so well equipped to deal with disease threats. it remains for humankind to summon the collective will to pursue these challenges and break the chain of infection and disease. national and international surveillance of communicable diseases health report: fighting disease fostering development. geneva: world health organization acute respiratory infections. geneva: world health organization indoor air pollution energy and health for the poor estimate of global incidence of clinical pneumonia in children under fi ve years the global burden of diarrhoeal disease number evl-97-002. a global review of diarrhoeal disease control new parameters for evaluating oral rehydration therapy: one year's experience in a major urban hospital in zaire symptomatic hyponatremia during treatment of dehydrating diarrheal disease with reduced osmolarity oral rehydration solution diarrhoea mortality in rural bangladeshi children for the human rotavirus vaccine study group. safety and effi cacy of an attenuated vaccine against severe rotavirus gastroenteritis guidelines for the control of epidemics due to shigella dysenteriae 1. publication no. who/cdr/95.4. epidemiology of dysentery caused by shigella. geneva: world health organization global tuberculosis control-surveillance, planning financing, geneva: world health organization who/international union against tuberculosis and lung disease global project on anti-tuberculosis drug resistance surveillance. epidemiology of antituberculosis drug resistance (the global project on anti-tuberculosis drug resistance surveillance): an updated analysis geneva: world health organization climate, ecology and human health global burden of disease and risk factors. geneva: world health organization update: global measles control and mortality reduction -worldwide towards the elimination of hepatitis b: a guide to the implementation of national immunization programs in the developing world. the international task force on hepatitis b immunization. geneva: world health organization global control of hepatitis b virus infection tetanus in developing countries: an update on the maternal and neonatal tetanus elimination control of neglected tropical diseases (ntd) incorporating a rapid-impact package for neglected tropical diseases with programs for hiv/aids, tuberculosis, and malaria emerging infectious diseases review of state and federal diseases surveillance fact sheet: ebola haemorrhagic fever. fact sheet no. 103. geneva: world health organization report of the public health laboratories division. who collaborating centre for research and training in viral diagnostics national institute of health update: vibrio cholerae o1-western hemisphere, 1991-1994, and v. cholerae o139-asia update: outbreak of nipah virus: malaysia and singapore sars and emerging infectious diseases: a challenge to place global solidarity above national sovereignty world avian infl uenza update: h5n1 could become endemic in africa global strategy for the prevention and control of non-communicable diseases. geneva: world health organization global comparative assessments in the health sector. geneva: world health organization life in the 21st century: a vision for all. geneva: world health organization life course perspectives on coronary heart disease, stroke and diabetes: key issues and implications for policy and research diet and life-style and chronic non-communicable diseases: what determines the epidemic in developing societies? in: krishnaswami k, ed. nutrition research: current scenario and future trends the double burden of communicable and non-communicable diseases in developing countries key: cord-271602-f14wccj3 authors: kim, hyun cheol; kim, soontae; kim, byeong-uk; jin, chun-sil; hong, songyou; park, rokjin; son, seok-woo; bae, changhan; bae, minah; song, chang-keun; stein, ariel title: recent increase of surface particulate matter concentrations in the seoul metropolitan area, korea date: 2017-07-05 journal: sci rep doi: 10.1038/s41598-017-05092-8 sha: doc_id: 271602 cord_uid: f14wccj3 recent changes of surface particulate matter (pm) concentration in the seoul metropolitan area (sma), south korea, are puzzling. the long-term trend of surface pm concentration in the sma declined in the 2000s, but since 2012 its concentrations have tended to incline, which is coincident with frequent severe hazes in south korea. this increase puts the korean government’s emission reduction efforts in jeopardy. this study reports that interannual variation of surface pm concentration in south korea is closely linked with the interannual variations of wind speed. a 12-year (2004–2015) regional air quality simulation was conducted over east asia (27-km) and over south korea (9-km) to assess the impact of meteorology under constant anthropogenic emissions. simulated pm concentrations show a strong negative correlation (i.e. r = −0.86) with regional wind speed, implying that reduced regional ventilation is likely associated with more stagnant conditions that cause severe pollutant episodes in south korea. we conclude that the current pm concentration trend in south korea is a combination of long-term decline by emission control efforts and short-term fluctuation of regional wind speed interannual variability. when the meteorology-driven variations are removed, pm concentrations in south korea have declined continuously even after 2012. particulate matter (pm; pm 10 , particles with a diameter of 10 µm or less, is used in the study unless specified) concentration is its interannual trend, which recently showed a signal of increase after a long downward trend. since the early 2000s, annual mean surface pm concentrations have decreased continuously over the sma and south korea (fig. 1 ). the annual mean concentration was 71.9 μg/m 3 in 2002, and continued to decrease until it reached its minimum (46.9 μg/m 3 ) in 2012, but since then it has begun to rise (51.2 μg/m 3 , 51.9 μg/m 3 , 51.0 μg/ m 3 in 2013, 2014, and 2015, respectively). although several reasons (e.g., regional transport changes in china 12, 13 or increased use of diesel-engine passenger cars) 14 have been suggested for the recent changes, the potential of meteorological variance has not been actively discussed until now. in addition to the changes in the amount of released emissions of pollutants and their precursors, meteorological conditions are also primary contributors to regional haze and air pollutions 15, 16 . wind, in its velocity and transport pattern, is one of the major meteorological components that affects surface air pollution 17, 18 . winds can control vertical mixing and regional ventilation 19 . persistent stagnant conditions (i.e. calm wind) provide critical conditions that lead to the development of local pollution episodes. wind direction controls the source-receptor relationship 20 , and it also directly initiates local emissions such as dust storms or sea salt emissions 21, 22 . large scale transport, both regional or inter-continental, can affect the atmospheric composition by altering their lifetime (e.g. longer lifetime at higher altitudes), and influences global meteorology and climate 23, 24 . identifying the major drivers in the long-term trend of surface pm concentration can be limited due to the intricacy of chemical and meteorological processes. a 12-year simulation with a constant anthropogenic emission inventory was designed to isolate the interannual variation of surface pm concentrations solely due to variations of meteorology (see method). after testing multiple meteorological variables, we found a significant association of wind speed and surface pm concentrations. normalized anomalies (annual averages subtracted and then divided by the 2004-2015 average) of surface pm concentration and 10-m wind speed averaged over three geographical coverages (i.e. 9-km domain-wide, korea, and the sma) are compared (fig. 2) . noticeably, interannual variations of modeled surface pm concentrations show very similar patterns in all regions. the observed pm, averaged over 247 sites in south korea, shows similar but slightly different interannual variability. its year-to-year variation pattern is very similar to that of modeled variation; a small drop in 2004, strong positives in 2005-2007, strong negative in 2012, and an increase in 2013-2014. its general pattern, however, is mostly positive in early years and negative in later years. it thus seems reasonable to say that the observations show mixed signals; likely a combination of a short-term year-to-year fluctuations (caused by meteorological changes) and a long-term decline (caused by changes in anthropogenic emissions) 25 . normalized anomalies of 10-m wind speed, on the other hand, show good agreement between observations (averaged over 79 sites in south korea) and modeled wind speed over three regions, demonstrating that the model reasonably simulated interannual variations of the wind field. the key feature from the interannual variations of surface pm concentrations and surface wind is that they show totally opposite phases in their interannual variabilities. it should be noted that the interannual variations of pm concentrations, in all three regions, are best explained by the changes of domain-wide averaged wind speed compared with smaller scale averages. this might imply that the controlling mechanism is not on a local scale (e.g. sea breeze or local circulation) but rather synoptic scale activities (e.g. frontal passage). considering the efficiency of the wipe-out mechanism by cold frontal activities, the annual wind speed variability seems to represent the efficiency of regional ventilation 26 . northeastern asia is a routine passage of mid-latitude cyclogenesis, initiated on the lee side of the altai-sayan mountains 27 . the role of altai-sayan cyclogenesis, as an efficient cleaning mechanism of pollutants over northern china and korea during cool season, is demonstrated and discussed in kim et al. 28 . the change of summertime circulation (i.e. east asia summer monsoon) on regional pollution is also discussed in zhu et al. 29 . scatter plots of normalized anomalies between wind speed and surface pm concentration from the model ( −10.9% and 7.7%, while the wind speed anomaly varied between −3.5% and 4.8%. the range of variability in pm concentration is impressive since it is almost compatible to total long-term changes; that is ~−2% per year or ~−24% during 2004-2015. remarkably, even with excellent agreement between modeled and observed interannual anomalies in surface pm concentration and wind speed, a direct comparison between observed pm concentration and observed wind speed variability shows poor correlation (i.e. r = 0.07). it clearly shows the advantage of the emission-isolating modeling approach, otherwise the meteorology-driven interannual variability of pm concentration seems to be overshadowed by emission reduction in the long-term trends. finally, we tried to remove the meteorology-driven variances from the original pm concentrations. fractional interannual anomalies from fig. 2a are multiplied to an overall mean of pm concentrations from each region, and then subtracted from the original annual mean concentrations. considering the uncertainties from the original model bias, using the relative variances instead of absolute concentrations from the model is a more robust approach 30 . adjusted annual pm concentrations, with meteorology-driven variances removed, are shown in fig. 3 in relation to seoul, the sma, and south korea. the most surprising change of the annual pm concentrations, compared with those of fig. 1 , is their trend in recent years. the increase since 2012, which had frustrated apparently, the decreasing rate in seoul is faster than the national average, implying the effectiveness of special emission control efforts in the locale, including replacing diesel buses and diesel garbage trucks with natural gas vehicles 31, 32 . the local minimum of 2008 in the adjusted pm concentrations is noteworthy. the most likely explanation for this decrease is the impact of the global recession during 2008-2009, as indicated by several previous researches 33, 34 . at this point, we are not able to distinguish if the impact is due to changes caused by the south korean economy's experience of the global recession, or due to changes of transported pollutants and precursors by chinese economic changes. the case of 2015 is also interesting. pm concentration was higher in early 2015 (64.1 μg/m 3 in 2014 jan-mar and 72.5 μg/m 3 in 2015 jan-mar), but the annual mean is lower than that of 2014 because its spring-to-fall concentration is very low, even with the weakest wind speed observed. this is likely an extraordinary case by the impact of the middle east respiratory syndrome (mers), which has seriously impacted the south korean economy and society 35 . although further investigations are necessary, these cases in 2008 and 2015 may provide interesting examples of the socio-economic impact on the environment, in addition to emission control policy-driven impact. three factors, long-term trend by emission control, short-term variation by meteorology, and sporadic offsets by unexpected social or economic episodes, seem to be affecting pm concentrations in south korea. to conclude, we found that there is a strong correlation between variations of surface pm concentrations in south korea and variations of wind speed. this study addresses several important implications. first, interannual variation of meteorological conditions has the strong potential to affect long-term trends in surface pm pollution events. at this point, we do not have any evidence that the reduced wind speed is part of long-term change or just short-term fluctuation in general circulations or ventilation patterns. however, it is worth further investigation since the frequency of mid-latitude cyclones can be reduced in warmer weather conditions, as suggested through observations [36] [37] [38] [39] and models studies 19, 40-42 . mickley et al. 19 used the goddard institute of space studies model to demonstrate that the severity and duration of summertime regional pollution can increase due to a decline in the frequency of mid-latitude cyclones under future warmer climates. this may provide a key feature to understand the frequent occurrence of severe haze episodes not only in south korea but also in east asia, especially in northern china. yang et al. 43 also demonstrated haze days over eastern china has increased between 1980 and 2014, and argued that the weakening of winds is the dominant factor leading the decadal increase. second, accurate simulation of surface wind field, especially in terms of wind speed, seems to be critical for an accurate regional air quality model and forecast. analysis suggests a 5% change in annual wind speed is associated with 10% annual surface pm concentration. in many air forecast simulations in south korea, including the current long-term simulation used in this study, modeled surface winds tend to be overestimated (2. third, most importantly, emission control efforts from the south korean government and community, as well as neighboring countries, seem to be effective. however, changes in meteorological conditions seem to offset those efforts. recent space-borne observations also confirm a considerable decrease of no 2 and so 2 vertical column densities over the sma, south korea, and northeastern china (i.e. the beijing-tianjin-hebei region) 44, 45 . in order to investigate the interannual variation of surface pm concentration in the sma, we conducted a 12-year simulation using a regional air quality modeling system. the weather research and forecasting model (wrf), the sparse matrix operator kernel emission (smoke), and the community multiscale air quality (cmaq) models were utilized to simulate meteorology and chemistry over east asia (2752 was used to prepare biogenic emissions. mcip-processed ground reaching solar radiation and 2-m temperature were used to adjust hourly biogenic emissions such as isoprene and monoterpenes. other vegetation data like leaf area index, plant function type, and emission factors were also used as released with megan v2.04. biomass burning and dust emissions were not included. the modeling configuration was tested for multiple years as part of the integrated multi-scale air quality study for korea (imaqs-k) system, which was initially developed as a prototype of the official national air quality forecast system in south korea. the imaqs-k system has been operational since 2012. descriptions on physical options are provided in kim et al. 53 , and basic model performance evaluations for 12-year period are provided in the supplementary materials. model performed well in reproducing spatial and temporal variations of meteorology and chemical components. while total particulate matter concentration generally underestimates in the model, current analysis, using percent change of inter-annual variation, is designed to be less affected by the model bias. surface monitoring data. hourly observations of surface pm concentrations and wind speed were obtained from nier and kma, respectively. pm measurements, based on the beta-ray absorption method 54 , were collected from 247 urban air monitoring network sites, and wind data were collected from 79 meteorological monitoring sites. locations of monitors are shown in the supplementary material. note on other controlling factors. (1) a recent study on the regional emission attribution to the south korea suggests that the relative attribution of foreign emission sources is not sensitive to inter-annual variation of meteorology 55 , contributing around 60% of the sma pm concentration. combined with the current declining trend of anthropogenic emissions from china, we can rule out the possibility of the increased efficiency of chinese emissions transport. (2) the number of diesel vehicles in south korea has increased 13% from 2012 to 2014. since non-truck diesel vehicles emit 5.6% of total no x emission in south korea 5 , resultant impact is small (<1% of total pm). however, careful and continuous monitoring of diesel vehicle emissions is necessary due to their high uncertainty in emissions factors as we have learned from the volkswagen emission scandal 56 . exploring the severe winter haze in beijing: the impact of synoptic weather, regional transport and heterogeneous reactions characterization of submicron aerosols during a month of serious pollution in beijing possible influence of atmospheric circulations on winter haze pollution in the beijing-tianjin-hebei region, northern china air quality modeling in east asia: present issues and future directions korean national emissions inventory system and effects of the asian dust events on daily mortality in seoul a review on east asian dust storm climate, modelling and monitoring the chemical composition of fine and coarse particles in relation with the asian dust events impact of siberian forest fires on the atmosphere over the korean peninsula during summer effects of siberian forest fires on air quality in east asia during may 2003 and its climate implication national reporting guidelines for csd-14/15 thematic areas -atmosphere/air pollution, republic of korea long-range transport of air pollutants originating in china: a possible major cause of multi-day high-pm10 episodes during cold season in seoul influence of transboundary air pollutants from china on the high-pm10 episode in seoul, korea for the period demand forecasting of diesel passenger car considering consumer preference and government regulation in south korea synoptic and mesoscale weather conditions during air pollution episodes in does weather confound or modify the association of particulate air pollution with mortality? review: untangling the influence of air-mass history in interpreting 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to the decadal-scale weakening of the east asian summer monsoon verification, validation, and confirmation of numerical models in the earth sciences co-benefit analysis of an air quality management plan and greenhouse gas reduction strategies in the seoul metropolitan area natural gas vehicles promotion program in urban areas trends in omi no2 observations over the us: effects of emission control technology and the economic recession reductions in nitrogen oxides over europe driven by environmental policy and economic recession middle east respiratory syndrome-advancing the public health and research agenda on mers-lessons from the south korea outbreak long-term trend and spatiotemporal variations of haze over china by satellite observations from 1979 to 2013 trends in cyclone and anticyclone frequency and comparison with periods of warming and cooling over the northern hemisphere multidecadal global and regional trends in 1000 mb and 500 mb cyclone frequencies trends in northern hemisphere surface cyclone frequency and intensity changes in mid-latitude variability due to increasing greenhouse gases and sulphate aerosols possible change of extratropical cyclone activity due to enhanced greenhouse gases and sulfate aerosols-study with a high-resolution agcm model-simulated northern winter cyclone and anticyclone activity under a greenhouse warming scenario increase in winter haze over eastern china in recent decades: roles of variations in meteorological parameters and anthropogenic emissions aura omi observations of regional so 2 and no 2 pollution changes from a space-based, high-resolution view of notable changes in urban no x pollution around the world a time-split nonhydrostatic atmospheric model for weather research and forecasting applications research data archive at the national center for atmospheric research review of the governing equations, computational algorithms, and other components of the models-3 community multiscale air quality (cmaq) modeling system model representation of secondary organic aerosol in cmaqv4 documentation of the saprc-99 chemical mechanism for asian emissions in 2006 for the nasa intex-b mission estimates of global terrestrial isoprene emissions using megan (model of emissions of gases and aerosols from nature) influence of fossil-fuel power plant emissions on the surface fine particulate matter in the seoul capital area measurement methods to determine compliance with ambient air quality standards for suspended particles regional contributions to particulate matter concentration in the seoul metropolitan area, korea: seasonal variation and sensitivity to meteorology and emissions inventory impact of the volkswagen emissions control defeat device on us public health h.c.k. and s.k. planned the research, s.k., c.b., m.b. performed simulations. h.c.k. wrote the paper. b.u.k., r.p. and a.s. provided discussion and comments on chemistry. c.s.k., s.h., s.w.s., and c.k.s. provided discussions and comments on meteorological aspect. supplementary information accompanies this paper at doi:10.1038/s41598-017-05092-8competing interests: the authors declare that they have no competing interests.publisher's note: springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.open access this article is licensed under a creative commons attribution 4.0 international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons license, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/. key: cord-286975-id5dn795 authors: carlitz, ruth d.; makhura, moraka n. title: life under lockdown: illustrating tradeoffs in south africa’s response to covid-19 date: 2020-08-28 journal: world dev doi: 10.1016/j.worlddev.2020.105168 sha: doc_id: 286975 cord_uid: id5dn795 this research note sheds light on the first three months of the covid-19 outbreak in south africa, where the virus has spread faster than anywhere else in the region. at the same time, south africa has been recognized globally for its swift and efficient early response. we consider the impact of this response on different segments of the population, looking at changes in mobility by province to highlight variation in the willingness and ability of different subsets of the population to comply with lockdown orders. using anonymized mobile phone data, we show that south africans in all provinces reduced their mobility substantially in response to the government’s lockdown orders. statistical regression analysis shows that such mobility reductions are significantly and negatively associated with covid-19 growth rates two weeks later. these findings add an important perspective to the emerging literature on the efficacy of shelter-in-place orders, which to date is dominated by studies of the united states. we show that people were particularly willing and able to act in the provinces hit hardest by the pandemic in its initial stages. at the same time, compliance with lockdown orders presented a greater challenge among rural populations and others with more precarious livelihoods. by reflecting on south africa’s inequality profile and results of a recent survey, we demonstrate how the country’s response may deepen preexisting divides. this cautionary tale is relevant beyond south africa, as much of the continent -and the world -grapples with similar tradeoffs. along with measures to contain the spread of disease, governments and other development focused organizations should seriously consider how to offset the costs faced by already marginalized populations. as covid-19 began its global spread, it still appeared that some world regions might be spared --in particular, sub-saharan africa (otu et al., 2020) . in short order, however, it became clear that such optimism was not merited. the virus quickly took a firm footing on the continent and as of august 7, 2020 the number of confirmed cases exceeded one million 1 --likely a significant underestimate given limited testing capacity. the virus's impact has varied considerably across the continent, reflecting countries' varying degrees of global integration and capacity to respond . one country that stands out in both regards is south africa. as seen in figure 1 , the virus has spread faster in south africa than in any of the continent's other large economies. [ figure 1 here] at the same time, south africa has been recognized globally for its swift and efficient response (kavanagh & singh, 2020) . in this research note, we illustrate how the south african government's response affected the lives of ordinary people, focusing on the initial outbreak and subsequent lockdown. first, we look at the impact of the government's strict lockdown orders on population mobility, which may be understood as a proxy for compliance. we leverage anonymized mobile phone data from google's covid-19 community mobility reports, which chart trends over time, across different categories of places such as retail and recreation, transit stations, and workplaces. we look at changes in mobility by province to highlight variation in the willingness and ability of different subsets of the population to comply with lockdown orders. we then analyze how changes in population mobility relate to the spread of disease, and conduct statistical regression analysis to show that mobility reductions are significantly and negatively associated with covid-19 growth rates two weeks later. while this suggests the lockdown measures have been effective in achieving their goals, we also reflect on how the government's response and corresponding mobility reductions interact with existing inequalities, keeping in mind the country's status as the world's most unequal nation. 2 this research note contributes to a rapidly expanding literature on covid-19's impact in the global south, and in particular to studies that demonstrate and explain variation within countries (okoi & bwawa, 2020; wenham & smith, 2020; brauer et al., 2020) . to our knowledge, ours is the first subnational analysis of population mobility in response to for south africa. 3 we also contribute an important perspective to the emerging literature on the efficacy of shelter-in-place orders, which to date has been dominated by studies of the united states. 4 finally, by discussing the tradeoffs inherent to stringent containment measures, we tell a story that resonates across the african continent and in other parts of the world where efforts to contain the spread of covid-19 may have as many or more negative consequences as the disease itself (coetzee & kagee, 2020) . this research note proceeds as follows. section 2 details south africa's efforts to contain covid-19, and compares the country's response to others on the continent. section 3 then presents our analysis of mobility trends and their relation to the growth rate of new infections. section 4 describes the nature of inequality in south africa in order to situate our results in context. section 5 concludes. the first case of covid-19 in south africa was confirmed on march 5th, 2020; subsequent cases were confirmed in the days that followed among citizens who had traveled to italy on a ski trip. while the initial cases suggested the disease might be limited to the country's affluent, cosmopolitan population, president cyril ramaphosa announced broad measures to combat the spread of covid-19 on march 15th. 5 as the timeline depicted in table 1 shows, the response accelerated quickly from there. [ table 1 here.] formal regulations were published on march 18th, promoting social distancing at one person per square meter of floor space (rsa government, 2020a). the regulations also closed schools, called for isolation of sick people, quarantining of asymptomatic people, limited gatherings to 100 people, and to 50 people at the premises where alcohol is sold and consumed. these regulations were amended on march 25th, ushering in a strict lockdown phase (rsa government, 2020b) . beginning march 27th, all businesses were to remain closed, except those involved in the production and provision of essential goods and services. 6 every person was to be confined to a place of residence unless performing essential services, obtaining essential goods or services, collecting social grants, emergency care or chronic medication attention. all places of work were to be closed except those providing essential services. movements between provinces, metropolitan areas and districts were prohibited, including commuter transport services, except when rendering essential services. the lockdown was extended on april 16th to the end of the month (rsa government, 2020c) to allow the government further time to prepare for management of the disease (karim, 2020) . revised regulations prohibited evictions from rental properties, permitted opening of refineries, and allowed mining to operate at reduced capacity. these were seen as laying the groundwork for re-opening the economy (rsa government, 2020d). at the end of april, the lockdown was relaxed to allow transition into alert level 4 beginning may 1st, 2020 (rsa government, 2020e). 7 the country transitioned to alert level 3 on june 1st (rsa government, 2020g), which provided for movements of school children across provinces and limited religious gathering to 50 people. compared to many of its neighbors on the continent, south africa's response has been swift and extensive, as shown in figure 2 . as of april 1st, 2020, south africa scored an 88 out of 100 on the "stringency index," as coded by the oxford covid-19 government response tracker . only 10 of 54 other countries on the continent were coded as having more stringent responses as of that date. [ figure 2 here.] as we show in the next section, the country's residents acted accordingly to reduce spread of the disease by dramatically reducing their mobility. this section examines how south african citizens responded to the government's strict containment measures, drawing on google's covid-19 community mobility reports. these reports are based on aggregated, anonymized data from users of google maps, and show how visits and length of stay at different places change compared to a baseline. 8, 9 we examine four categories: 1. workplaces: mobility trends for places of work. mobility trends for places like restaurants, cafes, shopping centers, theme parks, museums, libraries, and movie theaters. 3. transit stations: mobility trends for places like public transport hubs such as subway, bus, and train stations. mobility trends for places like grocery markets, food warehouses, farmers markets, specialty food shops, drug stores, and pharmacies. figure 3 shows that south africa 10 consistently "outperforms" its peers in terms of reduced mobility relative to the stringency of government response with the exception of grocery and pharmacy visits reflecting the exemption of such businesses from the lockdown order. [ figure 3 here.] the national average reduction in mobility masks considerable variation within the country. figure 4 illustrates mobility trends by province 11 in terms of retail and recreation from february 14-may 15, 2020. 12 although the provinces exhibit differences, in each case we can observe a substantial dip corresponding to the beginning of the strict lockdown period. table 2 depicts the overall average percent change in mobility reductions during the most stringent lockdown period (27 march-30 april 2020) by provinces for the different categories. [ table 2 here.] western cape registers the largest average decrease in mobility for all categories. on the other side, limpopo registers the smallest decline in retail/recreation; mpumalanga the smallest declines in grocery/pharmacy and transit station visits; and northern cape the smallest declines in workplace visits and smallest increase in residential mobility. we also calculate the average mobility reduction for the three most highly correlated categories: retail/recreation, workplace mobility, and transit stations (see correlation matrix in appendix table a4 ). this is depicted graphically in figure 5 . [ figure 5 here.] in order to account for variation in mobility trends across provinces, we consider a number of economic and demographic factors. we also consider each province's caseload (number of confirmed cases) at the beginning of the lockdown period. these features are summarized in table 3 . [ table 3 here.] we use qualitative comparative analysis (qca) to identify the features shared by the provinces experiencing the greatest mobility reductions. 13 our analysis suggests that the main factors associated with substantial mobility reductions are the number of confirmed cases prior to the lockdown period and the relative size of the provincial economy. the provinces containing south african's metropolitan hubs --gauteng (containing johannesburg) and western cape (containing cape town) also tended to experience larger mobility reductions. this may reflect the challenge of reducing mobility in rural areas among populations that are more likely to be food insecure (tibesigwa and visser, 2016) . emerging research on the determinants of compliance with social distancing and other measures suggests that concerns about income losses play an important role in determining compliance (wright et al., 2020; bodas and peleg, 2020) . in contrast to the united states, where partisanship has been shown to be a key determinant of mobility reductions and other efforts to contain the spread of disease (grossman et al., 2020; adolph et al., 2020) , party politics do not seem to feature prominently when it comes to explaining variation in mobility in south africa. both gauteng (controlled by the ruling african national congress party) and western cape (the only province held by the main opposition party, the democratic alliance) exhibit similar trends when it comes to mobility reductions. that said, such unity appears to be waning. for example, the democratic alliance filed a legal challenge against some coronavirus lockdown rules in mid-may (democratic alliance, 2020). the economic freedom fighters (the second largest opposition party) subsequently issued a statement calling for prolonged stringent lockdown (economic freedom fighters, 2020). south africa's strict lockdown policies --and corresponding reductions in mobility by the country's citizens --were put in place with the aim of reducing the spread of covid-19. this leads us to ask: how effective have they been? before we attempt to answer this question, we first present the trajectory of disease by province in figure 6 up until may 24th, 2020. although the first cases were confirmed in kwazulu-natal, the figure indicates how the disease has taken hold primarily in western cape. 14 [ figure 6 here.] in order to determine how the spread of disease has changed as a consequence of the mobility reductions discussed above, we estimate a series of regression models with average weekly exponential growth in confirmed cases as the dependent variable. 15 the independent variables are average weekly mobility reductions for each of the three main categories discussed above (workplace, retail/recreation, and transit stations) for the preceding two weeks. 16 all models include province fixed effects and standard errors clustered by province. we also include a time trend to account for any other factors changing over time within each province. the results, depicted in table 4 , suggest that people's mobility reductions have indeed helped to play an important role in reducing the rate of new infections. however, as we discuss in the next section, the benefits and costs of lockdown are unlikely to be distributed equally. [ table 4 here.] as noted above, south africa bears the unflattering distinction of the world's most unequal nation in terms of income inequality. furthermore, the nature of inequality in south africa extends beyond economic well-being (leibbrandt et al., 2012; tibesigwa and visser, 2016) . we 3. inequality in the social domain: whereas access to basic education is high and fairly even across the country, access to health care is characterized by greater inequality. more than 80% of black africans use public health facilities and fewer than 20% use private health facilities. there are considerable differences in access to private medical care across provinces, with limpopo reporting private coverage at less than 10%, whereas gauteng and western cape reported rates of 25.0% and 24.8% in 2017, respectively. 4. gender inequality: women were less likely to participate in the formal labor market as compared to men and also experienced higher unemployment (29.6%) compared to men (25.7%) in 2017. gender inequality is also observable in food security (tibesigwa and visser, 2016) . this multidimensional view of inequality is important to keep in mind when it comes to identifying tradeoffs associated with the country's response to covid-19. the dramatic reductions in population mobility documented above have come at a cost for many households, particularly those who are no longer able to work. income from the labor market has been the main source of household income in south africa, accounting for over 70% of overall income (statistics south africa, 2019). fears of losing such income can reduce compliance with measures to mitigate the spread of covid-19, especially in low income areas (wright et al. 2020; coetzee and kagee, 2020) . a web-based survey 18 conducted between april 29th -may 6th 2020 (statistics south africa, 2020b) paints a picture of the pandemic's impact on employment, income, and hunger, highlighting the potential for deepening inequality. while 60.2% of the respondents were employed on a permanent basis during the national lockdown, just under 2.0% lost their jobs and 5.2% had to close their businesses. further, while 89.5% of those who were employed before the national lockdown remained employed during this period, 8.1% lost their jobs or had to close their businesses, 1.4% became unemployed and 0.5% were out of the labor force. for those who stayed employed during the lockdown, 21.3% indicated reduced income. given the voluntary, web-based nature of the survey, these and other estimates are likely significant underestimates. 19 the survey also showed that while a majority (75.4%) of respondents who had businesses before national lockdown were white, among black africans and the coloured population, the share among those who had to close businesses were larger than their share of business ownership (19.9% vs. 14.6% and 6.4% vs. 4.6% respectively). while social grants and remittances have played a crucial role in reducing income inequality over the years in south africa, the survey shows other coping strategies. for example, 74.9% of respondents reduced their spending to compensate for the loss of income, while about half of respondents had to access their savings to close the income gap. some respondents (36.8%) relied on extended family members, friends and/or their communities for support, while 14.6% relied on claims from the unemployment insurance fund. disaggregated analysis of these claims is not yet possible but would shed further light on the extent to which lockdown has furthered pre-existing inequalities. as noted above, the more rural provinces and black africans on average have tended to lag further behind in access to basic services (statistics south africa, 2019). the covid-19 pandemic appears to have further deepened these inequalities. the survey shows that the majority of those able to work from home are in suburban areas (88%). in contrast, just 5.4% of township residents reported being able to work from home, followed by just 3.9% of those residing on farms and 0.9% of respondents in rural areas. the survey also revealed considerable food insecurity and income losses. since the start of lockdown, the proportion of respondents who reported experiencing hunger increased from 4.3% to 7.0%. the percentage of respondents who reported no income increased from 5.2% to 15.4% by the sixth week of lockdown. again, these figures are likely significant underestimates. notably, the government of south africa has provided a number of relief measures, including the release of disaster relief funds, emergency procurement, wage support through the unemployment insurance fund, and funding to small businesses. on april 21, 2020, the president announced a massive social relief and economic support package of r500 billion ($30,50 billion), amounting to around 10% of gdp (rsa government, 2020h) . this was complemented by the south african reserve bank easing monetary policy with reduced interest rates (sarb, 2020) and subsequent loan of about $4.5 billion from imf (rsa government, 2020i). these resources have been deployed to prepare health infrastructure, provide food and income support, and provide financial relief to businesses and individuals. the effectiveness and efficiency of such efforts are still yet to be determined. this research note paints a picture of life under lockdown in south africa, the world's most unequal nation. we present evidence of swift and effective action by the government -mirrored in substantial reductions in mobility among the population. people were particularly willing and able to act in the provinces hit hardest by the pandemic in its initial stages (gauteng and western cape). at the same time, compliance with lockdown orders presents a greater challenge among rural populations and others with more precarious livelihoods. by reflecting on south africa's inequality profile and results of a recent survey conducted during lockdown, we demonstrate how south africa's response may deepen preexisting divides. this cautionary tale is relevant beyond the country's borders, as much of the continent --and the world --contemplates similar tradeoffs. along with measures to contain the spread of disease, governments and other development focused organizations should seriously consider how to offset the costs faced by already marginalized populations. data from european centre for disease prevention and control (ecdc) in roser et al. (2020) . data from oxford covid-19 government response tracker . -0.14 *** -0.14 *** (0.03) (0.03) l14.average weekly reduction in mobility (retail/recreation) -0.14 *** -0.12 *** we supplement our analysis of the google covid-19 community mobility reports with mobility trends reports published by apple maps (https://www.apple.com/covid19/mobility). these reports present data on the relative volume of directions requests per country/region, subregion or city compared to a baseline volume on january 13th, 2020. higher proportions indicate smaller mobility reductions. in addition to being available at the country and province level, these reports are available for the cities of johannesburg and cape town, allowing us to compare trends in these cities to the greater provinces. note that these reports are available for both driving and walking for the two cities and south africa as a whole; and for driving only at the greater province level. figure a1 depicts city/province comparisons for driving trends over the same period considered in the manuscript (february 14-may 15, 2020; see figure 4 ). we see that the city-level trends appear to mirror the province-level trends. in order to confirm this and relate to the analysis presented in the paper, we also calculate average mobility reductions for the most stringent lockdown period (27 march-30 april 2020). these are depicted in table a2 below. as with our analysis of the google mobility reports, western cape and gauteng exhibit the largest mobility reduction (fewer directions requests compared to baseline, suggesting people are moving around less), and limpopo and mpumalanga province the smallest (a higher proportion of directions requests in comparison to the baseline, indicating less of a change in mobility). we also see that the city-level mobility changes mirror the province level for cape town/western cape and johannesburg/gauteng, confirming the results suggested by the figures above. it is notable that in cape town, driving requests and walking requests are on par with each other whereas in johannesburg the lockdown appeared to have a greater impact on people's driving habits compared to walking. this may be due to the fact that cape town and western cape are mostly tourist areas and thus when the lockdown instructions and impact of the disease set in, both driving and walking habits were similarly affected. on the other hand, the driving and walking populations of johannesburg and gauteng tend to be distinct. most of the drivers are wealthier, while the walkers tend to be poorer. when the lockdown instructions set in, it was easier to enforce compliance with driving (using the existing traffic enforcement framework), while it was more difficult to enforce walking restrictions (due to the lack of a coherent enforcement framework and insufficient resources). all figures in this section depict mobility trends from february 14-may 16, 2020, using data from google mobility reports in order to conduct crisp qualitative comparative analysis (qca) we begin by creating sets -dichotomizing the variables of interest to designate membership within a given set. the sets are defined as follows: • m = large average mobility decrease (defined alternatively as provinces in the top quintile of the distribution and provinces in the top two quintiles) • i = 100 or more confirmed infections as at march 26, 2020 (start of lockdown) • d = densely populated provinces, i.e. those with an average of 100 people or more per km sq. • g = provinces whose contribution to national gdp is greater than 10% • p = provinces with a multidimensional poverty rate greater than 10% • a = provinces with a proportion of agricultural households exceeding 25% we have reproduced a crisp set version of the relevant data in table a2 as a data matrix. we see that for either definition of m, the set also contains members of i and g --that is, provinces with at least 100 confirmed cases pre-lockdown and those that contribute significantly to national gdp. the dependent variable is the average weekly reduction in mobility to workplaces, retail and recreation, and transit stations. all models include province fixed effects and robust standard errors clustered by province. * p < 0.10, ** p < 0.05, *** p < 0.01 figure a5 . confirmed cases by province, march 1-may 24, 2020 (excluding western cape) pandemic politics: timing state-level social distancing responses to covid-19 self-isolation compliance in the covid-19 era influenced by compensation: findings from a recent survey in israel: a cross sectional study of the adult population of israel to assess public attitudes toward the covid-19 outbreak and self-isolation global access to handwashing: implications for covid-19 control in low-income countries structural barriers to adhering to health behaviours in the context of the covid-19 crisis: considerations for low-and middle strong social distancing measures in the united states reduced the covid-19 growth rate: study evaluates the impact of social distancing measures on the growth rate of confirmed covid-19 cases across the united states shaking stability: covid-19 impact on the visegrad group countries' financial markets economic freedom fighters statement on the covid-19 developments preparedness and vulnerability of african countries against importations of covid-19: a modelling study political partisanship influences behavioral responses to governors' recommendations for covid-19 prevention in the united states blavatnik school of government. data use policy: creative commons attribution cc by standard state of the ict sector report #listentotheexperts is south africa's epidemic trajectory unusual? professor salim abdool karim democracy, capacity, and coercion in pandemic response-covid 19 in comparative political perspective describing and decomposing post-apartheid income inequality in south africa modelling the potential impact of social distancing on the covid-19 epidemic in south africa how health inequality affect responses to the covid-19 pandemic in sub-saharan africa tackling covid-19: can the african continent play the long game coronavirus pandemic (covid-19 regulations issued in terms of section 27(2) of the disaster management act disaster management act 2002: amendment of regulations issues in terms of section 27(2). (government gazette disaster management act 2002: amendment of regulations issues in terms of section 27(2). (government gazette disaster management act 2002: amendment of regulations issues in terms of section 27(2). (government gazette disaster management act 2002: amendment of regulations issues in terms of section 27(2). (government gazette disaster management act 2002: amendment of regulations issues in terms of section 27(2). (government gazette president cyril ramaphosa: additional coronavirus covid-19 economic and social relief measures social distancing to slow the us covid-19 epidemic: an interrupted time-series analysis south african reserve bank (sarb) inequality trends in south africa: a multidimensional diagnostic of inequality quarterly labor force survey results from wave 2 survey on the impact of the covid-19 pandemic on employment and income in south africa assessing gender inequality in food security among smallholder farm households in urban and rural south africa discovery 20200305 first case of covid-19 confirmed in kwazulu natal province 20200307 second case of covid-19 confirmed in kwazulu natal province 20200311 first case of covid-19 confirmed in western cape province 20200312 first case of local transmission confirmed in free state province early response 20200315 president announces measures to combat covid-19 20200316 government declares state of national disaster 20200316 ports of entry closed (namibia testing capacity increased with 60 new mobile lab units launched 20200408 critical personal protective equipment secured for frontline healthcare workers 20200409 lockdown extended until end of april (with 7 days travel grace across provinces for relocation) 20200418 government postpones may/june exam rewrites 20200420 president announces interventions to address livelihoods of the vulnerable groups 20200421 president outlines expanded covid-19 economic & social relief 20200421 government recommends wearing of a cloth non-medical face-mask when in public 20200423 president announces risk-adjusted strategy to respond to covid-19 pandemic oxford covid-19 government response tracker, blavatnik school of government census 2011 agricultural households key highlights mid-year population estimates estimate as of august 10, 2020 from the european centre for disease prevention and control (ecdc) cited in roser et al according to the world bank's world development indicators, south africa's gini index is 63/100, the highest in the world according to available data the paper that bears the most similarity to ours is nyabadza et al. (2020), which models the impact of social distancing on the transmission dynamics of covid-19 in south africa these included travel restrictions, encouraging social distancing, limiting contact between persons who may be infected, and working to strengthen the public health response the prohibitions included the sale, dispensing, or transportation of alcohol the government has devised five coronavirus alert levels, in line with a risk-adjusted strategy that seeks to slow down the rate of infection and flatten the curve. level 5 entails "drastic measures are required to contain the spread of the virus to save lives further details about these reports and other data sources analyzed in this research not can be found in table a1 in the appendix according to the world bank's world development indicators, the country had 159.9 mobile cellular subscriptions per 100 people we are very grateful to clara tomé for excellent research assistance and to the organizers of the 2019 sustainability and development conference, which led to the authors' meeting and inspired our collaboration on this article. 1. we analyze subnational variation in population mobility as a response to covid-19 in south africa.2. we leverage anonymized mobile phone data to capture mobility reductions across provinces.3. people tend to reduce mobility substantially in response to government's initial lockdown orders.4. mobility reductions are significantly and negatively associated with covid-19 growth rates. 5. we illustrate how the government's response and corresponding mobility reductions can exacerbate existing inequalities. 10 south africa is labeled by its 3-letter country code, "zaf." 11 the province is the lowest level at which comparable data on mobility trends is available. we supplemented our analysis with data from the mobility trends reports published by apple maps (https://www.apple.com/covid19/mobility), which allow us to compare trends for cape town and johannesburg with the surrounding provinces. as shown in the appendix, this analysis depicts largely similar trends to those captured by the google reports. 12 additional province-level comparison charts are shown in the appendix. 13 this process is described in detail in the appendix.14 an alternative version of this figure, excluding western cape, is presented in the appendix for better visualization of the other provinces. 15 we first calculate the daily exponential growth rate and then take the weekly average. daily exponential growth is calculated as the natural log of cumulative confirmed cases minus the log of cumulative confirmed cases on the prior day. as in other recent studies ), we use this functional form because epidemiological models predict exponential growth in the absence of intervention. in computing exponential growth, we follow recent studies and add one for province-dates with zero cases to avoid dropping observations. 16 we take weekly averages given fluctuations in mobility, e.g. in workplace trends where the average reduction in mobility is considerably lower on weekends when people are typically less likely to go to their workplaces. 17 this section draws heavily on a recent report profiling trends since 1994 conducted by the country's statistical agency (statistics south africa, 2019). 18 the survey drew on a non-probability, convenience sample of 2,688 south african residents. 19 the most recent afrobarometer survey, conducted between august-september 2018, indicates that nearly 50% of all rural residents in south africa never use the internet compared to 29.5% of urban residents (http://afrobarometer.org/online-data-analysis/analyse-online). key: cord-256004-rqdeac7h authors: wilcox, elizabeth s.; chimedza, ida tsitsi; mabhele, simphiwe; romao, paulo; spiegel, jerry m.; zungu, muzimkhulu; yassi, annalee title: empowering health workers to protect their own health: a study of enabling factors and barriers to implementing healthwise in mozambique, south africa, and zimbabwe date: 2020-06-23 journal: int j environ res public health doi: 10.3390/ijerph17124519 sha: doc_id: 256004 cord_uid: rqdeac7h ways to address the increasing global health workforce shortage include improving the occupational health and safety of health workers, particularly those in high-risk, low-resource settings. the world health organization and international labour organization designed healthwise, a quality improvement tool to help health workers identify workplace hazards to find and apply low-cost solutions. however, its implementation had never been systematically evaluated. we, therefore, studied the implementation of healthwise in seven hospitals in three countries: mozambique, south africa, and zimbabwe. through a multiple-case study and thematic analysis of data collected primarily from focus group discussions and questionnaires, we examined the enabling factors and barriers to the implementation of healthwise by applying the integrated promoting action on research implementation in health services (i-parihs) framework. enabling factors included the willingness of workers to engage in the implementation, diverse teams that championed the process, and supportive senior leadership. barriers included lack of clarity about how to use healthwise, insufficient funds, stretched human resources, older buildings, and lack of incident reporting infrastructure. overall, successful implementation of healthwise required dedicated local team members who helped facilitate the process by adapting healthwise to the workers’ occupational health and safety (ohs) knowledge and skill levels and the cultures and needs of their hospitals, cutting across all constructs of the i-parihs framework. health workers (hws) are in short supply worldwide. it is estimated that by 2030, the global health workforce will be short approximately 18 million workers, primarily in low-and middle-income countries (lmics) [1] . in high-risk settings, where disease prevalence is high and health systems are stretched to provide basic health services, hws are at an elevated risk of contracting infectious diseases such as hepatitis, human immunodeficiency virus (hiv), tuberculosis (tb), and novel emerging threats from occupational exposure, including covid-19. they also suffer stigma and discrimination at work, in their communities, and at home from bearing these increased risks. effective coverage by the health workforce depends on availability, accessibility, acceptability, and quality of hws [2] . one of the top three factors reducing supply, along with migration and retirement, is the "risk of violence, illness or death" [3] . strategies to address the hw shortage ought to therefore include protecting hws by promoting their health and safety at work, particularly in high-risk settings. international organizations have developed tools to improve the occupational health and safety (ohs) of hws. one of these is healthwise, a participatory, quality improvement tool, jointly developed by the international labour organization (ilo) and the world health organization (who) [4] . in 2010, a tripartite group consisting of workers', employers', and governments' representatives, as well as specialists from the ilo and who, convened and agreed on a framework for improving the ohs of hws. based on principles from the original work improvement in small enterprises (wise) training program created by the ilo, healthwise was then developed to help support the implementation of this framework [4] . healthwise aims to improve working conditions, performance, and workplace safety through training and empowering hws with the ability to identify workplace hazards and areas requiring improvement in their work environments and to conduct processes for developing and implementing low-cost solutions to address them. healthwise consists of two workbooks, one for participants and one for trainers, with content organized into eight modules (figure 1 ). the workbooks are available online in five languages. as with addressing the supply of hws, the availability of the tool is only part of the solution. it is also important to understand the implementation of healthwise and to improve upon implementation processes to maximize the tool's potential. novel emerging threats from occupational exposure, including covid-19. they also suffer stigma and discrimination at work, in their communities, and at home from bearing these increased risks. effective coverage by the health workforce depends on availability, accessibility, acceptability, and quality of hws [2] . one of the top three factors reducing supply, along with migration and retirement, is the "risk of violence, illness or death" [3] . strategies to address the hw shortage ought to therefore include protecting hws by promoting their health and safety at work, particularly in high-risk settings. international organizations have developed tools to improve the occupational health and safety (ohs) of hws. one of these is healthwise, a participatory, quality improvement tool, jointly developed by the international labour organization (ilo) and the world health organization (who) [4] . in 2010, a tripartite group consisting of workers', employers', and governments' representatives, as well as specialists from the ilo and who, convened and agreed on a framework for improving the ohs of hws. based on principles from the original work improvement in small enterprises (wise) training program created by the ilo, healthwise was then developed to help support the implementation of this framework [4] . healthwise aims to improve working conditions, performance, and workplace safety through training and empowering hws with the ability to identify workplace hazards and areas requiring improvement in their work environments and to conduct processes for developing and implementing low-cost solutions to address them. healthwise consists of two workbooks, one for participants and one for trainers, with content organized into eight modules ( figure 1 ). the workbooks are available online in five languages. as with addressing the supply of hws, the availability of the tool is only part of the solution. it is also important to understand the implementation of healthwise and to improve upon implementation processes to maximize the tool's potential. implementation science is growing in the field of global health. madon and colleagues [5] called on researchers to (i) "develop theoretical models and new analytic methods that apply to resource poor settings" such as areas where hws are in short supply, (ii) build capacity and strengthen research institutions in lmics in regard to implementation science, in part to learn from valuable local knowledge and insights that influence implementation processes, and (iii) increase collaboration with governments, non-governmental organizations, and communities to incorporate research into implementation processes in order to improve upon them. implementation science is growing in the field of global health. madon and colleagues [5] called on researchers to (i) "develop theoretical models and new analytic methods that apply to resource poor settings" such as areas where hws are in short supply, (ii) build capacity and strengthen research institutions in lmics in regard to implementation science, in part to learn from valuable local knowledge and insights that influence implementation processes, and (iii) increase collaboration with governments, non-governmental organizations, and communities to incorporate research into implementation processes in order to improve upon them. this paper overviews the implementation of three healthwise modules in seven hospitals (designated the letters a through g) in mozambique, south africa, and zimbabwe. using the integrated promoting action on research implementation in health services (i-parihs) framework (described in "research methods" below), it aims to better understand the enabling factors and barriers to the implementation of healthwise in these hospitals and, considering previous implementation science research, to discuss how these might be leveraged or overcome in future implementations of healthwise. an existing north south partnership involving researchers and technical teams from canada and south africa [6] was expanded to include team members from mozambique and zimbabwe due to plans and interest to implement healthwise in those countries. this enabled a comparison of its implementation in different contexts. the three countries are in close proximity in the southern african region and represent high-risk settings where the ohs of hws is at different stages and resource levels and has yet to be fully given the importance that it is due. according to 2018 world bank classifications based on gross national income (gni) per capita, mozambique is a low-income country (gni per capita of us$460), south africa an upper-middle-income country (gni per capita of us$5750), and zimbabwe a lower-middle-income country (gni per capita of us$1790) [7] . total health expenditures per capita (and as a percentage of gross domestic product) from 2017 reflect this trend, with mozambique spending us$21.07 (4.94%), south africa us$499.24 (8.11%), and zimbabwe us$110.15 (6.64%) [8] . mozambique, south africa, and zimbabwe are amongst 30 high burden countries with regard to tb, tb and hiv co-infection, and multi-drug resistant tb [9] . in 2018, the incidence of tb per 100,000 people was 551 in mozambique, 520 in south africa, and 210 in zimbabwe. the total prevalence of hiv among their populations aged 15-49 was 12.6% in mozambique, 20.4% in south africa, and 12.7% in zimbabwe [8] . a planning meeting with representation from all countries was held in zimbabwe in february 2016. at this meeting, it was decided that the focus would be restricted to specific, related priority areas: biological hazards and infection control (module 3) and discrimination, harassment, and violence (module 4). over the following eight months, local team leads sought any necessary local, provincial, and national approvals and selected hospitals in which to implement healthwise. a total of seven hospitals participated: three in mozambique, two in south africa, and two in zimbabwe. implementation refers to the ensuing activities, including the introduction of healthwise, by training groups of hws at participating hospitals and the activities carried out by participants from this point through to the final capstone meeting. observation focused on if and how participants used healthwise in their hospitals and included the activities conducted by research team members, such as focus groups and questionnaires, to inquire into the enabling factors and barriers to its uptake and resultant activities. implementation was observed over 20 months, beginning with three training-of-trainers (tot) workshops (one per country) in october and november 2016. the three-day program was developed and carried out by local team members. in brief, the focus of day 1 was on introducing healthwise and modules 1 and 3. the focus of day 2 was on module 4. day 3 was devoted to developing healthwise action plans (activities to be carried out by trainees in their health facilities). throughout, participatory training techniques, including role plays and an interactive exercise on the topic of stigma [10] , were demonstrated, which might be useful for participants to help engage workers and disseminate new information in their workplaces. following the training, participants were expected to create healthwise teams and based on the healthwise principle of finding simple, low-cost solutions to workplace issues within their local contexts, carry out healthwise activities in their hospitals. based on budgets determined by the action plans, a small amount of project funds was made available for healthwise activities. additional practical training sessions were held in mozambique in july 2017 and in zimbabwe in february 2018. the healthwise teams trained during the tot workshops conducted walk-through assessments with the lay hws in one or more departments, helping to identify hazards and how they might be mitigated with low-or no-cost solutions. one year after the tot workshops, six follow-up workshops were held (one per hospital, with hospitals a and c in mozambique combined). during these workshops, participants presented on healthwise activities that had taken place in their facilities to date and participated in focus groups on the perceived enabling factors and barriers to implementing healthwise. participants were asked to individually brainstorm their own lists of enabling factors and barriers and to then read these out one-by-one and explain them to the group. questions and discussion were encouraged. participants in mozambique and south africa also completed an anonymous questionnaire. due to resource constraints within the hospitals, these questionnaires were unable to be administered in zimbabwe. shortly after the follow-up workshops, one representative from each hospital from all three countries attended a dissemination meeting in south africa to present on their progress implementing healthwise. the research focus of the project culminated in a final meeting in may 2018 in zimbabwe ( figure 2 ). one representative from each hospital presented on healthwise activities that had taken place to date and provided feedback on the implementation process and preliminary findings from the research. available for healthwise activities. additional practical training sessions were held in mozambique in july 2017 and in zimbabwe in february 2018. the healthwise teams trained during the tot workshops conducted walk-through assessments with the lay hws in one or more departments, helping to identify hazards and how they might be mitigated with low-or no-cost solutions. one year after the tot workshops, six follow-up workshops were held (one per hospital, with hospitals a and c in mozambique combined). during these workshops, participants presented on healthwise activities that had taken place in their facilities to date and participated in focus groups on the perceived enabling factors and barriers to implementing healthwise. participants were asked to individually brainstorm their own lists of enabling factors and barriers and to then read these out one-by-one and explain them to the group. questions and discussion were encouraged. participants in mozambique and south africa also completed an anonymous questionnaire. due to resource constraints within the hospitals, these questionnaires were unable to be administered in zimbabwe. shortly after the follow-up workshops, one representative from each hospital from all three countries attended a dissemination meeting in south africa to present on their progress implementing healthwise. the research focus of the project culminated in a final meeting in may 2018 in zimbabwe. one representative from each hospital presented on healthwise activities that had taken place to date and provided feedback on the implementation process and preliminary findings from the research. a multiple-case study, in which each hospital was treated as a single case, was used to examine the enabling factors and barriers to the implementation of healthwise [11] . within the case study, thematic analysis, "a method for identifying, analysing and reporting patterns (themes) within data", was used [12] . the integrated promoting action on research implementation in health services (i-parihs) framework was employed in this study [13] . the i-parihs framework was published in 2016, based on an earlier iteration from 1998 [14] and continues to be developed and refined. the framework describes four constructs related to implementation: (i) the 'innovation', or new knowledge informed by evidence-based research, that is being introduced; (ii) the 'recipients', or the individuals and teams who are involved in or affected by the implementation; (iii) the 'context', referring to three levels of local, organizational, and external health system settings in which the innovation is being implemented; and (iv) 'facilitation', or the strategies and actions performed by the facilitator(s) to enable implementation in response to the innovation and its recipients within their given context. the earlier version was classified as an explanatory framework that specified the relationship between the constructs [15] and while the integrated version maintains these linkages, the i-parihs framework is also descriptive as it breaks-down the constructs to further describe characteristics important to implementation. descriptive and explanatory frameworks are used to understand factors that might have positively or negatively influenced implementation processes [16] and given a multiple-case study, in which each hospital was treated as a single case, was used to examine the enabling factors and barriers to the implementation of healthwise [11] . within the case study, thematic analysis, "a method for identifying, analysing and reporting patterns (themes) within data", was used [12] . the integrated promoting action on research implementation in health services (i-parihs) framework was employed in this study [13] . the i-parihs framework was published in 2016, based on an earlier iteration from 1998 [14] and continues to be developed and refined. the framework describes four constructs related to implementation: (i) the 'innovation', or new knowledge informed by evidence-based research, that is being introduced; (ii) the 'recipients', or the individuals and teams who are involved in or affected by the implementation; (iii) the 'context', referring to three levels of local, organizational, and external health system settings in which the innovation is being implemented; and (iv) 'facilitation', or the strategies and actions performed by the facilitator(s) to enable implementation in response to the innovation and its recipients within their given context. the earlier version was classified as an explanatory framework that specified the relationship between the constructs [15] and while the integrated version maintains these linkages, the i-parihs framework is also descriptive as it breaks-down the constructs to further describe characteristics important to implementation. descriptive and explanatory frameworks are used to understand factors that might have positively or negatively influenced implementation processes [16] and given its continuing evolution, the i-parihs framework was chosen to explore the implementation of healthwise. it ought to be noted that several tools have been developed based on the original parihs framework to more thoroughly assess the context construct, including the context assessment for community health (coach) tool, specifically for use in lmics [17] . while the dimensions described therein were considered during this analysis, they are captured in the more recent i-parihs framework and the characteristics of the latter were therefore used. data were drawn from dissemination and capstone meeting presentations (powerpoint presentations), focus group transcripts (word documents generated from audio-recordings), and open-ended responses to completed anonymous questionnaires (paper and electronic pdf copies). using an inductive approach, three focus group transcripts, one from each country, were first open coded to generate a list of enabling factors and barriers. these codes were then compared and categorized according to the i-parihs constructs and characteristics to generate a draft codebook. the remaining three focus group transcripts were then coded using the draft codebook. some characteristics were subsequently removed or combined to refine the constructs and characteristics to those listed in tables 2-5 , which are the themes and sub-themes for the final codebook. using this codebook, all data were coded using nvivo 12 and excel to better understand the enabling factors and barriers to the implementation of healthwise. this study was approved by the behavioural research ethics board, university of british columbia, canada (h17-00286, h17-00039), the research ethics committee, university of pretoria, south africa (159/2017), and the medical research council of zimbabwe, zimbabwe (mrcz/a/2240). participants who were involved in the follow-up workshop focus groups, questionnaires, and dissemination and capstone meetings were provided with written information about the research objectives and processes prior to their involvement and individual informed consent was obtained. participation was voluntary and individuals were informed of their right to withdraw from the study at any time. all data was collected anonymously or de-identified before analysis to protect confidentiality. the seven participating hospitals ranged in size from 36 to 1652 beds and from approximately 139 to 4407 workers. in all hospitals, the workers were predominantly female. characteristics of the seven hospitals are presented in table 1 . results for the four constructs-innovation, recipients, context, and facilitation-are presented below, with quotes that help to reflect what was an enabling factor or barrier in the implementation of healthwise in each of the participating hospitals in mozambique, south africa, and zimbabwe. it is important to note that not all constructs or characteristics were explicitly mentioned by participants at each of the hospitals. this absence does not necessarily mean that a specific characteristic was or was not an enabling factor or barrier; while this could be the case, it could instead indicate that further questioning on specific characteristics of interest may be warranted in future studies. where a characteristic is designated as both an enabling factor and barrier (ef/b) within the tables, further information on how the implementation of healthwise was helped or hindered is provided in the ensuing description. the innovation construct included characteristics related to healthwise, the intervention being implemented. three of the seven characteristics of the innovation construct from the i-parihs framework were mentioned; whether they were enabling factors and/or barriers in each of the hospitals is shown in table 2 . table 2 . innovation construct characteristics and whether they were enabling factors (ef) and/or barriers (b) to the implementation of healthwise in each participating hospital (a-g). "clarity" about healthwise-what the tool was and why and how it was going to be used-was a key enabling factor in nearly all of the hospitals: "when personnel have been trained and they know . . . what is expected of them and what is going to be done, they are more cooperative than when they do not know" (hospital e, focus group). the "relative advantage" of healthwise-how it would be of benefit compared with existing interventions-particularly that the tool aimed to benefit workers and their working environment (as opposed to being focused solely on patients), helped to spur the implementation of healthwise in one hospital in mozambique and one hospital in south africa where the "anticipated positive results/effects of [the] healthwise project" (hospital d; capstone meeting) were an enabling factor. "observable results" were also mentioned as enabling the implementation of healthwise by one hospital in each country. in opposition, one barrier of the innovation construct, mentioned by all the hospitals in mozambique, was a lack of clarity or "lack of knowledge about exactly what to do" (hospital a, questionnaire). for some hospitals, there was also an inability to raise awareness about healthwise among hospital staff: "...we did not have much time to publicize this project to colleagues to understand what it was all about" (hospital b, focus group). one hospital in south africa echoed this lack of clarity and awareness, as represented by one comment of "supervisors not understanding the project" (hospital e, questionnaire). the recipients construct included characteristics related to the individuals and teams involved in, or affected by, the implementation of healthwise. the 11 characteristics of the recipients construct and whether they were enabling factors and/ or barriers in each of the hospitals are shown in table 3 . the "time, resources, support" characteristic from the i-parihs framework was split into four: "project funding", "human resources", "material resources", and "personal protective equipment (ppe)" to better capture their different impacts on the implementation of healthwise. two characteristics from the i-parihs framework, "values and beliefs" and "presence of boundaries", did not emerge during this analysis. table 3 . recipient construct characteristics and whether they were enabling factors (ef) and/or barriers (b) to the implementation of healthwise in each participating hospital (a-g). "motivation", or the "willingness of staff to participate in healthwise activities" (hospital c, capstone meeting), was mentioned as an enabling factor by hospitals c and f, where workers "showed much interest in this program" (hospital f, focus group). a lack of external incentives was mentioned as a barrier by both zimbabwe hospitals f and g, where "there is in most cases lack of incentives for trainers to keep their motivation high" (hospital f, dissemination meeting). lack of clear "goals and expectations" related to the implementation of healthwise was mentioned as a barrier by the three mozambique hospitals a, b, and c, where there was "difficulty of perception of some professionals about the objectives of the project" (hospital b, dissemination and capstone meetings) as well as "failure to comply with agreed deadlines" (hospital a, dissemination meeting). on the other hand, having clear "goals and expectations" was an enabling factor for both hospitals d and e in south africa and for hospital g in zimbabwe. goals came in different forms, such as an "attainable objective that was set by the team member" (hospital d, focus group), as well as "an action plan that served as our guiding point of reference" (hospital e, focus group). individual "skills and knowledge" related to ohs was both an enabling factor and barrier mentioned by hospitals a, b, and c in mozambique, depending on whether recipients were perceived as having or lacking ohs knowledge. there was some overlap with the culture characteristic in the context construct, which was discussed to a greater extent in zimbabwe and south africa. lack of "project funding" was mentioned as a barrier by all but one hospital in mozambique. "lack of resources for implementation" (hospital a, dissemination meeting), "financial constraint" (hospital e, questionnaire), and "lack of funding for full implementation of healthwise" (hospital f, capstone meeting) were some of the ways that this barrier was mentioned. since this initially proved to be a major constraint, it was addressed by local team members in all three countries through communication and practical training sessions that helped to redirect workers towards no-cost solutions. for example, a patient consultation room was rearranged to improve ventilation and reduce the risk of workers being exposed to airborne pathogens and, in the same area, ripped flooring that created a fall hazard was cut out and removed, as opposed to being replaced with new flooring (figure 3 ). workers involved in the practical training sessions expressed that "the search for solving problems that do not require financing was a great gain" (hospital a, focus group). where funding for larger project activities was available, it was an enabling factor. hospital c in mozambique was able to draw from external funding sources to begin construction of a new tb consultation and testing unit and laboratory when the old infrastructure was identified as a hazard by the healthwise team. one hospital in zimbabwe, which used project funds to purchase some equipment for their training sessions, indicated that the "allocation of funds" (hospital f, dissemination meeting) was an enabling factor to implementation in their hospital. "human resources" were a barrier mentioned by all hospitals except a and c in mozambique. all hospitals seemed to experience some degree of staff shortages, "when the departments are so shortstaffed, they are reluctant to take part in some of the activities and to attend some of the meetings" (hospital e, focus group); turnover, "staff movement, some people are exiting the system, others might be on night duty, you know, on leave" (hospital d, focus group); overwhelming "workload from the department" (hospital d, focus group); and lack of time, "we always have quite demanding tasks that we do every day, our jobs are quite demanding, so the lack of time maybe is one of the major barriers to the implementation" (hospital f, focus group). "material resources", including the availability of reference, training, and other materials for the practical application of healthwise were mentioned by all participating hospitals. where material resources were available, they were an enabling factor; where they were unavailable, they were a barrier. there was also an issue with the "scarcity of surgical medical material with an emphasis on personal protective equipment" (hospital b, capstone meeting) mentioned by the three hospitals in mozambique, however there were indications from one hospital in each south africa and zimbabwe that the process of implementing healthwise was helping to secure "some improvements in procurement e.g. availability of appropriate ppe for linen bank staff and food services personnel and respirators" (hospital e, capstone meeting) and that "if we procure that [ppe] then it will be, the healthwise program will be effective" (hospital g, focus group). where active and engaged, the "local opinion leaders", referring to the existing ohs teams or newly created healthwise teams, were an enabling factor. this was particularly the case at both hospitals in south africa, where ohs teams were in place before the implementation of the project. one was commended as a "knowledgeable, skilled, reliable and committed ohs team" (hospital d, capstone meeting) and the other as a diverse "healthwise team comprising of members from different departments e.g. hr [human resources], staff development, cleaning, ipc [infection prevention and control] and linen bank" (hospital e, capstone meeting), which helped contribute to their success. the smaller hospital in zimbabwe also noted their "dedicated healthwise champions" (hospital g, capstone meeting). the barrier was due to "peripheral involvement of medical doctors and the nurses' representative member" (hospital f, capstone meeting), again indicating that engagement of diverse teams was one of the keys to successful implementation. "collaboration and teamwork" were mentioned as enabling factors or, where lacking, as barriers by the three hospitals in mozambique. similar to the motivation characteristic or the willingness of the workers to engage in the healthwise project, this characteristic referred to the involvement and inclusion of workers. hospitals a and c felt that there was both "good participation and adherence from employees" as well as that "there must be greater involvement of employees in the healthwise project" (hospital a/c, focus group). "existing networks", referring to collaboration and communication within and between hospitals, was generally an enabling factor mentioned by six of the seven hospitals. communication, figure 3 . before (not shown), the physician's desk was positioned next to the window, with the patient to their right. after, the patient is positioned next to the window and the physician is seated on the opposite side of the desk, allowing the air to flow from the door outside. ripped flooring has been removed. "human resources" were a barrier mentioned by all hospitals except a and c in mozambique. all hospitals seemed to experience some degree of staff shortages, "when the departments are so short-staffed, they are reluctant to take part in some of the activities and to attend some of the meetings" (hospital e, focus group); turnover, "staff movement, some people are exiting the system, others might be on night duty, you know, on leave" (hospital d, focus group); overwhelming "workload from the department" (hospital d, focus group); and lack of time, "we always have quite demanding tasks that we do every day, our jobs are quite demanding, so the lack of time maybe is one of the major barriers to the implementation" (hospital f, focus group). "material resources", including the availability of reference, training, and other materials for the practical application of healthwise were mentioned by all participating hospitals. where material resources were available, they were an enabling factor; where they were unavailable, they were a barrier. there was also an issue with the "scarcity of surgical medical material with an emphasis on personal protective equipment" (hospital b, capstone meeting) mentioned by the three hospitals in mozambique, however there were indications from one hospital in each south africa and zimbabwe that the process of implementing healthwise was helping to secure "some improvements in procurement e.g., availability of appropriate ppe for linen bank staff and food services personnel and respirators" (hospital e, capstone meeting) and that "if we procure that [ppe] then it will be, the healthwise program will be effective" (hospital g, focus group). where active and engaged, the "local opinion leaders", referring to the existing ohs teams or newly created healthwise teams, were an enabling factor. this was particularly the case at both hospitals in south africa, where ohs teams were in place before the implementation of the project. one was commended as a "knowledgeable, skilled, reliable and committed ohs team" (hospital d, capstone meeting) and the other as a diverse "healthwise team comprising of members from different departments e.g., hr [human resources], staff development, cleaning, ipc [infection prevention and control] and linen bank" (hospital e, capstone meeting), which helped contribute to their success. the smaller hospital in zimbabwe also noted their "dedicated healthwise champions" (hospital g, capstone meeting). the barrier was due to "peripheral involvement of medical doctors and the nurses' representative member" (hospital f, capstone meeting), again indicating that engagement of diverse teams was one of the keys to successful implementation. "collaboration and teamwork" were mentioned as enabling factors or, where lacking, as barriers by the three hospitals in mozambique. similar to the motivation characteristic or the willingness of the workers to engage in the healthwise project, this characteristic referred to the involvement and inclusion of workers. hospitals a and c felt that there was both "good participation and adherence from employees" as well as that "there must be greater involvement of employees in the healthwise project" (hospital a/c, focus group). "existing networks", referring to collaboration and communication within and between hospitals, was generally an enabling factor mentioned by six of the seven hospitals. communication, expressed as "the exchange of information among workers and from workers to patients; reciprocal information sharing" (hospital a/c, questionnaire) was key, as was the "easy implementation and dissemination of information to colleagues" (hospital b, dissemination and capstone meetings). one participant from south africa mentioned that "hr has been absolutely amazing. having a member of hr in our healthwise team was the best thing" (hospital e, focus group), due to the improved communication between departments and with management that enabled more project activities to receive approval and take place. finally, the "collaboration between [hospital a] and [hospital c] -exchanged experiences and helped to overcome difficulties that were encountered" (hospital a/c, dissemination meeting) was particularly helpful. the barrier in this regard was "poor communication" (hospital d, capstone meeting). "power and authority" were identified as enabling factors for hospitals a, c, and g. this generally related to workers feeling empowered to take charge of their own health and safety. during the focus group, one participant mentioned the idea of greater ownership over their own safety: "for me the project came to change my way of thinking... i realized that i am able to improve . . . my safety in the workplace and not wait for the bosses to come to control something within the sector, and so it was positive for me" (hospitals a/c, focus group). this sentiment was shared by a participant in zimbabwe: "...when we started it was your program but now slowly it is becoming our program so if everyone is involved at that level then we are going to succeed" (hospital g, focus group). these feelings also manifested as achievements; at hospital c in mozambique, one team member used material from module 5, which was not part of the initial training, and worked and negotiated with management and the local municipality to more routinely dispose of waste that piled up on the hospital grounds. a "lack of authority to implement certain activities" (hospital e, capstone meeting) was a barrier mentioned by one hospital in south africa. the context construct included characteristics related to the setting in which the innovation was to be implemented. characteristics related to the local and organizational levels from the i-parihs framework were combined as these were difficult to piece apart and included six characteristics. the external health system level included three of five characteristics from the i-parihs framework, leaving out "policy drivers and priorities" and "incentives and mandates". identified enabling factors and/or barriers in each of the hospitals are shown in table 4 . "senior leadership and management support" was an enabling factor mentioned by all seven hospitals through comments such as "support from the management... and the participation of those in charge of the sectors" (hospital b, focus group), "buy-in from senior management" (hospital d, focus group), and "management acceptance of the program" (hospital g, focus group). "lack of support from some middle managers" (hospital d, capstone meeting) where, for instance, heads of departments were at times not willing or able to release workers from their duties to participate in healthwise activities, was a barrier in hospitals d, e, and f. elements of the "culture" characteristic were mentioned by five of the participating hospitals. where workers were perceived to have greater "commitment to work", with descriptions such as "strong workforce" (hospital g, focus group), this was designated as an enabling factor. in mozambique, "one of the barriers [was] that information [had] to be oral" since workers were "not in the habit of stopping to read" (hospital b, focus group). here, there were overlaps with the willingness of workers to participate and learn and the degree of teamwork and collaboration described in the recipients construct above. where difficulties were raised in regard to "knowledge application", this was designated as a barrier. in the two hospitals in south africa, a "lack of safety culture; lack of knowledge about the importance of ohs matters and the healthwise program" (hospital e, capstone meeting) was discussed as a barrier, referring to the idea that workers have ohs "knowledge but they are not interested [in applying it]" (hospital e, focus group). "negative hospital staff attitudes" (hospital d, capstone meeting) and "resistance to change" (hospital b, questionnaire) were also perceived as a barrier in several hospitals. one hospital in zimbabwe that had expanded the services of their regular staff wellness clinic as part of the implementation of healthwise also mentioned "fear to uptake services . . . due to fear of stigma and discrimination" (hospital g, capstone meeting). competing "organizational priorities" and programs were mentioned as a barrier by hospitals d, f, and g. hospital a seemed to have priorities and programs that served to support, instead of compete with, healthwise activities, indicating "reinforcement of the ongoing ipc activities; synergies have been built among healthwise and ipc" (hospital a, dissemination meeting). in regard to "structure and systems", infrastructure was a barrier mentioned by all hospitals. infrastructure was generally older and difficult to change and participants seemed to feel that "some infrastructure hinders the proper functioning of the project" (hospital a/c, focus group), such as the "lack of ramps to move trolleys" (hospital b, dissemination and capstone meetings) at one hospital in mozambique and that "buildings were not constructed in such a way that they allow for proper ventilation" (hospital f, focus group) at one hospital in zimbabwe. hospital g expressed that the "infrastructure . . . might not be ideal but we are going to work with what we have" (hospital g, focus group). "lack of a specific project space" (hospital a/c, focus group) was mentioned by one hospital in mozambique, while in south africa, both hospitals perceived the lack of a dedicated ohs clinic "where you can see your employees when they are sick" (hospital d, focus group) or "lack of equipment at our ohs clinics" (hospital e, questionnaire) as barriers as well. institution size, specifically in relation to the number of workers trained on healthwise, was also a barrier specifically mentioned by hospital f in zimbabwe. regarding "history of innovation and change", resistance to change was mentioned as a barrier by participants at hospitals a, b, c, e, and g. one participant from south africa indicated that "anytime there is a new project there will always be resistance . . . because people are used to the norm of how they usually do things" (hospital e, focus group) and another from mozambique indicated that "resistance to change on the part of some colleagues was a challenge in the past" (hospital b, questionnaire). "evaluation and feedback processes" were perceived to be both enabling factors and barriers to the implementation of healthwise. improvements to reporting procedures were an enabling factor in hospital a, demonstrated by the increased "willingness of staff to communicate accidents in the workplace" (hospital a, capstone meeting), however "lack of understanding and knowledge of procedures, e.g., incident reporting procedure" (hospital d, capstone meeting) and "poor reporting of incidents" (hospital e, capstone meeting) remained barriers elsewhere. lack of feedback was a barrier mentioned by hospitals b, d, and e. hospital b indicated the "need to find a way to get worker feedback" (hospital b, focus group) and hospital d felt that "if you don't give feedback to the unit . . . it may compromise participation at the later stage" (hospital d, focus group) . in regard to external context, existing ohs "regulatory frameworks" were mentioned as an enabling factor by the two hospitals in south africa, such as the existence of an "occupational health and safety act that we need to adhere to" (hospital d, focus group) . the "instability of the health system environment" was mentioned as a barrier by hospital f in zimbabwe, where significant political and socioeconomic changes and challenges occurred during the course of the project. having good "inter-organizational networks/relationships", particularly with trade unions that play more prominent roles in south africa, was mentioned as both an enabling factor and, where lacking, a barrier by hospitals d and e. the facilitation construct included characteristics related to the strategies and actions performed by the facilitator(s) to enable implementation by adapting healthwise in response to the workers who were asked to use it within the contexts of their hospitals and countries. two characteristics and whether they acted as enabling factors and/or barriers in each of the hospitals is shown in table 5 . table 5 . facilitation construct characteristics and whether they were enabling factors (ef) and/or barriers (b) to the implementation of healthwise in each participating hospital (a-g). at least one hospital in each country declared that the "healthwise trainings" were key enabling factors to the implementation of healthwise-that the tool would not have been implemented solely based on the workbooks being available. in the hospitals in mozambique, an identified barrier was that the "training time was too short" (hospital a/c, focus group) and was therefore insufficient to support the implementation process. the practical training sessions in mozambique and zimbabwe also helped participants with relatively less ohs experience better identify workplace hazards and solutions: "...what helped was a second meeting [implementation training]... when we realized what in theory we had to do in practice" (hospital a/c, focus group). ongoing "communication and support from the research team" was an enabling factor in five of the participating hospitals. the research team was available, however participants at the different hospitals reached out to varying degrees. in the hospitals in south africa, one member of the research team was more accessible to participants and was therefore able to more quickly answer questions and on occasion, help to troubleshoot issues that arose. at the same time, key participants at hospitals a and f in mozambique and zimbabwe, respectively, were also more engaged and would reach out more often if queries or problems arose and would, in turn, receive desired engagement. for instance, one worker expressed that "we had a permanent contact with the team that trained us . . . i would email him, and he would respond quickly" (hospital a, focus group). the research team was therefore accessible, however was used in different ways and amounts by participants at each hospital. where "continued interaction between the hospital and the research team" (hospital f, dissemination meeting) took place, it was perceived as an enabling factor. many programs and tools available for health facilities focus on measuring and improving patient health, quality of service, and safety culture and have been reviewed in several publications [18, 19] . the few that have been developed and studied related to hws include online infection control tools [20] and a seasonal influenza vaccination rate improvement tool [21] . healthwise is a widely available quality improvement tool that addresses a variety of ohs concerns encountered in health facilities, containing information and activities that are particularly suitable to areas with few resources and little ohs experience. while it has been piloted in several countries, including in senegal, the united republic of tanzania, and thailand, and has since been implemented in the united states [22], china [23] , and the gambia, few publications and reports discussing or evaluating these experiences are publicly available. this paper is therefore one of the first to detail the implementation of healthwise and provide an analysis of enabling factors and barriers encountered in different lmics during the process. applying the i-parihs framework enabled an identification of key enabling factors as characteristics of the "recipients" and "context" constructs and included the willingness of workers to engage in implementation, the presence of diverse teams that championed the implementation process, and supportive senior leadership. barriers were reported in all constructs and included a lack of clarity about how to use healthwise, insufficient funds, stretched human resources, older buildings, and lack of incident reporting infrastructure. overall, successful implementation of healthwise called for dedicated local research and technical team members who helped facilitate the process by adapting healthwise to the workers' ohs knowledge and skill levels and the cultures and needs of their hospitals, cutting across all constructs of the i-parihs framework. healthwise was well-received in all participating hospitals, demonstrating the importance of the innovation itself. workers in hospital a seemed especially interested in a tool that was aimed at their own needs as opposed to solely those of patients. in the majority of hospitals, even those that did not mention it explicitly, there was difficulty in fully understanding healthwise and how to use it, as well as how to spread awareness regarding its implementation throughout the hospital. the anticipated benefits or the results that were being observed over the course of the implementation spurred several hospitals forward. the research team felt there was room to improve the messaging related to healthwise, and future implementations might further explore how information related to the innovation impacts the implementation process. questions could explore what factors made healthwise more acceptable, such as its development by the ilo and who, the quality or contents of the materials, and its fit within existing hospital practices and values in order to explore additional aspects of the innovation construct. healthwise activities were accomplished in all hospitals due to the active efforts of healthwise recipients, the individuals and teams who were overall key to the implementation. barriers described in this study, including staff shortages, high workloads, and limited material resources, have been identified among common barriers to evidence implementation across clinical areas in lmics [24] . despite these issues, workers possessed a wealth of knowledge related to their hospitals and colleagues and therefore knew best when it came to implementing healthwise. while participants at hospitals in mozambique and zimbabwe mentioned feeling empowered and taking ownership over healthwise, more might have been done to help all teams recognize earlier on that their local insights and initiatives were what would make healthwise more successful. literature on team innovation and implementation points to the need for varied team composition to promote creativity and action [25] . where teams were more diverse, particularly where members helped link frontline workers to management, more activities seemed to receive approval and were able to move forward. having established ohs teams in both hospitals in south africa, along with the accompanying knowledge and skills, also enabled them to accomplish a variety of tasks. it seemed that healthwise was a catalyst to the implementation of available ohs policies and allowed workers to take ownership of their own health and safety, with the ohs professionals providing oversight. the importance of opinion leaders-"people who influence the opinions, attitudes, beliefs, motivations, and behaviors of others" [26] -has been shown in other examples of successful implementation processes and was similar here [27] . promoting collaboration and exchange between sites that are implementing the same innovation might be interesting to explore, since this was an enabling factor for hospitals a and c who worked together in mozambique and was of particular interest to participants in zimbabwe who expressed a desire to visit other sites and learn from them during the implementation process. implementing healthwise in hospitals in different countries enabled the exploration of several characteristics of the context construct, which in these low-resource settings were more often barriers to the implementation of healthwise rather than enabling factors. context has repeatedly been discussed as an important factor in regard to implementing various interventions, one that deserves more thorough definition and analysis [28] . findings from this study may help to better identify which characteristics are most important to the implementation of healthwise and, to some degree, other similar projects in lmics. in terms of the context construct, local and organizational factors were more often discussed than external health system ones. while senior management were supportive of the project in all hospitals and welcomed its implementation, middle management were perceived as a barrier at several sites. engaging more actively with middle management to explore strategies that would have allowed workers to be involved in healthwise activities, such as being relieved from their duties for a short time on a regular basis-perhaps one hour per week-to examine and improve their working environments, while also ensuring that their tasks remained fulfilled and that their departments ran smoothly, might have been one way to overcome this barrier. taking time to explain the longer-term potential of healthwise to the departments might have been another. the resistance by middle management highlighted the importance of communication and consultation across all levels of the hospital and all stakeholders when introducing new interventions to protect hws. birken and colleagues [29] developed a theory of the role of middle management in healthcare innovation implementation. engle and colleagues [30] expanded on this theory and found that middle management in organizations with "high change potential" promoted bidirectional communication and independent thinking and overall supported staff to facilitate implementation. emphasizing the goal of working within limits-of older infrastructure, inadequate human and material resources due to hiring freezes and health budgets, and manual incident reporting-might also have helped to avoid some blockages in the implementation process. also, given limited data collection and reporting procedures and mechanisms, understanding what type of feedback would have been attainable and useful might also have been helpful, as would have been pointing out synergies with existing organizational priorities and programs and external system regulatory frameworks and legislation. for the most part, workers were enthusiastic and engaged, although some negative attitudes and resistance to change were mentioned. a study by bergström and colleagues [31] that examined the organizational context construct of the earlier parihs framework found that hws' commitment to their work, or an "individual's devotion to the organization," had an impact on the implementation of knowledge translation interventions in uganda. change was less likely where commitment levels were lower and a shortage of human resources contributed to lower levels of commitment. this indicates that where human and possibly other resources are a barrier, organizational culture might need to be addressed and improved for implementation to be successful, particularly in low-resource settings. there is important interplay between constructs, particularly between "recipients" and "context". for instance, incentives that contribute to the motivation of participants and project funding for specific equipment and activities might be more effective in some contexts than others. a systematic review by liu and colleagues [32] found a range of macro, meso, and micro level context factors that influenced the types and impacts of incentives on the recruitment and retention of hws in multiple countries. in our study, participants from zimbabwe, where macro level political and socioeconomic factors were straining the country, mentioned that incentives might have been helpful for full participation. they were also initially focused on needing project funding to move forward with any activities and hospital f was the only facility to indicate that the allocation of funds enabled the implementation of healthwise. while our study did not specifically study the effects of externally funded projects, we got the impression that some participants were expecting extra incentives to motivate their participation. we acknowledge, however, that the local conditions and previous experiences with externally funded projects might contribute to this seeming dependency and expectation in lmics. harvey and colleagues [33] conducted a concept analysis of facilitation and presented the role of the facilitator as one of "supporting people to change their practice". this healthwise study used appointed facilitators, external to the hospitals, who focused on building capacity in ohs in order to enable change, all which fit within the defining characteristics of facilitation that they describe. hospital a, b, and c in mozambique considered the healthwise trainings useful, but too short, compared with hospitals d and g in south africa and zimbabwe, respectively, which alluded to them only as enabling the implementation of healthwise. all tot workshops were conducted in english; in mozambique, simultaneous audio translation using headsets and all materials, including the healthwise manuals, were available in portuguese. additional time may have been warranted due to the language difference, since interpretation demanded a slower pace and longer explanations. for hospitals a, c, d, e, and f, where participants communicated with the research team, this was perceived as an enabling factor. the process of communication, including tools for translation, ought to have been made clear to participants and questions encouraged, particularly following the tot workshops to help the initial implementation gain momentum, as opposed to waiting six months for check-in meetings. overall, the actions carried out by local team members were key to the implementation of healthwise. other studies have demonstrated the critical role of external facilitators and shown links between the different constructs of the parihs framework. a study by ellis and colleagues found that "good facilitation appears to be more influential than context in overcoming the barriers to the uptake of [evidence-based practice]" [34] . this experience helps to show that the roles of the facilitators were key and that improved facilitation across the different constructs could enhance the implementation. for example, facilitators could emphasize both the knowledge and practical aspects of the tool, improving its clarity; they could adapt the training based on workers' levels of knowledge and skills in regard to ohs; they could demonstrate how the tool fits within the workplace in relation to the hospital's mission and to other programs and priorities, and help participants advocate for its implementation to improve both worker and patient safety and to better align with existing ohs legislation. a key strength of this project was the existing north-south partnership, which enabled the collaboration between multiple countries, one in the global north and three in the global south [6] . according to landau [35] , "international research partnerships enact and expose the inequalities, structural constraints, and historically conditioned power relations implicit in the production of knowledge". caution is needed and care must be taken to mitigate factors that could exacerbate inequalities and inequities. in this study, local research partners and team members were instrumental in initiating, carrying out, and sustaining the project. one specific measure that was taken was to provide as much direct budget control to the southern partners as the funder permitted. some limitations were related to administrative issues, such as delays securing approvals from multiple countries and facilities. data collection instruments ought to also have been piloted, particularly following translation to portuguese, and streamlined to avoid overburdening participants. this may also have helped to reduce the missing data from incomplete questionnaires; as it stands, further research is required to fully understand the more nuanced aspects of certain constructs, particularly context, where responses were not specific or detailed enough to comprehend how minor differences affected implementation. understanding how healthwise-related changes affected the ohs of hws was a desired yet difficult-to-capture aspect of this study, particularly due to insufficient existing incident reporting procedures and data collection systems at the participating hospitals. therefore, while we were able to describe some improvements that were made, we were limited in assessing ohs outcomes and focused instead on enabling factors and barriers to implementation. as a final reflection on our experience, it is worth noting that the research team initially intended to participate as mere observers to the implementation of healthwise, to understand how a standalone tool to improve the health and safety of workers, introduced via a single training session, was implemented in different hospitals in different countries. this hands-off approach was also used to discourage dependency on local teams, whose resources and time are limited, and on international funds, of which there are less and less. however, the capacities of the countries to implement healthwise were limited by their differing knowledge and skill levels in regard to ohs; while hospitals in south africa had workers who specialized in ohs and existing committees, hospitals in mozambique and even more so in zimbabwe needed to start with more basic training. implementation was also limited by resources, which were undeniably scarce in all three countries, but again, especially so in mozambique and zimbabwe, as well as by the expectation that external funds were the solution. the team gradually increased their level of facilitation, providing additional practical training and encouraging larger hospitals to start small by focusing on one department instead of being overwhelmed by the whole hospital. this shows that in some contexts, a standalone tool is insufficient and a more robust toolbox that addresses the need to build capacity in implementation science is needed. future work is focused on developing and testing preparation strategies and materials that might make it easier for individuals and teams who are keen to improve the ohs of their health facilities to do so independently using healthwise. documenting experiences implementing healthwise and other tools, including any adaptations made, and making these available via publication or central repository ought to also be encouraged. the effort to develop tools for protecting hws must be accompanied by comparable attention to the way in which these instruments are implemented in settings of need. our study of the implementation of healthwise in seven hospitals in the southern african region provides clear documentation of how a variety of enabling factors and barriers can influence success. building on methods, such as the application of the i-parihs framework which we pursued, a valuable evidence base can be built to support efforts for ensuring that improved work environments for hws are part of strengthened health systems. with this vision, future implementations ought to focus on areas such as providing clarity about the tool and helping participants to develop clear goals and expectations based on their ohs knowledge and skill levels and on the amount of resources and time available to them. securing support from senior leadership and middle management and assembling a dedicated and diverse healthwise team would also be beneficial. emphasizing the need to work within existing constraints and find no-or low-cost solutions is also key in resource-poor areas. future research might focus on examining construct characteristics in further detail and on testing ways to overcome obstacles, as well as on what additional materials might help to create a toolbox, as opposed to a standalone tool, to enable facilities to implement healthwise on their own. promoting and improving the health and safety of hws at work is part of the solution to increasing recruitment and retention of these essential workers and curbing current and projected shortages in the global health workforce. 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context within research on population health interventions uncovering middle managers' role in healthcare innovation implementation what roles do middle managers play in implementation of innovative practices? health care manag knowledge translation in uganda: a qualitative study of ugandan midwives' and managers' perceived relevance of the sub-elements of the context cornerstone in the parihs framework analysis of context factors in compulsory and incentive strategies for improving attraction and retention of health workers in rural and remote areas: a systematic review getting evidence into practice: the role and function of facilitation from workshop to work practice: an exploration of context and facilitation in the development of evidence-based practice communities of knowledge or tyrannies of partnership: reflections on north-south research networks and the dual imperative this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license we would like to acknowledge the dedicated health workers who participated in the implementation of healthwise at each of the participating hospitals. we would also like to acknowledge the in-kind contributions from team members and staff at the international labour organization and the national institute for occupational health for their time and expertise in ohs. sincere thank you to ana tina titos mutola jemuce, jonathan ramodike, and shamiso muteti fana for their contributions to this project. the authors declare no conflict of interest. the funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results. key: cord-313712-2dwbxq3w authors: murshed, muntasir; tanha, muntaha masud title: oil price shocks and renewable energy transition: empirical evidence from net oil-importing south asian economies date: 2020-05-21 journal: energy ecol environ doi: 10.1007/s40974-020-00168-0 sha: doc_id: 313712 cord_uid: 2dwbxq3w this paper makes a novel attempt to model the nonlinear association between renewable energy consumption and crude oil prices concerning four net oil-importing south asian economies: bangladesh, india, pakistan and sri lanka. using annual data from 1990 to 2018, the long-run elasticity estimates confirm the nonlinear nexus and suggest that although rising crude oil prices do not facilitate renewable energy consumption initially, upon reaching a threshold level of crude oil price, further hikes in the oil prices are likely to elevate the renewable energy consumption figures. the estimated real oil price threshold, in this regard, is predicted to be around 135 us dollars per barrel, which is way above the prevailing oil price level. identical nonlinearity is also confirmed in the context of the oil prices and renewable energy share in total final energy consumption volumes. moreover, the nexus between renewable electricity share in aggregate electricity outputs and crude oil prices is also seen to exhibit nonlinearity. however, rising crude oil prices were not found to enhance the renewable electricity shares. besides, the causality results implicated that movements in crude oil prices influenced the renewable energy transition process across the concerned south asian economies. thus, these results, in a nutshell, impose critically important policy implications for attainment of energy security and environmental sustainability in south asia, particularly via curbing the traditional imported crude oil-dependencies of these nations. deteriorating environmental quality and aggravating climate change adversities worldwide have cumulatively sparked the consensus in aligning the global development policies with simultaneous safeguarding of the environmental attributes as well. in the past there had been an agreement to the concept of 'growing the economy now and cleaning up the environment later,' thus, accepting the trade-off between economic and environmental welfares. however, the contemporary development policies tend to primarily focus on greening of the global production processes, particularly to curb the greenhouse emissions that stem from the predominant combustion of fossil fuels. therefore, it is pertinent for the world economy to undergo a transition from use of non-renewable to renewable energy resources, keeping environmental sustainability into cognizance (murshed 2018 ). in the same vein, the sustainable development goals (sdg) agenda of the united nations has also called out for worldwide commitments to augment renewable energy (re) resources into the global energy-mixes for ensuring energy security and environmental sustainability across the planet. the 7th of the seventeen sdg specifically stresses for substantially elevating the shares of renewables in the global energy consumption figures by the end of 2030 (villavicencio calzadilla and mauger 2018) . therefore, the world economies have expressed their commitments with respect to the attainment the sdg within this stipulated time frame. the benefits of enhancing the volumes of renewable energy consumption (rec) within the economy can embody multidimensional forms. for instance, incorporating re technologies into the national energy policies worldwide is likely to complement the global energy security strategies which seem to be at risk due to the depletion of the global non-renewable energy (nre) reserves (valentine 2011) . thus, augmentation of re into the global energy-mixes would not only relieve pressures off the world demand for fossil fuels, but it would also complement the nre in significantly improving the overall reliability of energy supplies (zemin 2008) . besides, rec can also exhibit a pivotal role in curbing the intensities of greenhouse emissions, therefore, attributing to improvements in the environmental quality while slowing down the climate change phenomenon in tandem (perry et al. 2008) . boosting the consumption levels of re has also been appropriately acknowledged in the 2015 paris climate change conference to play a defining role in keeping the global temperature rise below the critical level of 2°c per annum which is pertinent in combating the climate change adversities to a large extent. 1 among the other positive impacts, rec is hypothesized to reduce the vulnerability of economies against the exogenous volatility of crude oil supplies (rentschler 2013) , stabilize energy prices (shen et al. 2010 ), enhance energy-use efficiency levels (murshed 2019) , expand electricity-access rates (oseni 2012) , attribute to rural electrification (urmee et al. 2009 ), facilitate off-grid electrification (sen and bhattacharyya 2014) and also create job opportunities within the local community (sari et al. 2008; llera et al. 2013) . however, despite such advantageous features, the adoption of re technologies is not so straightforward due to the generation, storage and transmission of both primary and secondary re sources being overwhelmingly conditional on the availability of the appropriate technology (painuly 2001) . thus, technological redundancy, within the developing economies in particular, often upholds the substitution of fossil fuels via renewable alternatives. besides, the underdeveloped energy infrastructure within these nations is also proclaimed to be one of the major hindrances bottlenecking their prospects of undergoing the renewable energy transition (ret) phenomenon (murshed 2020) . more importantly, implementation of the ret policies is relatively difficult in the context of net oil-importing countries (noic) courtesy of their acute vulnerability to exogenous shocks to the world crude oil prices (gupta 2008) . a particular reason behind this could be interpreted in terms of the predominant reliance of these nations on crude oil imports, mostly for domestic power generation purposes. in addition, inadequate natural re endowments often compel these nations to rely on imported oils as well. consequently, such monotonic fuel-dependency often restrains these economies from switching to re use; thus, attributing to the adverse environmental complications stemming from the obligatory combustion of the imported oils. besides, these economies are also referred to be highly susceptible to other multifaceted macroeconomic adversities, following the impulsive movements in world crude oil prices, as well (cunado et al. 2015) . moreover, the relatively higher startup costs of setting up the re power plants, solar in particular, have also accounted for high renewable electricity prices within the noic, thus, deterring the ret phenomenon further. in comparison to the traditional oil-based power prices, the prices of electricity sourced from solar and wind energy in britain are higher by more than two times (the economist 2014). moreover, the ideal locations of the renewable power plants are usually across regions far away from the cities which further inflate the associated power transmission and distribution costs. however, in recent times, the average cost of re production has gone down to a large extent. according to a report by the international renewable energy agency (irena 2019), the global weighted-average costs of solar power, between 2010 and 2018, have significantly declined to almost match the corresponding costs of generating electricity from the fossil fuels, oils in particular. more importantly, upon analyzing the levelized cost of energy (lcoe) 2 in the context of electric power generated from both renewable and non-renewable sources, it is evident that renewable power prices have substantially reduced over time. for instance, within south asia and the pacific, the lcoe produced using solar power declined the most from being around 350 us dollars per megawatt in 2010 to 69 us dollars per megawatt by the end of 2019 while the lcoe for natural gas-fired electricity remained fairly stagnated at around 72 us dollar per megawatt (harder 2019, august 1). moreover, among the asia pacific economies, india currently accounts for the lowest cost of re production whereby the nation's solar lcoe has dropped below the lcoe for power generated from coal (wood mackenzie 2019). hence, taking the lower costs of re generation, in recent times, into consideration, undergoing ret across the noic, in particular, can be expected to be a crucial energy policy intervention in simultaneously ensuring energy and environmental sustainability. against this background, this paper aims to probe into the dynamic impacts of world crude oil price shocks on the ret process across four major noic across south asia namely bangladesh, india, pakistan and sri lanka. the fact that all these nations have traditionally been vastly reliant on crude oil imports, investigation of the cross-price 1 for more information on the paris climate change conference of parties21 (cop21) see rhodes (2016) and robbins (2016) . 2 for more information on the lcoe see irena (2019). elasticity of re demand becomes a pertinent topic of research, keeping south asia's prospects of ret into consideration. although existing studies have probed into the impacts of oil prices on rec using a linear framework, in the context of south asia, the possible nonlinearity of the rec-crude oil price nexus is yet to be explored. it is germane to address the quadratic association between these variables from the notion that oil price movements may not be able to induce ret instantaneously, following the inability to undergo ret due to being a large share of their national outputs being generated using power sourced from the imported crude oils. thus, rec in the initial stages can be expected to pretty inelastic to rising crude oil prices in the world market. however, alongside substantial economic development of these economies with time, the barriers to re adoption could be expected to reduce whereby the elasticity of rec concerning further hikes in crude oil prices could be anticipated to improve to facilitate the ret process. this paper contributes to the literature in this regard by modeling the nonlinear association between rec and movements in the prices of crude oil. addressing this nonlinearity is of relative significance in the context of noic since these economies are highly rigid to ret in the short-run following their extensive reliance on imported crude oils. on the other hand, power prices have progressively gone up in the selected south asian noic as well. although such price hikes could partially be attributed to the overall growth of these economies, exerting demand-induced inflationary pressures on the electricity prices, the volatility of oil prices in the world market (yasmeen et al. 2019) and acute shortages of the primary energy resources (shakeel et al. 2016) have collectively driven up the price of electricity. in bangladesh, the flat rate of electricity provided to the small industries increased from 4.02 bangladeshi takas per kilowatt-hour in 2007 to almost 8.20 bangladeshi takas per kilowatt-hour by the end of 2017 (bpdb 2017). similar upward trends are also seen for prices of the residential, commercial, industrial electricity supplies. likewise, the wholesale electricity price index of india surged from 102.40 in 2013 to 108.70 by the end of 2018, depicting a 6.15% growth in the electricity prices during the aforementioned period (oea 2020). moreover, between 2010 and 2014, the nation's agriculture, residential, industrial and commercial electricity price indices on average grew by 66%, 30%, 17% and 14%, respectively (oea 2020). similar trends are also evident in the context of pakistan where the government has persistently raised the electricity prices to account for fuel cost adjustments (times of islamabad 2019, december 26). in contrast, average electricity prices in sri lanka have recently exhibited declining trends (climatoscope 2019) which can plausibly be attributed to the nation's relatively less oil-dependency for electricity generation purposes among the selected south asian noic. hence, keeping the trends in low lcoe for renewable electricity production and the surging electricity prices in the majority of these economies into consideration, reducing oil-dependency could be ideal in limiting electricity prices while safeguarding the environment via facilitating the ret phenomenon across south asia. this paper specifically addresses the following questions in the context of the selected south asian noic: 1. is the relationship between rec and crude oil prices nonlinear? 2. do exogenous shocks to crude oil prices facilitate the ret phenomenon? 3. does imported oil-dependency hamper the prospects of switching from nre to re use? 4. is there any causality between crude oil price movements and consumption of re? the remainder of the paper is organized as follows. section 2 provides an overview of the state of re use within the four south asian noic. a review of the relevant theoretical and empirical literature is put forward in sect. 3. section 4 presents the empirical model and chalks down the attributes of the dataset used. the methodological approach is explained in sect. 5, while sect. 6 discusses the findings from the econometric analyses. finally, sect. 7 concludes and highlights the potential policy implications. apart from belonging to the lower-middle-income group and being net importers of crude oil, all these four south asian economies have traditionally sourced a significant proportion of their respective national outputs using nre resources, imported crude oils in particular. as far as the national fuel-mixes for electricity generation purposes are concerned, fig. 4 in ''appendix'' illustrates the trends in the renewable and non-renewable electricity outputs across the selected south asian noic. it is apparent from the graphs that the shares of renewable electricity in aggregate electricity output levels of india, pakistan and sri lanka have declined, on average, between 1990 and 2015. similar downward trends revealed in the context of bangladesh over the 2005-2015 period. bangladesh accounts for the lowest renewable electricity output shares among the four south asian economies which can largely be credited to the nation's predominant reliance on indigenous natural gas and imported oils for power generation purposes. in contrast, sri lanka has traditionally been the forerunner in terms of registering the highest renewable electricity output shares. however, the nation's renewable electricity share has remarkably dropped by a staggering 51.37 percentage points, on average, between 1990 and 2015, while its reliance on imported oils for power generation purposes has significantly escalated in tandem. on the other hand, pakistan has gradually accentuated its reliance on imported oils as perceived from a rise in the nation's share of electricity from oil, in the aggregate electricity outputs, by almost 17 percentage points, on average, between 1990 and 2015. figure 4 also portrays heterogeneity across these economies concerning their respective national energy-mixes. it is evident that a major proportion of total electricity in bangladesh and pakistan is sourced from the combustion of the indigenous natural gas supplies, while india banks heavily on its coal resources to generate electricity. on the other hand, sri lanka produces a significant amount of its electricity outputs from the re resources. however, all these nations still import a significant amount of crude oil for producing electricity which seems to be one of the prime factors attributing to south asia's environmental hardships. figure 1 depicts the correlative plots of re shares in total energy consumption figures and real crude oil prices across the selected south asian economies between 1990 and 2018. the inverted-u shapes of the fitted lines, as shown in fig. 1 , portray the dependence of these nations on crude oil imports since rising crude oil prices are initially accompanied by lower re shares which, after a threshold level of oil price, elevates the re shares. hence, these interesting trends further stress on the need to investigate the potential nonlinearity of the rec-crude oil price nexus in the context of the south asian noic. moreover, fig. 5 in ''appendix'' plots the historical trends in the re shares, renewable electricity output shares and real crude oil prices between 1990 and 2015. it is apparent from the statistical trends that a persistent rise in the real oil prices has dampened both the shares of re consumption and renewable electricity outputs in most of the selected south asian noic. hence, these trends seem to further highlight the extent of oil dependency among these nations which makes it is difficult for these nations to completely switch from consumption of oil to the re alternatives. among the selected south asian noic, bangladesh is referred to as the most oil-vulnerable nation, while india is said to be least vulnerable to oil price shocks (mohsin et al. 2018 ). this section is subdivided into two subsections in which the former discusses the theoretical framework engulfing the rec-crude oil prices nexus while the latter sheds light on the empirical evidence in this regard. the impacts of exogenous shocks to world crude oil prices on rec can be explained using the concept of substitution usually, the total impact of a change in the price of a commodity can be expressed as a sum of the substitution and income effects. however, this paper confines the discussion to explaining the rec-oil price nexus using the se stemming from a rise in crude oil prices. several studies have referred to re resources as substitutes for the nre resources such as crude oil, coal and natural gas (kruger 2006) . hence, assuming re resources as a perfect substitute for fossil fuels, a rise in world crude oil prices is likely to induce a se whereby the volume of rec can be anticipated to go up. figure 2 illustrates the dynamics in this regard. prior to the rise in the crude oil prices, across the world market, the optimum level of rec takes place at point a where the indifference curve (ic) is tangential to the slope of the budget constraint (bc 0 ). the slope of this budget constraint is given by the relative price ratio of re resources and crude oil (pre 0 / poil 0 ). at point a, the optimum levels of rec and oil consumption are, respectively, shown as re 0 and oil 0 . now assuming that the price of crude oil, which is determined in the world market, goes up (from poil 0 to poil 1 ) while the price of renewables, which is locally determined, is assumed to stay put (at pre 0 ). hence, the relative price ratio would decline resulting in the slope of the budget constraint being flatter. the new budget constraint can be shown as bc 1 and the corresponding relative price ratio is given by pre 0 /poil 1 . under such circumstances, there will be a movement along the indifference curve, from point a to point b, whereby the consumption of renewables can be expected to rise while oil consumption is likely to decline. the se of the rise in world crude oil prices can, therefore, be shown as the increase in the levels of rec from re 0 to re 1 and the decrease in oil consumption levels from oil 0 to oil 1 . however, this mechanism is strongly grounded on the assumption of re resources and fossil fuels being perfect substitutes. in the case of these two variables not being perfect substitutes, the se could be negligible whereby the impact of rising crude oil prices on the level of rec may not be as pronounced. under more adverse scenarios, in which the ret is not possible due to certain macroeconomic limitations, particularly in the form of predominant oil-dependencies, rising crude oil prices may even foster higher consumption of crude oils to meet the aggravating demand for energy to produce the national outputs. as a consequence, the share of nre in aggregate energy consumption levels can be anticipated to rise along with the rise in crude oil prices. hence, it can be said that the exact nature of the reccrude oil price nexus depends on the possibility of the substitution between the nre and re resources and also on the extent of crude oil-dependency of the concerned economy. a plethora of studies have attempted to model the impacts of oil prices on the demand for re in the context of both developed and developing economies. in a country-specific study by sadorsky (2009) , the author probed into the factors attributing to rec within the group of seven (g7) the shortrun results from the error-correction model approach revealed that rising oil prices increased rec in france while reducing it in the context of the uk. however, no statistical short-run impact could be established for the rest of the g7 nations. the long-run findings, tapping the fully modified and dynamic ordinary least squares approach, showed that rising oil prices ultimately increased rec within france, germany and italy but led to declines in the rec levels in the context of canada, japan, the uk and the usa. however, the results also showed that rec is pretty elastic to changes in oil prices across germany, the uk and the usa while for france, italy, canada and japan evidence of an inelastic association between rec and oil price movements was ascertained. for the pooled data of all the g7 nations, a negative correlation between oil price and rec was also evidenced by the statistical significance of the long-run elasticity estimate. azad et al. (2014) used annual time-series data spanning across 1990 and 2011 to conduct simulation exercises for assessing the impacts of oil price shocks on australia's re demand. the results from the generalized method of moments (gmm) regression approach provided statistical evidence regarding re resources being substitutes for fossil fuels in the context of australia. the corresponding elasticity estimate denoted that the marginal effect of a rise in the price of crude oil attributed to a rise in the volume of rec by 0.14%, on average, ceteris paribus. the causal linkage between rec and real oil prices for the usa, over the period 1949-2009, was estimated by payne (2012) . results from the toda-yamamoto long-run causality approach suggested no causation between the two variables. moreover, the impulse response function analyses revealed that unexpected shocks to real oil prices could not establish a statistically significant impact on the country's rec over a 10-year period. instead, the statistical estimates revealed that rec in the usa responds positively to positive shocks to the country's real gdp and carbon emissions figures. in a recent study by ji and zhang (2019) , the factors affecting rec growth in china, between 1992 and 2013, were explored using variance decomposition techniques within a vector autoregressive (var) model framework. the corresponding results indicated that changes in crude oil prices accounted for almost 20% of the total variations in china's re share in aggregate final energy consumption figures. moreover, upon checking for the robustness of the findings using an alternate indicator of re use within the chinese economy, the findings revealed that oil prices explained almost one-fourth of the total variations in china's volumes of non-hydroelectric power. the overall results highlighted that the movements in oil prices were second to financial development in explaining the changes in the growth of the re sector of china. shah et al. (2018) analyzed the impacts of oil price shocks and other macroeconomic aggregates on re investment trends in norway, the usa and the uk. the study utilized annual data stemming from 1960 to 2015 to perform the forecast error variance decomposition analysis within a var framework. the results showed that shocks to both real and nominal prices of oil failed to exert much impact on the trends in re investments in the uk. in contrast, positive shocks to oil prices were found to trigger positive movements in the re investment figures of norway and the usa. the authors referred to state intervention in the uk as the core reason behind the ineffectiveness of oil price shocks to explain movements in the nation's re investment trends. the causality estimates revealed that only in the context of the usa, a unidirectional causality was found to be stemming from oil prices and investment in the nation's re sector. furthermore, the authors concluded that the impacts of oil price shocks on the development of the re sector depend on whether an economy is a net importer or a net exporter of oil. the fact that the usa was a net importer of oil across a lion's share of the study period was claimed to be the reason behind the nation's re investment trends being responsive to oil price shocks. among the various cross-country examinations documented in the literature, omri and nguyen (2014) used annual data in the context of 64 global economies, from 1990 to 2011, to model the elasticity of rec with respect to changes in real prices of crude oil. results from the dynamic system-gmm regression analyses revealed that rising crude oil prices reduced the volume of per capita rec across the entire panel of 64 countries. moreover, up classifying the countries in terms of their respective income group, the regression estimates revealed that a rise in the real values of crude oil prices by 1% was accompanied by a reduction in the per capita rec figures for the panel of the oil consumption fig. 2 the substitution effect of rising crude oil prices on energy consumption trends. source: authors' own middle-income economies by 0.34%, on average, ceteris paribus. however, no statistically significant impact could be ascertained in the context of the low-income and the high-income panels. thus, the authors opined in favor of the heterogeneity of the rec-oil price nexus across economies concerning the income group they belong to. the rec-oil price nexus in the context of seven central american nations was explored by apergis and payne (2014a) . the authors used annual data for all the seven economies over the period 1980-2010. the regression analysis was conducted using the fully modified ordinary least squares estimator. the elasticity estimates showed that the per capita rec within the selected central american economies responded to changes in both real prices of oil and coal. in particular, a 1% rise in the real oil prices was found to elevate the per capita rec figures by 0.29%, on average, ceteris paribus, thus, implicating the substitutive properties between re and fossil fuels in the context of the selected nations. moreover, the authors also concluded that real oil prices, over the entire study period, do not exert a causal impact of the per capita rec figures. however, allowing for regime shifts in the year 2002, the causality findings during the pre-2002 period revealed statistical evidence regarding unidirectional short-run causal impacts of real oil prices on per capita rec while in the long-run bidirectional causation between the variables was observed. on the other hand, in the post-2002 period, bidirectional causalities between real oil prices and rec per capita were found in both the short-and the long-runs. marques and fuinhas (2011) assessed the drivers of re use across 24 european union nations between 1990 and 2006. the uniqueness of this study involved the consideration of prices of disaggregated nre resources to estimate their conditional impacts on the demand for re. the regression results from the difference-gmm, system-gmm and the least squares dummy variable correlated estimators unanimously suggested that oil prices are statistically insignificant in explaining the changes in the shares of renewable in the total energy consumption figures of the european union member countries. in a similar study, damette and marques (2019) also probed into the drivers of rec within the 24 european union nations. upon controlling for the problem of dependencies across the cross-sections, the authors employed the pooled mean group panel data estimator to deduce the long-run elasticities. the results showed that oil prices exhibited a positive and statistically significant impact on the share of renewables in total energy production levels. moreover, the authors also opined that rising dependency on energy imports also contributed to higher re shares in total energy supplies. the dynamics engulfing the rec-oil price nexus in the context of 25 member states under the organization for economic co-operation and development (oecd) were examined by apergis and payne (2014b) . the study employed annual data from 1980 to 2011 to predict the long-run associations. the results advocated in favor of the long-run cointegrating associations between per capita rec and real oil prices. moreover, the long-run elasticity between these variables, as predicted using the panel fully modified ordinary least squares estimator, showed that the marginal impact of a rise in real oil prices triggered a simultaneous increase in the per capita rec figures by 0.45%, on average, ceteris paribus. moreover, the causality estimates from the panel error-correction method revealed a bidirectional causal association between per capita rec and real oil price both in the short-and long-runs. in a similar study, apergis and payne (2015) employed panel cointegration techniques to predict the long-run determinants of rec in the context of 11 south american nations, using yearly data between 1980 and 2010. the results from the fully modified ordinary least square technique indicated that rec per capita is positively influenced by rising real oil prices, thus, referring to re resources as alternative sources of energy to fossil fuels. a 1% rise in the real price of oil was found to be accompanied by a 0.37% escalation in the per capita rec figures, on average ceteris paribus. hence, these findings suggested that rec in the context of the concerned south american economies is inelastic to changes in world oil prices. moreover, the causality estimates from the vector error-correction model approach discovered bidirectional short-run causation between per capita rec and real oil prices. however, in the long-run real oil price was found to causally impact the per capita rec figures without the feedback. hence, it is apparent from the equivocal conclusions made in the aforementioned country-specific and crosscountry empirical studies that rising crude oil prices do not guarantee the replacement of fossil fuel consumption via the re alternatives. moreover, considering country-specific features, a great deal of heterogeneity concerning the nature of the rec-oil price nexus is also evident. more importantly, the existing literature has overlooked the possible nonlinearity between these variables which could be effective in reasoning the ineffectiveness of higher crude oil prices in instigating the ret phenomenon, particularly from the perspectives of the noic. this paper attempts to address this gap in the literature by modeling the rec-crude oil price relationship in a nonlinear framework in the context of the four noic across south asia. oil price shocks and renewable energy transition: empirical evidence from net oil-importing… 4 empirical model and data the selection of the empirical models is based on the underlying economic theories. to model the possible nonlinear association between crude oil prices and consumption of re resources across the selected south asian nations, the level of rec within the concerned economies is expressed as a quadratic function of real crude oil prices and controlled for key macroeconomic aggregates that may affect the overall nature of the rec-crude oil price nexus. the corresponding empirical model can be specified as: where the subscripts i and t, respectively, denote the individual cross-sectional units and the time period. b i (i = 1,…,7) are the elasticity parameters to be estimated while e is the error-term. the variable rec is per capita consumption of re, measured in terms of kilograms of oil equivalent. roilp and roilp 2 stand for the real prices of crude oil and its squared term, respectively. the unit of measurement of real crude oil prices is in terms of us dollars per barrel in constant 2016 prices. it is worth noting that the statistical significance of the elasticity parameters attached to roilp and roilp 2 would portray a nonlinear association between rec and real crude oil prices in the context of the selected south asian nations. among the other key variables controlling the econometric framework, rgdp abbreviates for the real gross domestic product which is included to account for the possible effects of economic growth on the facilitation of rec across the concerned economies. economic growth can be anticipated to exert a positive impact on the rec figures via empowering the concerned nations to overcome the limitations restraining the ret phenomenon (murshed 2020) . also, rgdp is interacted with roilp and included in the model to account for the joint impacts of economic growth and crude oil price shocks on the movements in the rec levels. the rationale behind the inclusion of this interaction term could be explained in the sense that as an economy, particularly the one that is a net importer of crude oil, experiences growth it can gradually lessen its dependence on the oil imports which, in turn, can be expected to elevate its rec levels. in the same vein, the econometric model is also controlled for the imported oil-dependency, abbreviated by depend, within the selected south asian economies. following damette and marques (2019) , imported oil-dependency is proxied by the share of energy imports in the total merchandize imports figures of the respective economies. a rise in the share of energy imports in aggregate merchandise import figures can be interpreted as a simultaneous increment in the degree of oil-dependency which, in turn, can be associated with lower rec within the economies. besides, the econometric model is also controlled for carbon-dioxide emissions. the variable co 2 stands for the volume of carbon-dioxide emissions measured in terms of kg per 2010 us dollars' worth of gdp. it is pertinent to include carbon-dioxide emissions in modeling the trends in rec since rising apprehensions regarding the air-pollution induced climate change adversities are likely to facilitate the substitution effect between the consumption of fossil fuels and the renewable alternatives (omri and nguyen 2014) . finally, to denotes the trade openness index, measured in terms of the sum of imports and exports as a percentage of the gdp. the relevance of considering openness to trade for modeling the rec trends can be justified in the sense that a rise in the trade openness indices can be interpreted as a reduction in the trade barriers which can be anticipated to facilitate cross-border flows of renewable power, thus, boosting the rec levels (murshed 2018) . for the robustness check of the rec-crude oil price nexus, model (1) is re-estimated using two alternate indicators of rec, namely the share of renewables in total final energy consumption figures and the share of renewable electricity in aggregate electricity output levels. the corresponding models can be specified as: where res and relec stand for the shares of renewable energy and renewable electricity, respectively, in the total final energy consumption and aggregate electricity outputs. all the variables have been transformed into their natural logarithms for the ease of the long-run elasticity estimation and also to minimize the sharpness of the annual data series to generate consistent and reliable estimates. the time frame of the dataset used in this paper stretches from 1990 to 2018. the real crude oil price data is sourced from british petroleum's statistical review of world energy 2019 (british petroleum 2019) while data for all the other variables are retrieved from the world development indicators website of the world bank (2019). table 6 in ''appendix'' provides the descriptive statistics of all the variables considered in the econometric analyses. the econometric analyses begin with the cross-sectional dependency (cd) analysis. the problem of cd is claimed to generate biased and inconsistent stationarity and cointegrating properties (dong et al. 2018 ). thus it is pertinent to investigate whether the panel series in the dataset are independent or not. cd usually stems from spatial effects whereby a particular economic data of two or more economies exert an impact on one another, thus, the associating the countries globally or regionally (chudik and pesaran 2013). this paper primarily employs the breusch and pagan (1980) lagrange multiplier (lm) test to identify the possible cd issues in the panel data series. the lm test statistic can be specified as: where n is the number of countries, t is the time period and q 2 ij is the predicted correlation coefficient sourced from the residuals of the econometric model. besides, the pesaran (2004) cd test, ideally suited for handling datasets with small cross-sections and short time dimensions, is also employed. the pesaran cd test statistic can be specified as: both these test statistics are, respectively, estimated under the null hypothesis of cross-sectional independence against the alternative hypothesis of cd. the results from the cd analyses for all three models are displayed in table 7 in ''appendix''. the statistical significances of the breusch-pagan lm and the pesaran cd test statistics reject the null hypothesis of cross-sectional independence, for the respective models, to validate the existence of the cd among the panel series. hence, the application of the conventionally used first-generation panel unit root and cointegration techniques is no longer valid since these methods fail to account for the cd issues in the dataset. in addition to cd analyses, it is pertinent to check the slope heterogeneity issue as well since ignoring the possible heterogeneity of the slope coefficients across the cross-sections could result in the estimations being biased. thus, this paper uses the slope heterogeneity test proposed by pesaran and yamagata (2008) which estimates two test statistics,d andd adj , under the null hypothesis of slope homogeneity against the alternative hypothesis of slope heterogeneity. the corresponding results from the slope heterogeneity test, for models (1), (2) and (3), are reported in table 7 in ''appendix''. the statistical significance of the test statistics, at 1% level, rejects the null hypothesis to suggest the slope heterogeneity issues. the second generation panel unit root techniques are claimed to generate estimates via addressing the cd issues, much unlike the conventionally used first-generation panel unit root tests that assume cross-sectional independence. thus, upon confirmation of the cd problem, the second generation panel unit root tests are employed. this paper uses the cross-sectionally augmented dickey-fuller (cadf) and the cross-sectionally augmented im, pesaran and shin (cips) panel unit root estimation techniques proposed by pesaran (2007) . the cadf test statistic can be obtained from the generalized regression given below: where y and d y are the cross-sectional averages of lagged levels and first differences, respectively, at time t for all cross-sections. the estimated t statistic from eq. (6) is then used to compute the cips statistic which can be specified as: where cadf i is the t statistic estimated from the cadf regression model shown in eq. (6). both the cadf and cips tests are performed under the null hypothesis of nonstationarity of the respective variable against the alternative hypothesis of stationarity. the popularly used panel cointegration methods namely the pedroni (1999) residual-based cointegration technique does not take the cd among the panels into account. thus, the westerlund (2007) panel cointegration analysis, which is robust to handling cross-sectionally dependent panel datasets, is employed to investigate the long-run associations between the concerned variables included in the econometric models. the cd is accounted for under the westerlund (2007) cointegration approach via estimation of the probability values of the test statistics using oil price shocks and renewable energy transition: empirical evidence from net oil-importing… bootstrapping methods. a total of two group-mean tests and two panel tests are performed under the null hypothesis of no cointegration against the alternative hypothesis of cointegration among at least one cross-sectional unit or cointegration among the whole panel, respectively. the four tests under the westerlund (2007) panel cointegration approach are structured in the context of an error-correction model which can be expressed as: where d t stands for the deterministic components and p i and q i are the lag lengths and lead orders which are allowed to vary across individual cross-sections. the two group-mean test statistics g t and g a and the two panel test statistics p t and p a within the westerlund (2007) cointegration analysis can be specified as: tâ î a i ð1þ ð10þ the statistical significance of these test statistics rejects the null hypothesis to suggest long-run associations between the variables included in the model. the presence of cointegrating relationships is a pre-requisite to estimating the long-run estimates using appropriate regression methods. the presence of cd issues in the dataset is likely to be translated into misspecification problems resulting in biased regression outputs (damette and marques 2019) . similarly, the slope heterogeneity issues are also likely to generate similar problems as well (pesaran and yamagata 2008) . although the conventionally used panel data estimation techniques namely the fully modified ordinary least squares (fmols) and dynamic ordinary least squares (dols) are claimed to be able to handle the cross-sectional correlations among the panels, such methods overlook the slope heterogeneity issues by inappropriately assuming the existence of the homogeneous slope coefficients across all the cross-sections. to account for this problem, this paper uses three panel data regression estimators which, in addition to handling the cd issues, allow for the slope coefficients to vary across the cross-sectional units (damette and marques 2019) . the first of the three panel data regression techniques used in this paper is referred to as the mean group (mg) estimator developed by pesaran and smith (1995) . the mg estimation primarily involves the estimation of the slope coefficients for each of the cross-sections, within the panel dataset, using the ordinary least squares (ols) method and then averaging them across the panel units. this allows for the possible heterogeneity of the slope coefficients across the different cross-sections to overcome the inefficiencies of the fmols and the dols techniques. the mg estimator can be specified as: whereb mg is the simple mean of the individual slope estimators from each cross-sectional unit. however, a major limitation of this technique is that it fails to account for the cd in the data. thus, the common correlated effects mean group (ccemg) estimator, proposed by pesaran (2006) , is tapped which is a cross-sectionally augmented version of the mg estimator to handle the cd issues as well. the ccemg corrects the limitations of the mg estimator by incorporating the time-variant unobserved common factors stemming from the cd issues into the estimation process via augmenting these unobserved common factors into the regression model before estimating the individual slope coefficients for each of the crosssections and then averaging them across the panel units. likewise the mg estimator, the ccemg estimator can also be specified as: whereb ccemg is once again the mean of the individual slope estimates from each cross-sectional unit. the only difference between the mg and the ccemg estimators, respectively, expressed in eqs. (13) and (14), is that the ccemg estimator estimates and averages the individual slope coefficients via augmenting the common factors across the cross-sections into the empirical model which is not the case in the context the mg estimator. finally, for the robustness check, the augmented mean group (amg) estimator proposed by bond and eberhardt (2013) is used for the regression analyses. the amg estimator, much like the ccemg estimator, also allows for slope heterogeneity and cd issues in the data. however, the amg estimator augments the year dummies into the model and refers the time-variant unobserved common factors to exhibit a dynamic process whereas the ccemg estimator includes the unobserved common factors in the error term (mrabet et al. 2019) . finally, the causality analyses are performed to understand the pairwise causal dynamics between the variables of concern. the newly developed dumitrescu-hurlin (dh) panel causality estimation technique developed by dumitrescu and hurlin (2012) is applied in this paper. application of the conventionally used granger (1969) causality test is inappropriate following the slope heterogeneity issues in the data since this technique assumes the slopes to be homogeneous across the cross-sectional units. the granger (1969) causality test statistic is estimated under the null hypothesis that causality does not exist between a pair of stationary variables belonging to all the cross-sections, against the alternative hypothesis of causality existing between these variables homogenously across all the cross-sections. in contrast, the dh causality technique allows for heterogeneity across the cross-sections to estimate the z-bar statistics using the null hypothesis that causality does not exist between a pair of stationary variables in all the cross-sections, referred to as the homogenous non-causality (hnc) null hypothesis, against the nonhomogenous alternative hypothesis of causality existing between these variables in at least one of the cross-sections. the mean statistic used to test the hnc null hypothesis can be specified as: where w hnc n;t is the mean value of the individual wald statistics w i;t . according to dumitrescu and hurlin (2012) , under the assumption that the individual residuals are independently distributed across all the cross-sections and their covariances are equal to zero, the mean statistic sequentially converges to the equation below when t and n tend to approach infinity: where z hnc n;t is the z statistic, n is the number of crosssections and k is the optimal lag length. moreover, dumitrescu and hurlin (2012) also argue that if t tends to infinity, the individual wald statistics are independently identically distributed with the mean individual wald statistic being equal to k and its variance being equal to 2 k. a standardized z statistic ( z hnc n;t ) is then approximately calculated for the mean wald statistic of the hnc null hypothesis which can be specified as: a graphical illustration of the empirical strategy is depicted in fig. 3 . the results from the second generation panel unit root tests are reported in (1), (2) and (3), are presented in table 3 . the statistical significances of the test statistics reject the null hypothesis of no cointegrating relationships between the variables in the respective models. hence, in the context of model (1), it can be said that rec across all the four south asian economies has long-run associations with real crude oil prices and other macroeconomic aggregates controlled for in the empirical modeling. the results coincide with the findings by apergis and payne (2015) in which the authors too found a long-run association between per capita rec and real oil prices in the context of 11 south american economies. similarly, in the context of model (2), it can also be asserted that there are long-run associations between the shares of re in aggregate final energy consumption figures and crude oil prices and all the other control variables for all the four south asian economies. finally, the statistical significance of the test statistics in the context of model (3) also provides statistical validity regarding long-run associations between the renewable electricity share in aggregate electricity outputs and the other independent variables. thus, the confirmation of the long-run associations calls for further investigation of the long-run conditional elasticities between the concerned variables. table 4 displays the long-run elasticity estimates from the mg, ccemg and the amg regression analyses. it is apparent from the overall results that the elasticity estimates, in the context of the three models, are robust across the alternate panel data regression techniques to the predicted signs and their corresponding statistical significance. in the context of model (1), the statistical significances of the elasticity parameters attached to lnroilp and lnroilp 2 confirm the nonlinearity of the rec-crude oil price nexus in the context of the selected net oil-importing south asian economies. moreover, the negative signs of the elasticity parameters attached to lnroilp advocate in favor of positive shocks to real crude oil prices, initially, not being able to facilitate rec across the concerned economies. the corresponding elasticity estimates implicate that a 1% rise in real crude oil prices is accompanied by a fall in the rec levels on average by 2.35-3.59%, ceteris paribus. the negative rec-crude oil price nexus was also reported in the study by sadorsky (2009) for canada, japan, the uk and the usa. it is worth mentioning that japan, the uk and the usa are all net importers of crude oils which further justify our results in the context of the four south asian net oil importers. however, although initially the rec-crude oil price nexus is found to be negative, the statistical significance and the positive signs of the estimated elasticity parameters attached to lnroilp 2 suggest that beyond a threshold level of real crude oil price the relationship reverses to induce greater consumption of re resources within the south asian nations. based on the elasticity estimates, the threshold level of real crude oil price is predicted to be around 135 us dollars per barrel in constant 2016 prices. 4 the corresponding elasticity estimates show that, beyond this predicted real crude oil price threshold, a further rise in the real price of crude oil by 1% is accompanied by increments in the rec levels by 0.10-0.14%, on average, ceteris paribus. therefore, it can be asserted that initially following a rise in crude oil prices the substitution of the imported crude oils via the re alternatives, within the selected south asian nations, may not be possible due to the predominant reliance of these nations on oil imports to source energy for generating their respective national outputs. a particular reason behind such imported oildependence can largely be attributed to the unavailability of indigenous natural oil endowments across south asia. this, coupled with the limited opportunities to locally generate power from renewables in most of the selected south asian countries, tends to restrain the ret process in the short-run. however, a persistent small rise in crude oil prices, approaching toward the predicted threshold, along with economic development over time would induce the ret phenomenon in these economies which possibly could be due to the gradual phasing out of the imported-oil dependencies of these economies over time. this mechanism can be explained using the estimated economic growth elasticities of rec. the positive signs of the statistically significant elasticity parameters attached to lnrgdp suggest economic growth does exhibit favorable impacts to facilitate ret within the economies which could be playing a key role in reducing their imported-oil dependencies. moreover, the positive signs of the statistically significant elasticity parameters attached to the interaction term further advocate in favor of the joint favorable impacts of economic growth and rising crude oil prices concerning the facilitation rec within the four the optimal lags are chosen based on the akaike information criterion (aic) ***, **, *statistical significance at 1%, 5% and 10% levels, respectively the bootstrapping regression is conducted with 100 replications. the optimal lag selection is based on aic ***, *statistical significance at 1% and 10% levels, respectively oil price shocks and renewable energy transition: empirical evidence from net oil-importing… table 4 long-run elasticity estimates from the panel regression analyses dep. var. model (1) model (2) model ( south asian nations. 5 furthermore, dependency on imported oils is also found to dampen the prospects of ret across south asia. the negative signs of the statistically significant elasticity parameters attached to lndepend denote that a 1% rise in the volume of energy imports leads to a fall in the rec levels on average by 0.17-0.24%, ceteris paribus. thus, reducing oil imports, which can be said to be synonymous with a reduction in imported-energy dependencies, is key to boosting rec within the south asian countries. this finding is similar to the conclusion made by damette and marques (2019) for 24 european union economies. the other important findings include the positive association between co 2 emissions and rec which explicitly points out toward the rec being triggered by environmental adversities stemming from air pollutions which, in turn, can largely be attributed to the combustion of the imported oils. thus, rising co 2 can be claimed to instigate the substitution between imported oils and the re alternatives. the positive co 2 -rec nexus is parallel to the findings by sadorsky (2009) in the context of the g7 countries. on the other hand, the regression results also imply that liberalizing trade barriers generate favorable outcomes concerning the facilitation of the ret phenomenon within the selected economies. this is evident from the positive signs of the statistically significant elasticity parameters attached to lnopen which imply that a 1% rise in the trade openness indices enhances rec by 0.23-0.29% on average, ceteris paribus. a specific reason behind this finding could be interpreted as lower trade barriers facilitating the cross-border flows of renewable power within the concerned economies whereby the levels of rec can justifiably be expected to go up. similar findings were reported in the study by murshed (2018) which included nepal as an additional south asian economy along with the four nations considered in this paper. as far as the shares of renewables in total final energy consumption figures are concerned, the elasticity estimates in the context of model (2), as reported in table 4 , also confirm the nonlinear association between renewable energy shares and real crude oil prices. the negative and the positive signs of the statistically significant estimated elasticity parameters attached to lnroilp and lnroilp 2 , respectively, provide support to this claim. the results show that a 1% rise in real crude oil prices initially curbs the shares of renewables by 0.61-0.99% on average, ceteris paribus. the small magnitudes of the predicted elasticities imply that the share of renewables in aggregate final energy consumption figures is pretty inelastic to changes in crude oil prices. however, beyond a certain threshold level of real crude oil price, a further increase in the crude oil prices by 1% enhances renewable energy shares on average by 0.01-0.07%, ceteris paribus. hence, once again it can be concluded that the rising price of crude oil in the international markets does not instantaneously lead to the substitution of crude oil via the re alternatives. however, beyond a certain price level, the substitution does take place to some extent whereby the ret phenomenon can be expected to take off. among the other key findings in the context of model (2), economic growth, although attributing to higher rec levels, does not simultaneously guarantee a rise in the share of re in the total final energy consumption figures. a 1% rise in the real value of gdp is found to reduce the re shares by 0.10% 0.12%, on average, ceteris paribus. hence, it can be said that the national outputs of these nations are relatively more intensive in the use of the nre resources which further implicates that the imported oildependency of the concerned south asian nations. moreover, quite expectedly, the marginal impacts of importedoil dependency are also found to dampen the re shares as perceived from the negative and statistically significant estimates of the elasticity parameters attached to lnde-pend in the context of model (2). on the other hand, rising carbon-dioxide emissions, despite accounting for higher rec levels, actually lead to lower shares of renewables in aggregate final energy consumption figures across the concerned south asian countries. this implies that although environmental pollution does trigger rec to some extent it does not undermine the use of the nre resources, thus, inhibiting the overall ret phenomenon. finally, openness to trade is also found to exert adverse impacts on re shares which corroborates to the findings by murshed (2018) . a 1% rise in the trade openness indices of the selected south asian economies is found to reduce the re shares by 0.14-0.18%, on average, ceteris paribus. the negative trade openness-renewable energy share nexus in the context of middle-income economies was also highlighted in the study by murshed (2020) . finally, the regression results in the context of model (3), as reported in table 4 , also confirm the nonlinear association between movements in real prices of crude oil and the shares of renewable electricity in aggregate electricity output levels within the selected south asian economies. the statistical significances of the estimated elasticities of rec concerning changes in real crude oil price and its squared term affirm the quadratic association between these two variables. however, the negative signs of the elasticity parameters attached to both lnroilp and lnroilp 2 explicitly point out the fact that rising crude oil prices do not stimulate the transition from non-renewable to renewable primary energy use for electricity generation purposes in the selected noic across south asia. this is a pretty concerning finding in the context of energy security within these nations. however, it is to be noted that the magnitudes of the estimated elasticities of the parameters attached to lnroilp 2 are relatively lower, and less than one, in comparison to the predicted elasticities of the parameters attached to lnroilp. this implies that as the real price of crude oil increases to a large extent, its dampening impact on renewable electricity shares seems to gradually diminish. hence, it can be expected that at extremely high crude oil prices, the marginal negative impact on the renewable electricity share can be anticipated to be completely phased out which, in turn, could go on to raise the share in the future. the other key results in the context of model (3) reveal that higher economic growth elevates the share of renewable electricity within the selected south asian economies. a 1% rise in the real gdp figures is found to increase the shares by 1.35-2.59%, on average, ceteris paribus. this implies that the growth of the economy empowers the concerned economies to get over the dependency on imported oils for generating electricity, thus, lessening the shares of non-renewable electricity. moreover, imported oil-dependency is found to undermine the renewable electricity share within the four noic within south asia. furthermore, rising carbon-dioxide emissions are found to ineffective in enhancing the share of renewables in aggregate electricity outputs which tends to suggest that there has somewhat been an acceptance regarding the trade-off between economic growth and environmental pollution. as a result, rising carbon-dioxide emissions across these south asian economies inhibit the overall prospects of transition from non-renewable to renewable electricity generation. the regression analyses are followed by the dh causality examinations. the results from the causality tests are reported in table 5 . it is evident from the statistical significance of the z-bar statistics that there is a bidirectional causal association between real crude oil price and rec. this finding is parallel to the findings by apergis and payne (2014a) in the context of the central american economies. moreover, findings from the causality analyses also reveal unidirectional causations stemming from real crude oil prices to the shares of re and renewable electricity in total final energy consumption and aggregate electricity output levels, respectively. hence, keeping the long-run elasticity estimates into consideration, the overall findings from the causality analysis advocate in favor of movements in real prices of crude oil, in the international market, influencing the overall prospects of ret within the selected noic across south asia. thus, safeguarding the concerned economies to overcome the predominant dependence on their oil imports is key to undergoing the non-renewable to ret within these economies. rising apprehensions in the context of energy insecurity and environmental degradation, on a global scale, in the future has sparked the need to undergo ret worldwide. the importance of transitioning from consumption of nonrenewable to re resources is of greater relevance in the context of the noic since predominant dependency on imported oils often goes on to bottleneck their prospects of ret. against this milieu, this paper attempted to investigate the impacts of exogenous shocks to the real crude oil prices on the ret phenomenon within four net oil-importing south asian economies namely bangladesh, india, pakistan and sri lanka. the overall results from the econometric analyses provided statistical validity regarding the nonlinear u-shaped association between crude oil price and rec. based on the estimates, the threshold level of real crude oil price was estimated to be around 135 us dollars per barrel which is way above the real crude oil price level of 45 us dollars per barrel in 2018. therefore, the estimated threshold implies that the real price of crude oils has to increase by almost three-fold in order to induce higher rec levels within these economies. this is a crucial finding since it partially explains the possible reason behind the existing imported-oil dependency amidst the selected south asian noic. moreover, following the ongoing novel corona virus (covid-19) pandemic, the price of crude oil is on the verge of going negative due to a stern fall in the global crude oil demand (widdershoven 2020, may 03) . under such circumstances, the degree of oil-dependency amidst the selected south asian noic can be anticipated to surge which, in turn, could adversely impact the environmental quality within these economies further. although the results from the empirical analysis implicated that the current real price of oil is way below the predicted threshold level, and the difference can be expected to widen particularly due to the covid-19 pandemic. hence, it is pertinent for the concerned economies to drift away from their predominant dependence on the imported oils for power generation purposes and undergo ret for the sake of establishing environmental well-being at the earliest. among the other key findings, statistical evidence regarding a similar nonlinear association between crude oil prices and re share in total final energy consumption figures was also ascertained. furthermore, the results also suggested that the relationship between crude oil prices and the share of renewable electricity in aggregate electricity outputs is also nonlinear; however, higher crude oil prices were not found to enhance the renewable electricity share in the context of the concerned south asian economies. finally, the causality findings revealed that changes in the crude oil prices influence movements in rec and the shares of re and renewable electricity in total final energy consumption and aggregate electricity outputs, respectively. therefore, in line with these aforementioned findings, it is ideal for the associated governments to adopt appropriate strategies to gradually phase-out the conventional imported-oil dependency of these south asian economies which, in turn, is likely to facilitate the overall ret phenomenon to a large extent. more importantly, keeping the immense potentials of cross-border re trade within south asia into cognizance, it is recommended to liberalize the corresponding trade barriers to facilitate the flows of renewable power into the four net oil-importing south asian economies considered in this paper. for instance, these economies can look forward to importing hydroelectric power from nepal while importing geothermal energy from bhutan. although the prospects of power-trade across south asia are often marginalized due to acute geopolitical and other macroeconomic issues, it is pertinent to overcome these hindrances keeping the attainment of the sdg into cognizance, particularly via the implementation of public policies that are precisely designed to foster ret within the south asian region. as part of the future scope of research, this paper can be replicated individually for the all the four net oil-importing south asian economies to identify the possible heterogeneous impacts of crude oil prices on the rec levels. moreover, this investigation can also be performed in the context of the net oil-exporting nations to understand the contrasting dynamics of the rec-crude oil price nexus ignoring the imported-oil dependency issues. funding no funding was received to conduct this research. conflict of interest the authors declare that they have no conflict of interest. output ( oil price shocks and renewable energy transition: empirical evidence from net oil-importing… ) lnres ? lnroilp 1.192 (0.231) lnrelec ? lnroilp 1.874 (0.382) lnrgdp ? lnrec 9.841*** (0.000) lnrgdp ? lnres 3.351*** (0.002) lnrgdp ? lnrelec 3.298*** (0.001) lnrec ? lnrgdp 2.113** (0.035) lnres ? 000) lnto ? lnres 6.993*** (0.000) lnto ? lnrelec 2.335** (0.020) lnrec ? lnto 2.228*** (0.006) lnres ? indicates does not granger cause renewable energy, output, co 2 emissions, and fossil fuel prices in central america: evidence from a nonlinear panel smooth transition vector error correction model the causal dynamics between renewable energy, real gdp, emissions and oil prices: evidence from oecd countries renewable energy, output, carbon dioxide emissions, and oil prices: evidence from south america the estimation of income and substitution effects in a model 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empirical evidence from net oil-importing… oil price shocks and renewable energy transition: empirical evidence from net oil-importing… key: cord-295833-z7r45291 authors: tang, biao; xia, fan; bragazzi, nicola luigi; wang, xia; he, sha; sun, xiaodan; tang, sanyi; xiao, yanni; wu, jianhong title: lessons drawn from china and south korea for managing covid-19 epidemic: insights from a comparative modeling study date: 2020-03-13 journal: nan doi: 10.1101/2020.03.09.20033464 sha: doc_id: 295833 cord_uid: z7r45291 we conducted a comparative study of covid-19 epidemic in three different settings: mainland china, the guangdong province of china and south korea, by formulating two disease transmission dynamics models incorporating epidemic characteristics and setting-specific interventions, and fitting the models to multi-source data to identify initial and effective reproduction numbers and evaluate effectiveness of interventions. we estimated the initial basic reproduction number for south korea, the guangdong province and mainland china as 2.6 (95% confidence interval (ci): (2.5, 2.7)), 3.0 (95%ci: (2.6, 3.3)) and 3.8 (95%ci: (3.5,4.2)), respectively, given a serial interval with mean of 5 days with standard deviation of 3 days. we found that the effective reproduction number for the guangdong province and mainland china has fallen below the threshold 1 since february 8th and 18th respectively, while the effective reproduction number for south korea remains high, suggesting that the interventions implemented need to be enhanced in order to halt further infections. we also project the epidemic trend in south korea under different scenarios where a portion or the entirety of the integrated package of interventions in china is used. we show that a coherent and integrated approach with stringent public health interventions is the key to the success of containing the epidemic in china and specially its provinces outside its epicenter, and we show that this approach can also be effective to mitigate the burden of the covid-19 epidemic in south korea. the experience of outbreak control in mainland china should be a guiding reference for the rest of the world including south korea. coronavirus, an enveloped virus characterized by a single-stranded, positive-sense rna, causes generally mild infections but occasionally lethal communicable disorders leading to sars, mers 1 and the current covid-19 outbreak 2,3 that has gradually spread out from the epicenter wuhan/china and affected 103 countries/territories and international conveyances including the cruise ship diamond princess harbored in yokohama/japan as of march 7 th 2020. in the absence of effective treatments and vaccines, an early adoption of stringent public health measures is crucial in mitigating the scale and burden of an outbreak. unprecedented restrictive measures, including travel restrictions, contact tracing, quarantine and lock-down of entire towns/cities adopted by the chinese authorities have resulted in a significant reduction of the effective reproductive number of covid-19 4, 5 . however, these public health interventions may not be considered and/or implemented as effectively in other settings and contexts. decision-making and implementations may require adaptations and modifications to take into account setting-specific characteristics in terms of community features, local epidemiology and risk assessment, social habits, juridical provisions, organizational coordination, and availability of economic-financial resources. for instance, particularly restrictive measures may not be effective in certain countries 6 . several public health interventions can be implemented to counteract the threat posed by an emerging outbreak 7 with pandemic potential. these interventions can be basically classified into two major categories: the measures of the first category are aimed at protecting the borders and include interventions like travel restrictions and border entry screening, whereas the measures of the second category have the objective of locally controlling the spreading of the virus and include enhanced epidemiological surveys and surveillance, contact tracing, school closure and other interventions that favor a reduction in number of social contacts. the effectiveness of such measures from both group is variable and some is still under debate. regarding, for example, extensive travel restrictions, a recent systematic review has shown that this intervention may contribute to delaying but not preventing the transmission and diffusion of a viral outbreak. as such, it is not recommended for implementation, if not within a broader package of public health measures aimed at rapidly containing the outbreak 8 . a similar conclusion can be reached for border entry screening, considered as ineffective or poorly effective per se, and therefore needs to be combined and provided together with other strategies 9 . school closure appears to be potentially effective in containing/reducing viral outbreaks, although further research is warranted to identify the best strategy in terms of timing and length of closure 10 . the measure of quarantine is also particularly controversial, since it raises ethical dilemmas, and political and social concerns 11, 12 and quantification of its real impact 11 is difficult due to a high uncertainty in its efficacy. however, in the absence of effective medical interventions, these measures must be implemented and the success of these measures, despite their disruptive impact on social-economic activities, depends heavily on how these measures are adapted to the specific scenario, in terms not only of clinical and epidemiological variables but also of social aspects, including social habits, juridical provisions, and economic-financial resources. how differentiation and combination of these interventions within a coherent and systematic package of public health measures contributes to different outbreak outcomes is an urgent global health issue that must be addressed in order to ensure that lessons from countries that have early experienced covid-19 outbreak can be learnt by other countries in their preparedness and management of a likely pandemic. in south korea, the first covid-19 case (a 36 years old chinese woman, with a recent travel history to wuhan) was reported on january 8 th 2020. a severe cluster of cases emerged in the city of daegu, where on february 23 rd 2020 a 61 years old woman spread the virus to hundreds of worshippers at shincheonji church of jesus. on march 5 th 2020, a further cluster of cases occurred at a nursing home in gyeongsan, which has been declared "special care zone" in an effort to contain the viral outbreak. as of march 8 th 2020, south korea has reported 7,313 cases, with 130 total recovered cases and 50 deaths, with no sign that the epidemic is slowing down. in comparison, intensive social contacts and massive mobility associated with the chinese traditional spring festival, combined with an initial delay in responding to the outbreak, resulted in an exponential growth of infections in the (then) epicenter (wuhan) and large case importations to other chinese cities. on january 23 rd 2020, the chinese government decisively implemented a systematic package of measures in the epicenter, including the lock-down/quarantine of wuhan city and other cities/towns of the hubei province, intense contact tracing and isolation. this led to rapid and effective mitigation of the covid-19 epidemic. case importation before the january 23 rd lock-down also resulted in outbreaks in all chinese provinces, but the systematic package of interventions implemented across the country led to effective containment. on march 8 th 2020, the newly confirmed cases in the entire country reduced to 40. particularly, guangdong, the province with the largest population in china at present, with gdp ranked first since 1989 and with the level of middle and upper income countries and middle developed countries, reported the first confirmed covid-19 case on january 19 th . on january 23 rd , the government of guangdong province announced the first-level response to major public health emergencies for controlling the spread of covid-19. as of march 8 th , there are totally 1325 confirmed cases and 8 deaths in guangdong province, and no new case is reported. in contrast to south korea, there was a relatively large ratio of imported cases in guangdong province, particularly, in shenzhen (a mega city in guangdong province) more than 70 percent of the . cc-by-nc 4.0 international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint confirmed cases are imported 13 . we obtained data of the confirmed covid-19 cases, cumulative number of quarantined individuals, cumulative death cases in mainland china from the "national health commission" of the people's republic of china 14 . data information includes the newly reported cases, the cumulative number of reported confirmed cases, the cumulative number of cured cases and the number of death cases, as shown in figure 1 (a-c). in addition, we obtained the data of the cumulative confirmed cases, cumulative cured cases and daily cases under medical observation for the guangdong province ( figure 1 (e)) of china. we also obtained the data of cumulative confirmed cases and cumulative tested cases for south korea from the korea centers for disease control and prevention (kcdc) 15, 16 , as shown in figure 1 (d), (f). the data were released and analyzed anonymously. note that the first confirmed case was reported on january 23 rd 2020 for south korea, and also on january 23 rd 2020 mainland china started the lock-down of wuhan city, the epicenter, and implemented other interventions. note that the data for reported cases, either confirmed or quarantined, or under medical observation or tested, was used in china or south korea since january 23 rd 2020. our baseline model is the classical deterministic susceptible-exposed-infectious-removed (seir) epidemic model refined by incorporating contact tracing-quarantine-test-isolation strategies ( figure 2 ). we stratify the population into susceptible ), exposed ( ), symptomatic/asymptomatic infected ( ), hospitalized ( ) and recovered ( ) compartments, and we further stratify the population to include quarantined susceptible ( ), and quarantined suspected individuals ( ). these stratifications were used in our previous studies 4, 5, 17 and is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted march 13, 2020. . https://doi.org/10.1101/2020.03.09.20033464 doi: medrxiv preprint agreement of model predictions with real data provides a validation of the model structure reflecting the interventions implemented in wuhan and in mainland china. here, we add an additional quarantined suspected compartment, which consists of exposed infectious individuals resulting from contact tracing and individuals with common fever. these individuals with common fever but quarantined as covid-19 suspected contributed to the difficulty of implementing an effective quarantine process due to the size of this compartment. in what follows, exposure, transmission and infection compartments are always used for modeling the covid-19. in our model formulation, the transmission probability is denoted by β and the contact rate is denoted by c. by enforcing contact tracing, a proportion, , of individuals exposed is quarantined, and can either move to the compartment or with rate of (or -), depending on whether they are effectively infected or not 18, 19 , while the other proportion, 1q, consists of individuals exposed to the virus who are missed from contact tracing and move to the exposed is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted march 13, 2020. . the prevention and control interventions were gradually improved in mainland china, and there are several key time points when mitigation measures were gradually strengthened: 1) on january 23 rd wuhan was locked down, and most parts of china shortly adopted a similar strategy; 2) on january 26 th , the government announced to extend the chinese traditional new year festival holiday so self-isolation/protection was maximized; 3) on february 7 th the chinese government created the partnership between each one of the 16 provinces to its sister-city in the epicenter, the hubei province, to reinforce the health care workers and equipment in the sister-city in hubei; 4) on february 12 th the hubei province started to include the clinically diagnosed cases into the confirmed cases to enhance its quarantine/isolation measure; 5) on february 14 th , wuhan refined its management protocol of residential quarters; 6) on february 16 th , the national health is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted march 13, 2020. with the same notations and assumptions described above, we can also estimate the effective reproduction number following cori 21 . namely, using within the bayesian framework, we can obtain an analytical expression of the posterior distribution of by assuming a gamma prior distribution for . then we can get the posterior means and confidence intervals of . by using the number of daily newly reported cases from january 10 th to january 23 rd 2020, we estimate for mainland china, and using the newly reported cases from january 19 th to january 31 st 2020 we estimate for the guangdong province. also, we estimate for south korea based on the number of daily newly reported cases from january 23 rd to march 2 nd 2020. all the estimates are given in table 2 . in particular, given the serial interval with mean of 5 and standard deviation of 3, for mainland china, the guangdong province and south korea is is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted march 13, 2020. . estimated to be 3.8 (95%ci: (3.5, 4.2)), 3.0 (95%ci: (2.6, 3.3)) and 2.6 (95%ci: (2.5, 2.7)), respectively. in particular, the initial covid-19 reproduction rate in south korea was smaller than that in the guangdong province. in order to investigate the variation of with respect to the serial interval, we carry out a sensitivity analysis by changing the mean of the serial interval from 4 to 8 days, the standard deviation (std) from 3 to 5. the sensitivity analysis is reported in table 2 , and we notice that increases when the mean of the serial interval increases and we remark that serial interval examined by recent studies is shorter than that earlier estimation [22] [23] [24] . it also follows from table 2 that increasing std of the serial interval only slightly decreases the estimated for a given mean of the serial interval. we also estimate the effective reproduction numbers for the considered regions, using the number of daily newly reported cases from the date the first case was reported until march 2 nd 2020 ( figure 3 ). it shows that the effective reproduction number in mainland china and in its guandong province has fallen below the threshold 1 since february 18 th and february 7 th , while the effective reproduction number of south korea remains very high, indicating that there is still room for improving the interventions in south korea. by simultaneously fitting the model (c1) to the multiple source data on the cumulative number of reported cases, deaths, quarantined and suspected cases in mainland china, we obtain estimations for unknown parameters and initial conditions, listed in table 1 . the best fitting result is shown as black curves in figure 5 with the estimated baseline exponential decreasing rate ( ) in the contact rate function. we then conduct a sensitivity analysis of the cumulative reported, death, quarantined, suspected cases, and the infected (asymptomatic/symptomatic) individuals by shrinking the exponential index , representing the weakening of the control interventions relevant to the contact rate. as shown in figure 5 , the numbers of cumulative reported, death, quarantined, suspected cases, and the peak value of the infected all increase significantly. in particular, with corresponding to no reduction of the contact rate from the initial period, the cumulative confirmed cases increases by more than six times as of april 1 st (~600,000 cases) and the peak value of the infected will increase by more than 3 times, in comparison with the actual situation under the strong control measures implemented by the chinese government. we also conduct a sensitivity analysis regarding the detection rate , by decreasing the value of . we obtain a similar conclusion that the cumulative confirmed cases would reach the number of 350,000 cases as of april 1 st with a constant detection rate (no improvement of is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted march 13, 2020. . https://doi.org/10.1101/2020.03.09.20033464 doi: medrxiv preprint detection), shown in figure 6 . as illustrated in figure 6 (f), we can observe that while decreasing the detection rate would not affect the decreasing trend of the effective reproduction number, it however postpones the time when the threshold value of 1 is reached. therefore the outcome in the mainland china, both in terms of the infections avoided and the timing when the outbreak begins to be under control, is the consequence of a systematic package of social distancing (self-isolation and self-protection), contacting tracing, and detection/diagnosis. similarly, by simultaneously fitting the proposed model (k1) to the cumulative number of reported and tested cases for south korea, we obtain the estimations for the unknown parameters and initial conditions, listed in table 1 . the best fitting result is shown as black curves in figure 7 with the estimated constant contact, testing and detection rates. for the purpose of a comparative study, we simulate the situation in south korea by importing some of the interventions and measures implemented in the mainland china. we focus on the cases when we can 1) replace the contact rate and detection rate estimated in the (k1) model from the south korea data with the time-dependent rate function (c3), and 2). adopt the time-dependent testing rate similarly to the quarantined rate function q(t) in (c3) to use (k3) with parameters to indicate the initial and maximal testing rate. we report the simulations in four scenarios: scenario a: using the testing rate function in (k3), representing an enhanced testing strategy, the cumulative tested and confirmed cases significantly increase, and the cumulative confirmed cases will reach 300 thousands on april 5 th 2020 (red curves, figure 7 (c-d)). scenario b: using only the detection rate function in (c3), the cumulative tested and confirmed cases increase too, and the cumulative confirmed cases will reach 200 thousands on april 5 th 2020 (green curves, figure 7 (c-d)). scenario c: using only the contact rate function in (c3), the cumulative confirmed cases will reach 100 thousands on april 5 th 2020 (blue curves, figure 7 (c-d)). scenario d: using the time-dependent contact, detection and testing rate functions, representing an integrated systematic package of public health control strategies, the cumulative confirmed cases will reach around 60 thousands on april 5 th 2020 (black curves, figure 7 (c-d)). we conclude that a significant reduction of covid-19 cases is achievable only through a systematic package consisting of enhanced control measures including self-isolation/self-production, effective quarantine and rapid detection/testing. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint similarly, by simultaneously fitting the model (c1) to the multiple source data on the cumulative number of reported cases, recovery and suspected cases of guangdong province, we parameterize the model and obtain the estimations for the unknown parameters and initial conditions, listed in table 1 . the best fitting result is shown as green curves in figure 8 . similarly, we consider the is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted march 13, 2020. . gradual enhancement leading to the effective control of otherwise potentially catastrophic outcomes. in comparison with south korea, guangdong has more inhabitants and a less developed economy. also, from our model-free estimation, the basic reproduction number in south korea is less than that computed for the guangdong province. therefore, the covid-19 epidemic potential in south korea was initially weaker than that in guangdong. however, our model-based analysis also shows that the effective reproduction number in south korea remains greater than 1 while the epidemic in the guangdong province has already been under control. our simulation results indicate that the covid-19 epidemic in south korea will change from a quick to a slow increase if the integrated control measures are implemented, as illustrated in figure 7 (c). hence, the experience of epidemic control in mainland china is worth popularizing, especially for the reference of western countries and other settings, including south korea. more in detail, a comparison of the parameter estimations of the guangdong province and the entire country china shows that (1) the initial and maximum quarantine rates in guangdong were much higher than those in the entire country china, while the initial and minimum contact rates were lower than those in the country, contributing to the observed better control effect in the province than the national average. (2) the confirmation ratios of the guangdong province and south korea were much lower than the ratio of the entire country china, indicating the better efficiency of contact tracing and testing in the guangdong province and south korea than that in the entire country of china. (3) the constant contact rate in south korea was larger than that in the guangdong province and even the entire country of china, with an even bigger minimum contact rate in south korea, suggesting the need of raising the awareness of the importance of self-isolation and self-protection. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted march 13, 2020. . table 1 is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted march 13, 2020. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted march 13, 2020. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted march 13, 2020. . https://doi.org/10.1101/2020.03.09.20033464 doi: medrxiv preprint is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted march 13, 2020. . https://doi.org/10.1101/2020.03.09.20033464 doi: medrxiv preprint is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted march 13, 2020. . https://doi.org/10.1101/2020.03.09.20033464 doi: medrxiv preprint coronaviruses: an overview of their replication and pathogenesis the wuhan sars-cov-2 -what's next for china the epidemiology and pathogenesis of coronavirus disease (covid-19) outbreak estimation of the transmission risk of the 2019-ncov and its implication for public health interventions an updated estimation of the risk of transmission of the novel coronavirus (2019-ncov) adapting and disseminating effective public health interventions in another country: towards a systematic approach potential interventions for novel coronavirus in china: a systematic review effectiveness of travel restrictions in the rapid containment of human influenza: a systematic review exit and entry screening practices for infectious diseases among travelers at points of entry: looking for evidence on public health impact school closures and influenza: systematic review of epidemiological studies evidence and effectiveness in decisionmaking for quarantine lessons from the history of quarantine, from plague to influenza a health commission of guangdong province national health commission of the people's republic of china korea centers for diseases control and prevention (kcdc) available online analysis of covid-19 epidemic traced data and stochastic discrete transmission dynamic model (in chinese) mathematical models of isolation and quarantine modeling infectious diseases in humans and animals a likelihood-based method for real-time estimation of the serial interval and reproductive number of an epidemic a new framework and software to estimate time-varying reproduction numbers during epidemics special expert group for control of the epidemic of novel coronavirus pneumonia of the chinese preventive medicine association, the chinese preventive medicine association. an update on the epidemiological characteristics of novel coronavirus pneumonia (covid-19) the serial interval of covid-19 from publicly reported confirmed cases serial interval of novel 1 coronavirus (covid-19) infections key: cord-263698-5w70yhvy authors: kim, y.; jiang, x. title: evolving transmission network dynamics of covid-19 cluster infections in south korea: a descriptive study date: 2020-05-12 journal: medrxiv : the preprint server for health sciences doi: 10.1101/2020.05.07.20091769 sha: doc_id: 263698 cord_uid: 5w70yhvy background. extensive contact tracing and testing in south korea allows us to investigate the transmission dynamics of the covid-19 into diverse local communities. objective. understand the critical aspects of transmission dynamics in a different age, sex, and clusters with various activities. methods. we conducted a retrospective observational study with 3,127 confirmed cases' contact tracing data from the center for disease and prevention (cdc) of south korea. we investigated network property concerning infected persons' demographics and different infection clusters. findings. overall, women had higher centrality scores than men after week four, when the confirmed cases rapidly increased. older adults have higher centrality than young/middle-aged adults after week 9. in the infection clusters, young/middle-aged adults' infection clusters (such as religious gatherings and gym facilities) have higher average path lengths and diameter than older adults' nursing home infection clusters. interpretation. some women had higher reproduction numbers and bridged successive transmission than men when the confirmed cases rapidly increased. similarly, some older adults (who were not residents of nursing homes) had higher reproduction numbers and bridged successive transmission than young/middle-aged adults after the peak has passed. the young/middle-aged adults' religious gatherings and group workout have caused long successive transmissions. in contrast, the older adults' nursing homes were a small world where the transmissions within a few steps can reach out to many persons. amid the global pandemic on coronavirus disease 2019 (covid19) , epidemiologists promote containment strategies to prevent community transmission.(1) contact tracing of susceptible persons and extensive testing in south korea demonstrated as an example of successful containment.(1) south korea reported the first confirmed cases on january 20, 2020, and the instances spiked from february 20 to 29, 2020.(2,3) as of mid-march, 2020, such containment strategies helped flatten the curve of new confirmed cases. (2) the contact tracing and testing allow us to investigate different transmission dynamics into various local communities. person-to-person transmissions can be represented as a transmission network, and this network facilitates investigation of topological dynamics in disease transmission and detection of super-spreaders. (4, 5) also, the transmission network can be divided into individual infection clusters that have different characteristics in terms of demographics and network topology. the network analysis has been widely studied in various infectious diseases such as middle east respiratory syndrome (mers), (4, 5) several acute respiratory syndrome (sars),(6)(6,7) tuberculosis, (8, 9) and cholera.(10) some covid-19 studies have revealed evolving person-to-person transmission dynamics in china in a longitudinal view. (11, 12) a genomic mutation study has investigated country-to-country transmission dynamics on a global scale. (13) a piece of critical missing knowledge is how person-to-person transmission differs across different demographics and also different super-spreading environments in cluster infections. thus, the objective of our study was to investigate network characteristics of person-to-person transmission in the different granularity: entire country and individual cluster infections. we provided interactive visualization in the code repository (https://github.com/yejinjkim/covid19-transmission-network) for an intuitive understanding of the evolving transmission network. to the best of our knowledge, our work is first to compare transmission dynamics in cluster-wise. we conducted a retrospective observational study with contact tracing data from the center for disease controls and prevention (cdc) of south korea. the south korea cdc actively performed testing, monitoring, and tracing contacts and disseminated the information to the public. we collected the contact tracing data prepared in the data science for covid-19 project in south korea,(14) which enables researchers to access the data publicly. this data contains demographics, exposure type or travel history, confirmed/release date, underlying disease, deceased status. this study used 3,127 patient's transmission data from january 20, 2020 to april 7, 2020, retrieved on april 8, 2020. the evolving transmission network. we built a longitudinal transmission network using the transmission data. the transmission network consisted of nodes for the infected persons and directed edges from infectious nodes (infector) to infected nodes (infectee). the nodes and edges had timestamps at which the infectee's infections are confirmed. this longitudinal network evolved over time as accumulating all previous nodes and edges. transmission network characteristics. we presented network characteristics in terms of centrality and path lengths: -centrality is a useful measure to investigate individual patients who shed the virus most (i.e., superspreaders) over time. we analyzed network centrality with degree and betweenness. node degree is the number of edges linked to the node in the network. betweenness is the extent to which a node lies on the shortest paths between other nodes.(15) nodes with high betweenness may have high control over transmission passing between nodes. we used betweenness to measure how much a patient contributed to the transmission as intermediate hosts. we defined a super-spreading person as a person with a degree > 3.5 for degree or top 5% betweenness values.(16) note that the node degree was calculated based on all accumulated transmissions (whereas the reproduction number is generally calculated within the observation period). -path length can measure how far the transmission chain of successive cases can go. the path length is the number of nodes or steps in the shortest path from a source node to a target node. the average path length is the average value of the shortest path lengths between all pairs of nodes in the network. the longest path length (also known as diameter) is the maximum amount of the shortest path length. infection clusters. we divided the transmission network into subgraphs with connected nodes (i.e., the connected components). the connected components are an extended concept of infection cluster, as the connected components include all successive infected persons who are infected from the infection cluster. for briefly, we denoted the connected components as the infection cluster. during the contact tracing, it is expected that the index patient was unidentifiable in each infection cluster. to represent links among the nodes in the same cluster with an unknown index patient, we set a virtual index patient and we made edges from the virtual index patient to infected patients for each infection cluster. the evolving transmission network. from january 20, 2020 to april 7, 2020, we identified a total 1,611 transmission from 3,127 patients (727 person to person; 884 persons in infection clusters with unknown index patient). we presented demographic characteristics of patients and their transmission ( fig.1 , table 1 ) when newly confirmed cases rapidly increase (weeks 4, 5, 6) and after the recently confirmed cases decrease (after peak, week 10). note that the mass cluster infection occurred at week 4 with an outbreak in religious gathering in daegu. (17) the demographic characteristics of patients and their transmission varied in different observation periods. until week 4 (the confirmed positive cases were at a low level), male to female ratio was similar (53% male; 47% female). after week 4 south korea reported more female cases than male ones. also, female-to-female transmissions were more frequent than male-to-male transmissions (but there was no statistical power as chi-squared value of the contingency table=1.36, p-value=0.2430). throughout all observations, the largest age group was age 25-49. although there was no reported transmission among similar aged children and adolescents (presumably due to strict school closure), this young age group sometimes infected their middle-aged parents. in week 6, south korea reported an increased number of new confirmed cases from older adults, and the transmissions occurred mostly among the older adults. we also presented the network property of the transmission network. the transmission network had a mean degree of 1.88 after aggregating all time windows. the system was getting sparse as new confirmed cases exponentially increased with unknown transmission paths (complete network visualization in supplement 1). the centrality of individual patients. we further investigated the distribution of the network centrality concerning infected persons' sex and race (animated plot in supplement 2). we computed the statistical significance on the difference of centrality distribution using the mann-whitney-u test. (18) as a result, we found that women have higher centrality scores than men as the confirmed cases exponentially increase around week 5 to 6 (fig. 3) . during the first four weeks after the first case, the number of instances slowly increased, and men tend to have higher degrees and betweenness. women, however, started to have higher degrees and betweenness after week 5. we used the mann-whitney-u for hypothesis testing on whether super-spreading women have higher centrality values than super-spreading men. the p-values were statistically significant after week 6 for degree (p-value=0.0156) and week 11 for betweenness (p-value=0.0402). we found that older adults have higher centrality than young/middle-aged adults after the peak has passed around week 9 (fig. 3) . after week 9, more older adults had higher degree and betweenness values than young/middle-aged adults. we used the mann-whitney-u for hypothesis testing on whether the super-spreading older adults have higher centrality than super-spreading young adults. the p-values were statistically significant after week 9 for degree (p-value=0.0413). note that there was a time lag between degree and betweenness as the betweenness increases after successive transmission occurs. there were a total of 147 clusters (defined as connected components) and we selected 12 clusters that have at least 20 patients involved. these clusters turned out to be related to religious gatherings, gym facilities, nursing homes, and customer call center office (table 3 , fig. 4) . the clusters' network visualization is available at supplement1. overall, the top four largest clusters were related to guro customer call center, shincheonji church, river of grace community church, and gym facilities in cheonan. a common characteristic of the four largest clusters was that they all had higher women rates (72%, 55%, 60%, and 72%, respectively). clusters with the smallest path lengths were all related to nursing homes (gunpo nursing home, cheongdo daenam hospital psychiatric ward, and bongwha nursing home). clusters with the most considerable path length were related to gym facilities in cheonan and shincheonji church. we observed that similar activities share similar path lengths (three nursing homes had the path length of 1.91-1.94; four churches had the path length of 2.42-2.94). all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 12, 2020. . the objective of this study was to provide the evolving transmission dynamics of covid-19 in south korea. we investigated network property and demographic features from the whole transmission network and also clustered level. the demographics of newly confirmed patients and their transmission provided an overview of how various demographic groups contribute to transmission. the main observation includes: i) in early days until week four most confirmed positives were imported cases who were male in their 40s; ii) women were more than 50% of newly confirmed cases after week 4; iii) there were more female-to-female transmissions than male-to-male transmissions; iv) children and adolescents infected their parents; and v) older adults infected other older adults. further investigation is needed to obtain statistical power. we expect these observations can provide situational awareness to future contact tracing efforts. the network characteristics of the entire system found the transmission network's density and successive transmission lengths evolved over time. the transmission network was getting sparse as the number of newly confirmed cases rapidly increased. the sparsity limitation was inherited from the contact tracing containing the increasing number of unknown transmission paths in local communities. thus our estimate on network property (degree, betweenness, diameter, and path length) should be interpreted as a lower bound. the main finding from network centrality analysis was that women had higher centrality (in both degree and betweenness) than men had as the instances rapidly increased. this implies not only that women's reproduction number was larger than men's, but also that some women bridged the long successive transmissions. a possible explanation might be that men are more likely to die or critically ill than women, and consequently men have less opportunity to shed the virus. (19) note that the higher portion of confirmed cases does not necessarily cause higher centrality. the second finding is that older adults had high centrality after the peak has passed around week 9. note that these older adults with high reproduction numbers were not related to nursing homes. older adults are more vulnerable to critical illness.(20) based on our findings, they were not active super-spreaders in the early days. still, after the virus propagated into local communities, the older adults were more likely to be infected by the virus and be superspreaders. a breakdown into smaller infection clusters allowed us to find common network characteristics within similar activities. there were three major types of clusters: religious gatherings, gym facilities, and nursing homes. the religious gathering and gym facilities clusters had high path length and diameter. these clusters mainly consisted of young/middle-aged adults. this observation may imply that the active behavior (e.g., physically close gatherings in church, active group workout in closed facilities) of young/middle-aged adults can spread further away to other communities. thus, restricting trips to other cities would be an adequate policy to prevent the spread effectively. in contrast, the nursing home type clusters consist of older adults with low path lengths and low diameter. each nursing home cluster grew fast with relatively short path length, implying that the clusters might have a small-world property that spread the virus rapidly as the majority of nodes were reachable in a small number of steps. among the three nursing homes, cheongdo daenam hospital psychiatric ward had the highest fatality, 31.82%. this closed psychiatric ward has many long-term patients with underlying diseases. (17) apart from the above local community infections, imported cases were also consistently increasing during all observation periods. the mean age of the imported patients was 42 years old at week two and consistently decreased to 35.6 years old until week 11. men took more than 50% of the imported cases for all observation periods (from 71% to 59% at week two and week 11). this study's limitation mainly comes from the sample bias in contact tracing data. the contact tracing of the rapidly evolving infectious disease inevitably contains case ascertainment biases, non-homogenous sampling over time and location, and uncontrolled correlation.(11) a substantial number of cases were missing (officially confirmed cases from korea cdc was more than 8,000 as of april). each local province government performs and reports the contact tracing, but the difficulty of the instances or granularity of reporting varies from each local government. for example, the import cases were more likely to be tracked well, but the mass infection cluster in shincheonji church has not been carefully investigated. despite the limitations, our descriptive study can provide an overview of evolving transmission dynamics in the country and infection clusters for the rapidly emerging infectious disease. our findings suggest a different level of reproduction and successive transmission chain over sex, age, and cluster activities. our analysis code is publicly available to adapt to newly reported cases. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may 12, 2020. . https://doi.org/10.1101/2020.05.07.20091769 doi: medrxiv preprint from mitigation to containment of the covid-19 pandemic: putting the sars-cov-2 genie back in the bottle regular briefing: covid-19 domestic outbreak status information technology-based tracing strategy in response to covid-19 in south korea-privacy controversies topological dynamics of the 2015 south korea mers-cov spread-on-contact networks. sci rep network analysis of mers coronavirus within households, communities, and hospitals to identify most centralized and super-spreading in the arabian peninsula network theory and sars: predicting outbreak diversity model parameters and outbreak control for sars. emerg infect dis transmission network analysis of infectious disease: a study of tuberculosis transmission in portugal transmission network analysis to complement routine tuberculosis contact investigations integration of spatial and social network analysis in disease transmission studies evolving epidemiology and transmission dynamics of coronavirus disease 2019 outside hubei province, china: a descriptive and modelling study epidemiology and transmission of covid-19 in 391 cases and 1286 of their close contacts in shenzhen, china: a retrospective cohort study [internet]. the lancet infectious diseases global transmission network of sars-cov-2: from outbreak to pandemic korean society for antimicrobial therapy, korean society for healthcare-associated infection control and prevention the mann-whitney u: a test for assessing whether two independent samples come from the same distribution tutorials in quantitative methods for psychology covid-19: the gendered impacts of the outbreak clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study the lancet we collected the contact tracing data prepared in the data science for covid-19 project in south korea. y.k. and x.j. were partly supported by the ut startup award, ut stars award, and cancer prevention research in texas (cprit rr180012), and national institute of health (nigms r01gm124111). supplement 1: network visualization for cluster infections supplement 2: animated degree distribution concerning age and sex supplement 3: animated evolving transmission dynamics of clusters author contributions yk collected data; yk and xj performed statistical analysis; and yk and xj prepared the manuscript. the sponsor of the study had no role in study design, data collection, data analysis, data interpretation, or writing manuscript. ** * ** * ** ** ** * * ** ** ** religious gatherings imported casesnursing homes key: cord-312840-jvdph782 authors: white, laura f; archer, brett; pagano, marcello title: determining the dynamics of influenza transmission by age date: 2014-03-21 journal: emerg themes epidemiol doi: 10.1186/1742-7622-11-4 sha: doc_id: 312840 cord_uid: jvdph782 background: it is widely accepted that influenza transmission dynamics vary by age; however methods to quantify the reproductive number by age group are limited. we introduce a simple method to estimate the reproductive number by modifying the method originally proposed by wallinga and teunis and using existing information on contact patterns between age groups. we additionally perform a sensitivity analysis to determine the potential impact of differential healthcare seeking patterns by age. we illustrate this method using data from the 2009 h1n1 influenza pandemic in gauteng province, south africa. results: our results are consistent with others in showing decreased transmission with age. we show that results can change markedly when we make the account for differential healthcare seeking behaviors by age. conclusions: we show substantial heterogeneity in transmission by age group during the influenza a h1n1 pandemic in south africa. this information can greatly assist in targeting interventions and implementing social distancing measures. the importance of the dynamics of influenza transmission between age groups is well-appreciated [1] [2] [3] [4] [5] [6] . several studies have assessed the non-uniformity of the impact of influenza, particularly pandemic influenza, on different age groups [1] [2] [3] [4] [7] [8] [9] . the overarching interest in these studies is to gather information in order to influence policy to best determine a strategy to impact on the spread of outbreaks. which age groups carry the greatest disease burden and which groups are responsible for the greatest amount of disease transmission is an important component of this information. one key aspect of this work is to estimate the extent to which people in different age groups interact with one another and to what degree they are in contact. this information can then be used as a surrogate for transmission probabilities between age groups [10] [11] [12] . several studies have generated matrices with estimated numbers of contacts between various age groups [5, 12, 13] . additionally, social network models have been used to estimate these contact patterns [7] . a common finding amongst these studies is that children tend to mix mostly with each other, and to a lesser extent with their parents, while adults mix with individuals from a larger range of ages [5, 7] . these matrices have subsequently been used in modeling exercises to better understand the dynamics of disease spread by age. when determining which groups to target for interventions in an outbreak, one strategy is to target those who potentially carry the greatest burden of disease [14] , which has typically been found to be children [1, 5, 7, 8, 13] . for instance, bansel et al. [4] consider data from influenza pandemics over the past century and show that the burden of disease is highest amongst children during a pandemic and then shifts to adults the following season. to better understand the utility of targeting the groups with the greatest burden of disease, it is also important to determine when different age groups tend to have their peak incidence of cases. this can also be seen as a surrogate measure for the age group that is driving an outbreak [15] [16] [17] . most recently schanzer et al. [16] used 10 years of canadian surveillance data of laboratory confirmed cases of influenza and found that during seasonal influenza the 10-19 and 20-29 year-old age groups tended to peak one week earlier than other groups. during the pandemic in 2009, the peak came earliest for only the 10-19 year old age group. this is inconsistent with the findings of brownstein et al. [15] who found that children aged 3-4 were consistently the first to peak. a different tactic for determining which groups should be the target of interventions is to select those groups most responsible for transmission [18] . studies examining disease transmission by age have consistently shown that children have higher estimated values of the reproductive number than adults. recent work has focused on the dynamics during the 2009 influenza pandemic. during the initial phase of the pandemic in japan, nishiura et al. [19] report that children were transmitting illness at higher rates than adults. glass et al. [2] used japanese data and a novel method to estimate the reproductive number, r 0 , for adults and children that assume particular forms for a nextgeneration matrix and estimate the parameters of this matrix, leading to outbreak specific estimates of r 0 . they estimate r 0 to be between 2.8 and 3.6 for children and between 0.2 and 0.7 for adults, depending on the assumptions made. in a later study, glass et al. [3] used serosurvey data and estimate r 0 from the final size of the epidemic to be 1.6 for kids and less than 1 for adults. wallinga et al. [18] have similarly shown that the rate in change of the reproductive number for a particular group is related to the incidence of infection and force of infection and suggest allocating resources based on examining these two quantities. in the present study, we present a new approach to estimating the reproductive number by age group by modifying a method initially proposed by wallinga and tuenis [20] . we study age dynamics in south africa during the 2009 influenza h1n1 pandemic and illustrate the importance of an appropriately estimated measure of the transmission dynamics on final estimates. finally, we discuss our results and their implications for future studies on how to respond during an emerging outbreak. we use de-identified data previously reported in [21] that includes a line list of the 12,543 confirmed cases reported in south africa during that outbreak. included in the data are the ages of the individuals, the provinces where the specimens were collected, the sex of the individuals, the dates of onset of symptoms, and the dates of the reporting of specimens. the information on the date of symptom onset was reported for 758 cases (6%). we use multiple imputation techniques to create 500 different datasets with the missing onset times imputed, as predicted by the province and an indicator of whether the specimen was collected on a weekday or weekend, using poisson regression [22] . we report the averages and ranges over the 500 imputed datasets. contact tracing information was collected on 100 initial cases, to provide an estimate of the serial interval, as has been previously reported [21] . we only use data from gauteng province (n = 5579, 44% of cases) to avoid confounding the results with potential spatial variation in transmission. gauteng province is the most populous, yet smallest geographically, of the nine provinces in south africa, with over 10 million inhabitants, predominantly in the cities of johannesburg and pretoria. wallinga and teunis [20] (denoted wt method hereafter) proposed a method for the estimation of the effective reproductive number by making use of the epidemic curve, n = {n 1 ,…, n t }, where n t is the number of cases at time point t, and an estimate of the serial interval, p 1 ,…, p k , where p i describes the probability of a serial interval of length i and the maximum serial interval length is k. we review this method in appendix 1. the estimator they obtain for the effective reproductive number for individual j on day t' is where n s denotes the number with symptom onset on day s and q s,t denotes the relative probability that case s was infected by case t. we propose the use of additional structure in this method to describe the probability of an infection event occurring between two cases that incorporates information on their ages by modifying the probability of transmission to be: where a j is the age group of individual j and w a i 0 a j is a measure of the likelihood of transmission between individuals in age group a i and a j . the matrix w = { w a i a j } does not necessarily have to be symmetric. this method requires information on the likelihood of infectious contact between different age groups, or the w a i a j . increasingly studies are being conducted to obtain such information by assuming that transmission is directly related to contact patterns. we use the results of two such studies: the first is a study of 571 randomly selected individuals in a south africa township performed in 2010 and reported by johnstone-robertson et al. [12] . the authors report two matrices with age specific contact patterns in five year intervals up to a 45+ category. the first matrix only considers contacts that involve all close contacts while the second includes information on only those contacts that involve physical touch. the second set of matrices we use comes from the european based polymod study of mossong et al. [5] . this study includes information on 97,904 contacts amongst 7,290 participants from eight countries in europe: belgium, finland, great britain, germany, italy, luxembourg, the netherlands, and poland. contact matrices describe all close contacts, and then separately, close contacts that involve physical touch. the matrices report age-specific values for five year age groups up to 70+. we modify these matrices to match those presented by johnstone-robertson et al. [12] and to match the demographics of south africa's young population by averaging all values above 45 years of age to create a single 45+ age category. in our results we focus on those obtained using the contact matrices from south africa, as these matrices would seem more appropriate for the data at hand. we report results from the polymod matrices as a sensitivity analysis. we estimate r t and r 0 using the 18 matrices described above with the imputed epidemic data from south africa, and report age specific estimates of these quantities, as well as aggregate estimates across age groups. the reproductive numbers for each age group represent the expected number of infections generated across the population by an individual in that particular age group. in the appendices, we further report the results of two sensitivity analyses: first we test the sensitivity of the results to potential errors in the reporting dates by selecting a single imputed dataset and randomly jittering the onset dates of 10% of the individuals, within 30 days of their observed (or imputed) onset date (appendix 2). we create 50 such datasets and repeat all analyses on these datasets and compare these results to those obtained without jittering the data. the second sensitivity analysis tests the impact of differential healthcare seeking behaviors by age. we smooth the distribution of the proportion of cases that were hospitalized by age group to serve as a surrogate distribution of healthcare seeking behavior and/or reporting patterns by age. this distribution is u-shaped, indicating that the very young and very old are more likely to seek medical care, a finding that has been reported elsewhere [23] . we attach various weights to this distribution and augment 25 of our imputed datasets according to this distribution. we reanalyze this augmented data to determine the potential impact of differential case reporting by age group on the results (appendix 3). figure 1 provides the epidemic curves across all age groups. here, school age children and young adults tend to have the greatest number of cases initially in the outbreak. ther t estimates are similar regardless of the type of contact matrix assumed (close contact versus those involving physical contact). overall,r t is much higher for those in the 15-19 and 20-24 year old groups throughout much of the epidemic, with the 10-14 and 25-29 year old age groups rapidly achieving high values, as well. those over 45 initially have fairly high estimates ofr t but these taper off quickly. estimates ofr t are not obtainable for those between 5 and 9 and those less than 5 until the outbreak is well under way, due to the paucity of observed cases for those age groups early on in the epidemic. we obtain estimates of r 0 , the basic reproductive number, by averaging the estimates of r t during the epidemic period. in reality this can be viewed as a pseudo-r 0 given the prior immunity to this strain of influenza. we will refer to it as r 0 throughout the text. we assume that the epidemic period corresponds to the point at which transmission was sustained in gauteng province until the overall number of cases peaked. this corresponds to the period between 22 june 2009 and 21 august 2009. figure 3 and table 1 show the estimates of r 0 across age groups along with the number of individuals in each age group who were reported infected throughout the epidemic. regardless of the choice of matrix, supercritical values of r 0 are obtained for those between the age of 5 and 24, with the highest values being observed for those in the 10-14 age-group (r 0 = 1.53 for close contacts). we contrast these estimates with those obtained using contact matrices from europe [5] . figures 3a and 3b shows the estimates of r 0 across the 10 age groups obtained when using contact patterns from south africa and the eight european countries in the polymod study for all close contacts (figure 3a ) and all contacts involving physical touch (figure 3b ). there are few notable differences between the estimates. in figure 4 , the mean estimates of r 0 are shown for each age group. we observe a similar overall trend for the estimate of r 0 across the age groups. finally we provide the overall estimate of r 0 collapsed over all age groups ( table 2) . for comparison purposes, we first estimate r 0 by using a traditional analysis that assumes homogenous mixing among the age groups (r 0 =1.28, range: 1.26-1.31). this is similar to that obtained for all the other contact matrices considered. additionally there are virtually no differences observed between results from the two contact matrices. our first sensitivity analysis, which jitters the onset dates of a subset of the population, (additional file 1: table s1 ) provides results that are consistent with the results presented. not surprisingly, the impact of reassigning onset dates to a portion of the dataset has the impact of flattening the epidemic curve and thus lowering the estimates of r 0 . however the results remain consistent and, coupled with the imputation variability reported, provide insight on the overall variability of the estimates reported. in our second sensitivity analysis (additional file 2: table s2 and additional file 3: figure s1 ), examining the potential impact of differential reporting by age, we note a page 5 of 10 http://www.ete-online.com/content/11/1/4 dramatic impact on the results. as we assume a greater underreporting of cases among those who are middle aged, we estimate the bulk of transmission being attributable to those who are older and less transmission being attributed to the very young, a finding contrary to the original results we present. we present a novel approach to estimating the effective and basic reproductive number by age group, and have applied this method to data from the 2009 influenza h1n1pdm in gauteng province in south africa. this method requires some estimate of contact patterns between age groups. we show results for 18 different possible contact matrices and the impact that these matrices have on the estimates. additionally, as with the original method proposed by wallinga and teunis [20] , it is necessary to have an estimate of the serial interval and we use an estimate obtained from contact trace data in south africa. as has been previously noted, that the burden of disease appears to be greatest amongst the young [21] , a finding consistent with other studies [1, 4, 7] . these data argue that aiming interventions at youth would target the group that carries the largest burden and should have the best chance of success in limiting transmission. this finding is consistent with the strategy proposed by wallinga et al. [18] and provides further information in the form of actual estimates of the reproductive number. our results also illustrate the importance of accounting for the age structure when estimating reproduction numbers. though the overall estimates of r 0 are unaffected by the incorporation of this information, we obtain much richer information with the ability to obtain age-specific estimates of the reproductive number. this analysis provides greater insight into the dynamics of disease transmission and informs intervention strategies. the results obtained using information on transmission dynamics from the study based in south africa [12] as well as that of the polymod study [5] , appear to corroborate previous results for influenza pandemics [2, 3, 19] which seem to imply that school aged children are responsible for the bulk of disease transmission. specifically we estimate thatr 0 is highest for 10-14 year olds when using south african contact trace matrices (close contacts:r 0 = 1.53, range, 1.49-1.58; physical touch contacts:r 0 = 1.47, range, 1.44-1.51). these results are similar to the results from other studies [2, 19] and those obtained using the european based contact matrices. interestingly, it does not appear to make a substantial difference which contact pattern matrix we use in our analysis. one would assume that the matrices obtained in south africa would be most relevant to the outbreak data we are analyzing and indeed, we have chosen to present the majority of our results using these matrices. we note, however, that when we use contact patterns from other european countries, where the demographics, climate, healthcare system, government, overall health, etc. are different from that of south africa, there are only minor changes in the results. indeed, the contact patterns observed in the polymod study and the south african contact study are not substantially different, however they are not identical. this appears to argue that using some form of adjustment is superior to assuming homogenous mixing, but the method we propose is not overly sensitive to the form the adjustments take [24] . this result is similar to that of glass et al. [2] who experimented with four forms of next generation matrices to estimate the reproductive number for adults and children separately. they found that the estimates of the reproductive numbers were not overly sensitive to the matrix forms that they assumed. however, one should still take care in the assumptions used when implementing this method, or others like it. our study is only one instance and it is not clear that the results we obtain would replicate in other settings. for instance, if one were to always use the polymod study information for studies throughout the world, there is still the potential for errors if contact patterns do differ dramatically from those observed in europe. while it is impossible to know with certainty if this is the case without detailed contact pattern information for the area of study, one can, at the least conduct a sensitivity analysis to determine the potential impact of the contact matrix on the analysis. additionally we implicitly assume that contact patterns are directly related to transmission probabilities, an assumption that has yet to be rigorously tested. there is also work to show that contact patterns can change considerably during illness [25, 26] . our work relies on the contact patterns of healthy individuals. while we suspect, based on our sensitivity analyses, that this will not have a substantial impact on our results, this is important to note. it is important to note the caveats and limitations of this study. our results would be impacted if reporting was inconsistent throughout the outbreak among the age groups. for instance if reporting was very good among one age group initially but declined in quality as the outbreak progressed, we can expect that our results would be biased [27] . in general the default assumption is that the pyramid of disease reporting described in [28, 29] is the same for all age groups. our second sensitivity analysis (appendix 3) explores the impact of this assumption and shows that if reporting or healthcare seeking behavior is much lower among middle aged groups than the very old and very young, our results will change dramatically. in the extreme case, we see that transmission is mostly attributable to those who are at least 30 years old and that the very young are unable to sustain transmission. while this result is contrary to what has been reported in the scientific literature to date, the potential for reporting inconsistencies that we explore are not unlikely, and have not been recognized and corrected for in other analyses that we are aware of. brooks-pollock et al. [23] report results from a survey conducted during the 2009 h1n1 influenza pandemic in the uk that showed that the very young and very old were more likely to seek healthcare when ill. the impact of correcting surveillance data to accommodate this phenomenon was to shift the burden of illness from the very young to the middle-aged. further investigation into potential reporting inconsistencies is important to better understand infectious disease dynamics by age similar to what was previously done but not incorporating age [27] . another reporting issue arises from silent infections, or those who carry infection and have the potential to transmit it, but are asymptomatic. we did not investigate the impact of these individuals, though the issues are similar to those we have just described. additional reporting inconsistencies are possible spatially or across other socio-economic factors. our analysis was only performed on data from gauteng province, the most urban province in south africa. it is possible that reporting would not be as dramatically variable as it would be if we were to make use of data from the entire country. it is also important to note that we chose to limit our analysis to gauteng province so as to limit the impact of spatial effects and make the assumption of homogenous mixing more reasonable. this could limit generalizability. we have also assumed that the contact matrices we use are correct and do not allow for any uncertainty in their estimation. these results might be improved upon and made more realistic by allowing for greater stochastic effects and/or flexibility in the transmission matrix. ideally we would estimate these parameters in our study, but we do not have sufficient data to do so in the present framework. glass et al. [2] have shown how to do this for a matrix with adults and children, but are limited to two by two matrices that presume a pre-specified structure and are unable to consider a larger number of age groups, thus limiting their ability to gain a more thorough and detailed understanding of transmission. we have applied a novel method to estimate transmission patterns between individuals from different age groups during the 2009 influenza h1n1pdm in south africa. we show that assumptions regarding the assumed contact patterns between age groups do not substantially impact the conclusions one draws from the data analyses in our study. our results are consistent with other studies that show children are much more likely to become ill and transmit disease than adults during a pandemic, if the completeness of the data reported is independent of the age of the patients. these methods can be used to estimate heterogeneity in transmission parameters in real time by using the modification proposed by cauchemez et al. [30] and thus inform the use of targeted interventions by age group. wallinga and teunis (20) (denoted wt method hereafter) proposed a method for the estimation of the effective reproductive number by making use of the epidemic curve, n = {n 1 ,…, n t }, where n t is the number of cases at time point t, and an estimate of the serial interval, p 1 ,…, p k , where p i describes the probability of a serial interval of length i and the maximum serial interval length is k. for ease of presentation, we assume that the time step is a day. individuals are placed in a network temporally by symptom onset date and the probability of transmission occurring between two individuals in the network is determined by the serial interval. the calculation of r t occurs in three steps. in what follows, we let t i denote the i th individual with symptom onset on day t, where i = 1,…,n t . 1. for the i th individual with symptom onset on day t, calculate the probabilities of infection by all those with symptom onset on prior days t 2 (t2 < t.) these probabilities equal the serial interval probability for the distance in time between the potential infector, t j 2 , and infectee, t i , p (t j ' →t i ) = p t i −t 0 j . calculate the relative probability that the case t i was infected by the j th case on day p (t j ' →t i ), denoted by q t i ;t j 0 , q t i ;t j 0 ¼ where n s denotes the number with symptom onset on day s. sensitivity analysis: impact of errors in reporting dates in this analysis, we choose a single imputed dataset and randomly jitter the onset dates of 10% of the sample within 30 days of their observed (or imputed) onset date. we create 50 such datasets and repeat all analyses on these datasets and compare them to the results on the non-jittered dataset. household transmission of influenza (h1n1-2009) in japan: age-specificity and reduction of household transmission risk by zanamivir treatment estimating reproduction numbers for adults and children from case data 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parameters for respiratory-spread infectious agents h1n1 surveillance group. improving the evidence base for decision making during a pandemic: the example of 2009 influenza a/h1n1 identifying pediatric age groups for influenza vaccination using a real-time regional surveillance system age-specific differences in influenza a epidemic curves: do children drive the spread of influenza epidemics? age-related trends in the timeliness and prediction of medical visits, hospitalizations and deaths due to pneumonia and influenza optimizing infectious disease interventions during an emerging epidemic transmission potential of the new influenza a(h1n1) virus and its age-specificity in japan different epidemic curves for severe acute respiratory syndrome reveal similar impacts of control measures interim report on pandemic h1n1 influenza virus infections in south africa epidemiology and factors associated with fatal cases reproductive number and serial interval of the first wave of influenza a (h1n1) pdm09 virus in south africa using an online survey of healthcare-seeking behaviour to estimate the magnitude and severity of the 2009 h1n1v influenza epidemic in england estimating the reproductive number in the presence of spatial heterogeneity of transmission patterns the impact of illness and the impact of school closure on social contact patterns the impact of illness on social networks: implications for transmission and control of influenza reporting errors in infectious disease outbreaks, with an application to pandemic influenza a/h1n1 estimates of the prevalence of pandemic (h1n1) 2009, united states food-related illness and death in the united states estimating in real time the efficacy of measures to control emerging communicable diseases determining the dynamics of influenza transmission by age the project described was supported by award number u54gm088558 from the national institute of general medical sciences to l.f.w. and m.p. the content is solely the responsibility of the authors and does not necessarily represent the official views of the national institute of general medical sciences or the national institutes of health. sensitivity analysis: impact of differential reporting by agewe assume that the reporting distribution by age follows a u-shaped distribution, implying that the very young and very old are most likely to seek healthcare and have their cases reported. to obtain a distribution that follows this shape, we use the distribution of hospitalized cases by age in our data, rescale it so that the highest proportion is one, and smooth the distribution using a loess smoother (additional file 3: figure s1 ).we use 25 of our imputed datasets and augment each dataset using the distribution f (x), where f (x) is a function of the original age distribution observed in the data, g (x), and the reporting distribution shown in additional file 3: figure s1 , h (x), as follows:here λ ranges between 0 and 1. we run analyses for λ = 0.0, 0.25, 0.50, 0.75 and 1.0 (corresponding to the original analysis). results for all 25 datasets are shown in additional file 2: table s2 . additional file 1: table s1 . results for the sensitivity analysis using the south african based age contact information. result presented is the estimate obtained from the original dataset and the values in the parentheses represent the range of values obtained over the 50 datasets generated for the sensitivity analysis.additional file 2: table s2 . estimates of r 0 using 25 of the 500 imputations described in the original text. results shown are the mean and range of estimates across the 25 imputed datasets. λ=1.00 corresponds to the results from the original analysis.additional file 3: figure s1 . smoothed distribution to reflect potential rates of healthcare seeking behavior and/or case-reporting by age. the authors report no conflicts of interest. key: cord-133998-yni5wnwq authors: lee, myeong; lee, seongkyu; kim, seonghoon; park, noseong title: human mobility during covid-19 in the context of mild social distancing: implications for technological interventions date: 2020-06-28 journal: nan doi: nan sha: doc_id: 133998 cord_uid: yni5wnwq the covid-19 pandemic has brought both tangible and intangible damage to our society. many researchers studied about its societal impacts in the countries that had implemented strong social distancing measures such as stay-at-home orders. among them, human mobility has been studied extensively due to its importance in flattening the curve. however, mobility has not been actively studied in the context of mild social distancing. insufficient understanding of human mobility in diverse contexts might provide limited implications for any technological interventions to alleviate the situation. to this end, we collected a dataset consisting of more than 1m daily smart device users in the third-largest city of south korea, which has implemented mild social distancing policies. we analyze how covid-19 shaped human mobility in the city from geographical, socio-economic, and socio-political perspectives. we also examine mobility changes for points of interest and special occasions such as transportation stations and the case of legislative elections. we identify a typology of populations through these analyses as a means to provide design implications for technological interventions. this paper contributes to social sciences through in-depth analyses of human mobility and to the cscw community with new design challenges and potential implications. the recent covid-19 pandemic (sars-cov-2) has caused radical social changes world-wide, driven by both citizens' prevention efforts and health authorities' policies and recommendations for flattening the curve. as part of such efforts, technological interventions such as mobilitytracking and self-diagnosis apps have been developed to help mitigate the risks (e.g., [8, 33] ). while the context could be different from pandemics, crisis management strategies and technological interventions have been widely studied in a similar manner in the computer-supported cooperated work (cscw), human-computer interaction (hci), and a broader field of crisis informatics (e.g., [41] ). for example, scholars have studied information and communication technologies (icts) for disasters and emergencies, which include, but are not limited to, effective communications tools [16] , people's re-appropriation of existing icts [44] , and crowdsourcing technologies for curating crisis-related data [51] . to make these kinds of technological interventions effective for pandemics, understanding human mobility needs to be preceded, because the spread of the virus is closely related to human mobility [29] . due to this reason, social distancing has been one of the major guidelines for citizens in many countries, among other measures during the covid-19 outbreak. human mobility is a strong predictor of the epidemic diffusion in its early stage, but it is also a direct indicator for measuring people's social distancing practices [29] . by monitoring mobility in local communities, health authorities can benefit by having data-driven evidence to adjust contingency plans and prepare strategies for future pandemics dynamically. from a technological intervention perspective, the context of covid-19 poses new challenges for cscw scholars in understanding the new norms and mobility with respect to people's work and life. while outdoor activities are not recommended during the pandemic, it is still necessary for many people to work either from their homes or workplaces, to go for grocery shopping, and to do exercises for their health. because the forms of these essential activities vary significantly by region, available resources, and even people's demographic characteristics [10] , people's behavioral patterns shaped by social determinants might be different by social, geographical, and cultural groups. this is why understanding human mobility during pandemics is a basis for implementing health policies and augmenting technological interventions to flatten the curve as well as to build the community resilience capacity. without understanding the dynamics of human mobility that are often contingent on people's socio-economic and socio-cultural characteristics, a technological intervention that is effective for one group could be a source of inequality for another. in light of this implication, there have been many studies that focus on mobility changes during the covid-19 outbreak. on the one hand, research has examined national-, state-, or county-level mobility changes, which tend to reflect people's mid-to long-term mobility during the pandemic (e.g., international students and employees go back to their home countries for the pandemic period) [19, 26] . on the other hand, with the support of it companies and non-profit organizations that have curated mobility data of their customers, many others studied mobility changes at the granular geospatial levels, such as point of interest (pois) [35] . these studies and statistics show where hot or dead spots are located during the pandemic and how people change their behaviors in a high geographical resolution, such as at a census block or a location level. they can also capture people's daily mobility patterns under strong social-distancing measures such as travel restriction [26, 52] . however, these studies' implications could be limited when it comes to a context where social and economic activities are weakly restricted. to understand the role of socio-political context during the covid-19 outbreak, we study the human mobility change between december in 2019 and may in 2020 in a metropolitan city in south korea, where social distancing was encouraged but not implemented in the form of strong travel restrictions or stay-at-home orders. this mild social distancing was possible partially by virtue of the health authority's aggressive management in the early stage of the outbreak [2] . from a scientific point of view, the context of mild social distancing in south korea provides opportunities to understand: (1) how human mobility manifests based on people's prevention behaviors and perceptions, rather than by the government's policies and administrative enforcement, (2) how social determinants of health outcomes such as demographic and socio-economic features shape people's mobility, (3) how mobility changes when the infection rate is decreasing (i.e., during a releasing period), and (4) what the mobility changes during special occasions such as the national election look like during the pandemic. in addition to these scientific contributions, this paper also provides design implications for pandemic-related technological systems. beyond crisis management, the cscw community has a long tradition of studying technology-assisted collaborative work for mobile workers [41] and crowdsourcing strategies for solving community problems through spatio-temporal data [31, 42] . understanding human mobility during the pandemic is useful not only for the design of crisis management systems but also by suggesting a typology of potential users who respond differently to the pandemic. it also provides implications for technology-assisted collaborative work strategies such as collaborative problem-solving in distant work settings. the mobility patterns of workers and their new norms in workplaces and homes might raise new challenges for collaborative systems, which might require a re-design of the existing systems. unpacking these design challenges based on people's mobility patterns will help develop mobile working and crowdsourcing strategies during the pandemic. we expect that exploring this design space will facilitate discussions about the collaborative system design for the new norms after the pandemic by introducing a new set of behavioral characteristics that manifest in diverse socio-political contexts. to this end, we make use of the 5-month pedestrian location data in the city of incheon where the largest international airport is located. 1 the data collection period is from december 18th in 2019 through april 30th in 2020, which covers the periods of pre-pandemic, the major covid-19 outbreak, and relief. 2 this dataset is a by-product of the location-based advertisement recommendation systems and was made available based on a partnership between the authors' institutions and a start-up company in south korea. we aim to understand human mobility during covid-19 in the context of mild social distancing through this data analysis. based on this analysis, we identify a typology of populations from a mobility perspective during the pandemic: crowd-avoiding outdoor workers, old workers, working voters, flexible office workers, and leisure-time seekers. this typology provides design implications for technological interventions during pandemics. we first review scientific research about human mobility during the pandemic in diverse contexts. mobility research can be classified into macro-, meso-and microscopic analyses depending on the geographical unit of analysis and the mobility data aggregation level [26] . the macroscopic-level analysis includes studies that focus on international, inter-state, or inter-county mobility patterns, which might help understand mid-to long-term migration behaviors rather than daily mobility patterns. the mesoscopic level covers regions smaller than a county or metropolitan area, such as within a combined statistical area (csa) of the united states census. such analyses focus on small-region mobility, such as cross-census tract dynamics. finally, microscopic-level analyses focus on place-level or location-based analysis where the resolution of the geographical unit is precise geo-coordinates. along with this classification, we review pandemic-related mobility research in several socio-political contexts related to the pandemic. subsequently, we review known risk factors and social determinants of health outcomes that can give rise to human mobility. many studies about human mobility during the covid-19 outbreak have focused on regions or countries that implemented a strong social distancing measure such as a stay-at-home order for a majority population. the analysis level in this context ranges from macroscopic-to microscopiclevel analyses. many of them made use of mobility data provided by it companies or non-profit organizations that was made available to the public or on-demand as part of efforts to overcome the pandemic. these studies examined the effects of strong social distancing measures in different governance units. for example, a macroscopic-level study using the mobility data from baidu showed that the inter-city and inter-province mobility in china was a proxy of the spread of the virus in the early stage of the pandemic [29] . this study concluded that the correlation between inter-city mobility and the spread of the virus weakened significantly after the country had taken a strong measure of locking down the affected cities. while the degree of enforcement was different from that in china, studies in the contexts of north america and europe provide similar implications for the impact of social distancing measures. del fava et al. showed decreasing patterns in social contacts by directly surveying people during covid-19 and found that the reduction in social contacts after announcing the social distancing guideline was smaller in north america and european countries, except for italy than china [13] . similarly, by making use of the cuebiq data, klein at al. found that, after the stay-at-home order in multiple states in the united states, inter-csa travels decreased by 60% to 80% (macroscopic) and inter-census tract mobility decreased by 50% (mesoscopic). individual-level mobility measured using the radius of gyration decreased by 40% to 60% during weekdays (microscopic) [26] . using the same dataset but focusing on the new york metropolitan area, bakker et al. reported similar patterns at the place level, showing that individuals' average travel distance per day decreased by 70% during weekends, the social contact rate decreased by 93%, and the place visiting rate decreased by 60% after the national emergency declaration in the area [1] . using the same mobility data, similar findings were found in italy, in which a strong social distancing measure was implemented [39] . studies with other datasets confirmed the same findings as that of the studies using the cuebiq data. for example, descartes lab. curated human mobility data from smartphone users' gps logs [50] . this study reported sharp mobility drops in many states in the united states after strong measures and explained some contextualized patterns by regions (macroscopic). combining this data with the safegraph dataset, another study also developed a gis-based visualization system for monitoring county-level human mobility, showing the change of people's dwelling time by county over time [17] . a study that used the unacast data reported that, at the county-level, a reduction in mobility was associated with a rise in the local infection rate [14] , which is consistent with the findings of other studies [18, 29] . overall, these studies show the effects of strong social distancing measures on human mobility in various locations, regions, and countries. although the administrative management of health authorities do affect human mobility, people's voluntary efforts and prevention behaviors also give rise to their mobility changes [50] . this phenomenon can be observed better when social distancing measures are weakly implemented because government policies may have had relatively small effects on human mobility. the number of countries that took a mild social distancing measure is smaller than those that took a strong measure. countries that were studied in the context of mild social distancing are sweden and south korea [12, 38] . although both countries took similar measures, their backgrounds and motivations are different. according to a news article, the "swedish model, " which keeps schools and other facilities open while encouraging social distancing, is intended to maintain the national healthcare system's stability by sharing the burden of the healthcare workers in taking care of their children [45] . this article reported that the swedish model was implemented based on people's strong trust towards the health authorities. meanwhile, in south korea, a mild social distancing was implemented, aided by their testings to trace all individuals who contacted confirmed patients [2] . while taking a strong measure of self-quarantine and converted schools online, korean governments have allowed free movement for most of the population. because of these differences between the two countries, their meso-or microscopic mobility patterns might be different. to our knowledge, only several studies have analyzed mobility during covid-19 in the context of mild social distancing. a study that used call detail records (cdr) acquired by a telecom company in sweden reported that there was a 64% decrease in mobility in residential areas (mesoscopic), a 33% decrease in commercial areas during daytime (mesoscopic), and a 38% decrease in the maximum travel distance per day (microscopic) in the greater stockholm region [12] . another study using the seoul metropolitan subway data in south korea reported that daily passengers decreased by 40.6% overall (mesoscopic) [38] . these studies provide a similar mobility change implication to that in the countries with strong measures: (1) the overall mobility in metropolitan areas decreases significantly; (2) the mobility in commercial areas decreases relatively less compared to residential areas, maybe due to the continued operations of businesses; and (3) demographic and socio-economic features minimally give rise to the variation of mobility change. although these studies analyzed mobility changes during covid-19 with respect to demographic and socio-economic status at the micro-and mesoscopic levels, their analyses are limited due to their short analysis period, implicit classification of land-use, and low temporal resolution. the sweden case focused on daytime mobility during an early stage of the covid-19 development, and the south korean case focused on only subway transit logs for a small number of subway stations. due to these limitations, more systematic and contextualized analyses are necessary to understand how mobility patterns change and manifest in the context of mild social distancing. to provide better implications for mobility changes in this context, we aim to conduct analyses by land-use types, socio-economic factors, and demographic features at the mesoscopic region level. as the first step toward the goal, we ask the following research question 1: â�¢ rq1: how did socio-political events about covid-19 affect human mobility in south korea? 3 in addition to socio-political events, social determinants of health outcomes, such as demographic features, could be related to a risk of covid-19, which in turn might affect people's preventive behaviors. while chronic diseases and other health conditions are considered critical factors, this paper focuses on social determinants of health outcomes for our focus on community dynamics. in public health, it is known that health outcomes such as mortality rate are heavily influenced by people's socio-economic status (e.g., income, education, and employment status), demographic features (e.g., age), and social capital (e.g., the strength of social support networks) [21] . because these factors are closely related to or confounded with individuals' access to healthcare services, health-related behaviors, and nutrition levels, mitigating the potential inequality in local communities is one of the main goals on which many medical and public health experts have focused. during covid-19, while it is still a developing phenomenon as of may 2020, individuals with high socio-economic deprivation were victimized most in the united states [46] . countries with mild distancing measures might present similar patterns to the united states when it comes to social determinants of health outcomes, even though their socio-economic and socio-cultural dynamics are different. of course, the healthcare systems in south korea and sweden are universal and government-funded, so the effect sizes of the social determinants could be different from that in the united states. however, human mobility can still vary depending on socio-economic status in these countries because of the nature of different professions and occupations across socio-economic groups [10] . because it is still unclear whether socio-economic status shaped the mobility patterns of individuals under mild social distancing measures, we ask research question 2 as follows: â�¢ rq2: how did human mobility in south korea vary depending on socio-economic status? demographic features are also known as important risk factors for covid-19. studies found that age and sex give rise to the degree of risk (mortality rate) [6, 23] . men were reported as being more vulnerable to covid-19 than women and women tend to pursue safety more actively than men from a behavioral perspective [40] . this shows that gender-driven risk-taking behavior may mediate the effects of the reported medical risk on human mobility (i.e., the social construction of the reported risk). age also matters. the medical risk from covid-19 is higher among older people; thus, the perceived risk of covid-19 may be higher among them as well. a study showed that the social distancing rate during the covid-19 outbreak was higher among older people than young people in eight european countries [13] . because the demographic factors correlated with the medical risk may shape people's perception of covid-19 differently, human mobility might vary depending on the demographic characteristics. overall, we expect that both the medical risk and the socialconstruction of gender-based prevention behaviors give rise to human mobility. previous studies on sex as a biological factor [23] and gender-based behavioral discrepancies [40] suggest two potentially-conflicting inferences for the effects of sex on mobility during covid-19. because the reported risk from covid-19 is higher among men, we can hypothesize that the drop rate of men's mobility might be higher than that of women. conversely, it is also reasonable to infer the other way around due to the behavioral patterns. therefore, we ask research question 3 as follows: â�¢ rq3: how are demographic characteristics related to human mobility during covid-19? several recent studies used the classification of places as a proxy for understanding the motivation of mobility changes at the microscopic level during covid-19 (e.g., whether each individual's movement was for an essential or non-essential purpose) [26, 35] . while partially providing similar implications, we study unique pois that are related to, but are not limited to, the international travel through a hub airport, the domestic travel through major bus stations, and the national election day. there is the biggest international airport in south korea in the city of incheon. for example, the mobility change in the airport area can imply the volumes of international travel from and to south korea. another major event during the pandemic was the national elections for congressmen and congresswomen, which were held on april 15th, 2020 [37] . this was the first national elections in the world under covid-19, which let the south korean governments take new approaches. for example, the government employees made sure that voters keep social distancing while waiting on line, wear masks, and sanitize their hands throughout the voting process. because of this new [32] . the signal decoding time in the collecting device is also under a few microseconds. therefore, a probing message is received instantaneously, and data is curated in real-time, even at the taxi velocity of 100km/h. measure, human mobility on the election day would present a unique mobility pattern compared to other days. because some of these poi-based analyses may show unique mobility patterns that can be observed only under the mild social-distancing measure, poi-based analyses might provide a nuanced understanding of the mobility changes during covid-19. in this regard, we ask research question 4 as follows: â�¢ rq4: how did human mobility change during covid-19 in the regions with important pois and on the national election day? data is curated by a location-based advertisement start-up in south korea. this company works with one of the largest telecom companies in south korea to detect real-time demographic information around a taxi. taxis use this demographic information to provide targeted advertisements that are streamed through the rooftop displays. overall, there are more than 200 taxis deployed in the city of incheon, the third-largest city in south korea. incheon international airport, located in this city, carries 77% of south korea's international flights. each taxi has a wifi intelligent access point (iap), a long-term evolution (lte) cellular modem, a gps. iap is a customized version of the general wifi access point (ap) that captures mac addresses of wifi devices such as smartphones in real-time. to protect user privacy during the data acquisition process, the demographic information is collected in an aggregated manner, and mac addresses are randomized. the data curation process is as follows. the numbers for the following steps correspond to those in the workflow in fig. 1. (1) individual smartphones keep sending wifi probe requests to find a new ap. because the iap on a taxi keeps scanning these wifi probe request messages, it can extract an mac address from a request message. (2) the taxi sends the extracted mac address to both the telecom company and the data server of the start-up company. (3) the telecom company looks up its subscriber database, as mac addresses are received, and aggregates the demographic information (i.e., age and gender) every minute. then, they send the aggregated demographic data to the start-up's server every minute. as a result, the returned demographic data does not include table 1. the notation table symbol meaning i, t taxi i, time point t in second (e.g., t can be 23:59:59, 2020-03-13) d a set of discrete time points t the entire time period in our dataset, i.e., from 00:00:00, 2019-12-18 to 23:59:59, 2020-04-30 the first outbreak time t f , the first massive infection time t m , and the golden-cross time t ð´ t 0 , t l the first and last time point of t in our dataset h an hour band in a day. h can be one of voronoi cell c and a cluster c of voronoi cells the <longitude, latitude> information of taxi i at time point t the volume of floating population detected by taxi i for the past one minute from t , i.e., [t â�� 60, t ]. we call this as volume per minute (vpm). this is taught by the telecom company. the average volume of per-minute floating population in cell c at time points in d. where p is a set of vpms with t â�� d and the longitude/latitude of taxi i belong to c at time point t . the average volume of per-minute floating population in a cluster c at time points in d similar to p c, d but we use only vpms in d whose hour band is h. p h,c, d similar to p c, d but we use only vpms in d whose hour band is h. any original mac addresses. the start-up company ensures privacy by making it impossible to join taxis' sensory data and the returned demographic data. finally, (4) the returned demographic data is used for targeted advertisements that stream through the rooftop displays in real-time. the number of captured mac addresses and their corresponding demographic information aggregated every minute are the key to understanding mobility in our analysis. volume per minute (vpm), denoted p i,t for taxi i at time point t, is the unit of human mobility (see our notations in table 1 ). the quality of data collection was tested at up to 100km/h without failure, which ensures the data consistency and stability (see the description in fig. 1 ). in this section, technical details are presented to show how key variables are generated and how the spatial and temporal units of analysis are determined. this process includes (1) the voronoi decomposition [3] of the city of incheon for determining the geospatial unit of analysis, (2) the temporal aggregation of the collected demographic data for determining the temporal unit of analysis, (3) the land-use classification in the city of incheon, (4) the socio-political segmentation of the data collection period, denoted t , and (5) the geographical imputation of socio-economic status at the voronoi cells. we present key notations in table 1 . q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q although there are municipal boundaries available within the city of incheon, these administrative boundaries tend to be inconsistent with those of meaningful mobility or people's perception of the neighborhoods, as previous work demonstrates [11, 34] . in addition, the uneven distribution of taxi locations in our data may cause varying uncertainty levels of mobility across regions if municipal boundaries are used. these potential issues lead us to generate geographical boundaries based on taxi locations. this taxi-report-driven approach to determine the geographical unit of analysis ensures the regularity of taxi density across the city's regions. one of the best ways to generate geographical boundaries based on location data is voronoi diagram [3] . to generate voronoi cells, we first run the k-means clustering [4] for the geo-coordinates of taxis to find k centroids. fig. 2 (a) shows the sum of the squared distances to cluster centroids, a popular unsupervised metric to evaluate the quality of clustering [30] , as k increases. we use the elbow method [47] to choose the optimal k configuration and k = 1, 000 is selected. to make use of the elbow method, we first draw a line segment connecting the first and last points (i.e., k = 500 and k = 2, 500) in fig. 2 (a) and calculate the perpendicular distance to the line segment for each point. as a result, k = 1, 000 yields the longest perpendicular distance. using the 1,000 centroids identified by the k-means clustering, we draw a voronoi diagram and the entire city can be segmented into 1,000 voronoi cells, as depicted in fig 3 (a) . as mentioned, p i,t is reported every minute from the partner telecom company, which poses a similar challenge to that of the geospatial unit of analysis but in a temporal manner. if the vpm data is used directly, it may not cover all the temporal range for a given voronoi cell c, due to the uneven distribution of taxis across the time slots. this means we also need to determine the temporal unit of analysis for covering an enough number of time slots for each voronoi cell. we take the following approach to decide the temporal unit. first, let u, e.g., one hour, be a new temporal unit after aggregating the original time unit t. we divide the entire time period t into many time slots of size u, we count the number of unique mac addresses for each time slot [xu, (x + 1)u) and then calculate the percentage of the time slots where the count is non-zero in a cell c. we choose such a configuration of u where the number of cells with non-empty periods (i.e., the count is non-zero) is large enough. fig. 2 (b) shows the histogram for the non-empty time slot percentages when u is one hour. in that case, a majority of cells have more than 50% of non-empty time slots. we think that the histogram of u = 30 minutes has many cells with empty time slots, and u = two hours is too coarse to observe meaningful changes in our analysis. therefore, we use one hour as the temporal unit of analysis. because human mobility patterns depend on the characteristics of the voronoi cells, mobility needs to be understood by land-use. government-provided land-use exists, but based on our qualitative examination, it does not reflect the land-use of each polygon well, maybe because people's use of the land is often mixed and varies significantly. for example, the incheon national airport area is designated as a green area according to the government's classification, but people's main use is international travel. this inconsistency between the official land-use classification and their manifestation is common in many cities that present a high population density in asia [48] . this makes it challenging to use the government's land-use classification and necessitates identifying the ground truth of the land-use in each cell in a different way. for identifying the land-use of voronoi cells, four student assistants who are familiar with the city of incheon manually assessed the land-use of each cell based on the amenities and places in it. they were asked to rank four land-use types for each voronoi cell: residential, commercial, green, and industrial, instead of selecting the best use because many cells were a mix of different uses. for each cell c, we randomly assigned three raters and have them rank the land-use types for each cell without talking to each other to minimize peer-influence. we classified each cell with a land-use type that was rated by equal to or more than two raters based on the manual coding results. to evaluate the quality of the initial tagging results, we use the fleiss' kappa [20] , denoted îº, which is a standard way to measure inter-rater agreement on rankings. the fleiss' îº was 0.41, which is a moderate agreement level and suggests a reasonable coding result for the analysis. after that, we encouraged people to discuss and make a consensus for each cell's land-use type. the first covid-19 case in south korea was reported on january 20th, denoted t f = 00:00:00, 2020-01-20 and the first massive infections started from a cult ceremony in the city of daegu on february 18th, denoted t m = 00:00:00, 2020-02-18 [7] . even though the city of daegu was about 250km away from incheon, this massive outbreak brought a serious concern to south korean people, reminding them of the criticalness of social distancing practices. about a month later, since this event, the "golden-cross," where the number of daily new confirmed cases became smaller than that of daily discharged patients from self-quarantine or hospitalization for the first time, happened on march 13th, denoted t ð´ = 00:00:00, 2020-03-13 [53] . this event was meaningful to people, signaling that the covid-19 outbreak was going downhill. these events overall were symbolically noticeable to people because the korea centers for disease control and prevention (kcdc) provided guidelines or announcements on these days, and online/offline news media also highlighted these events through many articles [28] . using these socio-political events that are symbolically and practically meaningful about covid-19, we divide the entire period t into four segments: (1) before the first case in korea, i.e., [t 0 , t f ), (2) between the first case in korea and a large outbreak in the city of daegu, i.e., [t f , t m ), (3) between the outbreak in daegu and the golden-cross, i.e., [t m , t ð´ ), and (4) on and after the golden-cross, i.e., [t ð´ , t l ]. we use t 0 and t l to denote the first and last time points, respectively, in our dataset, i.e., t 0 = 00:00:00, 2019-12-18 and t l = 23:59:59, 2020-04-30. these four time-segments are characterized as ordinary, alert, panic, and relieved, respectively, based on how south korean people feel about covid-19. we also note that alert includes the lunar new year (january 25th), which is one of the biggest holidays in east asia, and relieved includes the national legislative elections day (april 15th). because we focus on voronoi cells within the city of incheon, high-resolution data that indicates the socio-economic status of residents is needed at the cell level to answer rq2. however, south korea has not made the socio-economic status data open to the public at the granular geographical level within a city; instead, it only provides income and education status data at the city and province level [27] . due to a lack of official socio-economic status data at the voronoi cell level, we use the housing transaction data as a proxy for measuring the socio-economic status. this is feasible because, in south korea, real estate occupies the most significant portion of wealth, especially since the 2000s [25] . although housing prices weakly predicted the household income in the 1990s in south korea [24] , the structure of the real estate financing market has radically changed. since the 2000s, real estate owners have heavily relied on the chonsei system, a unique rent system in south korea that allows the owner to keep a large amount of money from tenants during their rental period, instead of receiving monthly rent [25] . this system made it possible for the owners to finance by themselves in acquiring additional real-estates, without relying on banking systems such as a mortgage. as a result, real estate ownership underpinned by the chonsei system has become a significant source of socio-economic inequality in south korea in the 2010s by hampering the entrance of new owners to the real estate market, because the institutional support for real-estate financing was insufficient for newbies [25] . these studies on the korean real-estate market justify that the housing price data based on real-world transactions can be used as a proxy of socio-economic status for the voronoi cells. the housing price data was part of the real-estate transaction dataset for the period between april 1st in 2019 and april 30th in 2020. this data was released by ministry of land, infrastructure and transport through their open data portal [36] . while the transaction data provides precise locations with physical addresses, the real-estates' locations cover only part of the voronoi cells. this led us to use a geospatial imputation method to estimate the housing prices of empty cells. when the locations of the real estate transactions were geographically aggregated into voronoi cells, 573 out of 1000 cells had housing price values. for each of the empty cells, we selected the real-estates that are located within a 1km radius from the centroid of the cell and imputed the housing price by averaging the unit prices of the selected real-estates. the length of the radius, 1km, was determined based on the size of "dong," the smallest census unit in south korea. the mean value of all dong areas in the city of incheon is 3.4km 2 , and the median value of the areas is 2.1km 2 , showing a long-tale distribution. this means the average radius of dong areas is about 1.04km, and the median radius of dong areas is about 0.82km, which justifies 1km as the radius for imputing the housing prices of empty cells. after the imputations with the 1km threshold, 114 voronoi cells (11.4% of entire cells) were still empty, meaning that there were no real-estate transactions within a 1km radius from the centroids of these cells. because many of these cells were located in the peripheral areas of the city or green areas such as mountains, we used a well-known statistical imputation method, mean substitution for these regions: the 114 cells were imputed with the average value of all the other cells. we use the results of this multi-step imputation process as the proxy of socio-economic status for the voronoi cells. in this section, we describe our main analysis results, including their detailed charts. after describing descriptive statistics in our dataset, we answer all the research questions. fig. 3 (a) shows the voronoi diagram with 1,000 cells generated based on taxi locations in the city of incheon, following the steps presented in section 4.1. using the average unit price of the realestates that were purchased or sold or the value that was imputed based on the method presented in section 4.5, the voronoi cells are color-coded in fig. 3 (a) . the smallest cell has a size of 0.01km 2 , the largest has 124km 2 , and the median size of the cells is 0.2km 2 , showing a long-tale distribution, just like that of 'dong's. 4 the total volume change of the floating population in our dataset is shown in fig. 3 (b) . more than 1m unique mac addresses are collected in a day for the data collection period. compared to that in alert, the total volume of working days decreased by 3.3% (p=3.56e-18) during the panic period. we expect that the weak implementation of a social distancing measure in south korea resulted in a small decrease compared to that in other countries [2] . south korea? to precisely analyze the human mobility influenced by important socio-political events, we first perform a t-test to test whether a voronoi cell c's mobility is influenced by the occurrence of the first massive infections at t m . after dividing each working day and each holiday in alert/panic into 24 hour bands, respectively, we construct an array of 48 values (24 for working days and 24 for holidays), denoted as follows: . we compare these two arrays, one for alert and the other for panic, using a paired t-test in each cell c. the massive infections at t m put people into a panic so comparing alert and panic is an effective method to understand the mobility change during covid-19. using the p-value threshold of 0.05, we found that 146 cells presented decreases in mobility, 47 cells showed increases, and the other remaining cells had no significant changes in mobility before and after t m . we analyze the decreasing, increasing, and non-changing cases separately to highlight each case's unique patterns as well as to identify diverse populations. we classify voronoi cells with decreased mobility into four types of land-uses, namely, residential, commercial, industrial, and green, using the manual tagging, as described in section 4.3. fig. 4 shows their mobility patterns. y -axis is the volume relative to the hourly baseline volume of ordinary. 5 both the residential and commercial regions show significant drops in mobility in panic. the cells for residential use present a mobility ratio of -14.50% (p=3.81e-39) between alert and panicthese residential cells include many standalone high-rise apartments with commercial places on their lower floors, which are usually more expensive than other residential types. the commercial cluster that consists of commercial places around bus stations, stadiums, administrative buildings presented -13.41% (p=2.39e-38) between alert and panic. in particular, the working day mobility of the residential regions decreases by -16.00% (p=8.68e-78). their mobility is not recovered even in relieved. for the industrial cluster around the port of incheon, the mobility does not decrease during working days. however, weekend mobility shows a meaningful difference between alert and panic by -25.71% (p=1.32e-6). in the 12 voronoi cells of the green cluster, their mobility decreases during panic by -16.13% (p= 1.88e-15). these cells include not only park areas but also hills and small mountains, so their absolute volume of mobility is much smaller than the baseline. one interesting pattern across residential, commercial, and industrial clusters is that while morning time mobility decreases in general, mobility at the peak rush hour time around 8 am does not decrease that much. also, slight peaks around the 6 pm (rush hours) during ordinary working days disappear in panic. this suggests that many people who can work remotely started working from home, while people who need to go to work still commute to workplaces but may have changed their commuting patterns to avoid rush hours. similarly, mobility peaks during ordinary disappear in both holidays and working days for the green cluster. this means the massive outbreak at t m affected people's commuting behavior as well as their leisure activities during weekends. fig. 5 shows the mobility patterns of the increasing cases. in all but the green cluster, their increasing rates are 80.14% (p=1.76e-5) -this residential cluster has many apartment complexes, a typical living type for many people in south korea, for the middle and working classes. in particular, the mobility of the green cluster in panic increases the most in our dataset compared to that in alert for early morning on working days (245.99%, p = 0.029). we speculate that this radical increase is due to people's increased exercise in early morning times under the covid-19 situation. for holidays, both early-morning and afternoon mobility increases significantly, maybe, also due to outdoor exercise (166.30%, p=0.015). this cell that shows such an abnormal pattern is a park and the only cell in the green cluster. this region is highlighted with a red circle in fig. 3 (a) , and its nearby cells are one of the most expensive areas and the best school district in the city of incheon. 6 another interesting pattern is that there are new peaks observed in early morning times and late afternoons on working days during panic in the residential cluster. in the commercial cluster, the pattern is similar to the residential cluster where the morning and afternoon peaks are slightly shifted to earlier times, respectively, during working days. these changes might be due to commuting citizens who had to shift their commuting times to avoid the crowds. also, the increased volumes on both working days and holidays in these clusters indicate that some people had work more during and after the pandemic, which might be caused by decreased income. finally, fig. 6 presents voronoi cells with non-significant mobility changes (residential: -0.62%, p =0.198, commercial: -0.34%, p =0.713, industrial: -0.84%, p =0.418, green: 0.68%, p =0.438). as noted, p-values are not significant in these cells between alert and panic, when the paired t-test is used. however, we can still observe some pattern changes for particular time frames. for example, on working days in the green cluster during panic, a peak in mobility is observed at around 6 pm, maybe due to people's outdoor exercises. during the morning times on holidays in the residential cluster, a peak is observed as well, maybe due to extra work or outdoor activities. these cells are a random sample of 210 cells out of all the 777 cells that do not present changes in mobility because many cells are in peripheral areas and we assumed that a random sampling of these cells would show a representative mobility pattern of the population (i.e., the 777 cells). in the aggregate level, there was no significant change in mobility that is shaped by socio-economic differences, which is consistent with the reporting from the sweden case [12] . we further analyze the impact of socio-economic status to see how they vary in more contextual conditions. using the housing price information in section 4.5, we choose residential cells and group the cells into quantiles. the mobility patterns for the top and bottom quantiles of housing prices are shown in fig. 7 . in the top quantile cells in fig. 7 (a) , the average mobility on working days and holidays slightly decreases during the daytime of panic compared to that of alert (-2.69%, p=0.050). relieved, however, shows an increased mobility pattern by 3.44% (p=0.007) in comparison with panic. one more interesting point is that the top quantile's mobility is mostly larger than the baseline marked with the dotted horizontal line (i.e., y=100). this might be because wealthy areas in south korea tend to have well-managed parks, and people would have better access to these parks. in the bottom quantile cells in fig. 7 (b) , there are no significant changes observed in working-day mobility during panic, and its mobility pattern is mostly lower than the baseline. one possible interpretation is that people still need to work even in the covid-19 situation, so there are no significant working-day mobility changes. maybe for a similar reason, the golden-cross does not cause any mobility change for the bottom quantile. also, increased mobility in the morning and afternoon times on holidays during panic compared to alert confirms such inferences. meanwhile, its holiday mobility shows meaningful increases across time frames (9.10%, p=1.24e-4). however, the absolute volume is not as large as that of the top quantile, maybe due to the limited access to parks and recreational zones. rq3 is answered through analyzing the mobility patterns by gender and age during covid-19. according to a study that assesses risk factors of covid-19 [23] , the age of more than 60 is the most vulnerable demographic group. therefore, we analyze the most vulnerable age band in conjunction with gender in figs. 8 (a) and (b) . we do not consider land-use and socio-economic factors for this analysis but show the mobility averaged over all cases. interestingly, the male population in their 60s or more shows greater mobility in general than females of the same ages. this might be due to the cultural embeddedness of traditional gender roles in mobility patterns, where men tend to work outside while women work as housewives. the changing gender roles in younger generations can be observed in the mobility patterns of people in their 20s, where the mobility difference between men and women is minimal (fig. 8 (c) and (d) ). another finding is that the holiday mobility of males in their 60s or more increases during panic and afterward. the mobility of females also increases but not as much as that of males. to understand the increase of mobility in old generations better, we plot the mobility change by age group as bar charts in figs. 8 (e) and (f). these figures show the average mobility changes (%) and standard deviations as error bars in the residential areas reported in fig. 4 (a) and fig. 5 (a) , respectively. similar to the patterns observed in fig. 4 (a) , the overall mobility of all age groups decreases during panic with varying degrees. in the cells with increased mobility, while they are not statistically significant due to the small number of cells, older generations tend to move more than other age groups. these observations indicate that the older generations show less mobility change in many areas after the covid-19 outbreak and sometimes present even increased mobility compared to younger groups. this pattern is counter-intuitive to what we have reviewed in section 2.3, where we expected that the older generations' perceived risk of covid-19 through news articles might hamper their mobility. this result implies that older generations might be more vulnerable than expected not only due to their age from a medical perspective [23] , but also because of the mobility pattern that does not show a meaningful decrease during the pandemic. 5.5 rq4: how did human mobility change during covid-19 in the regions with important pois and on the national election day? passenger transportation. fig. 9 shows the hourly patterns in the two voronoi cells related to mid-to long-distance transportation. the mobility around incheon national airport drastically decreases after the first massive infections (-31.46%, p=8.24e-6). compared to ordinary, the mobility in relieved is almost four times smaller (-80.50%, p=1.21e-56). this is because many international flights have canceled or temporarily stopped services; international travelers have also decided to stay in the country due to the global pandemic. in the cell with the city's major ground transportation, however, the mobility pattern decreases only on working days during panic and relieved (-17.76%, p=1.10e-4). 7 on holidays, mobility change shows two interesting patterns. during the afternoons and night times, the mobility increases during panic; conversely, during the morning and dinner times, the mobility decreases sharply. this might indicate that mid-to long-term travels to other cities increased while shortterm trips decreased. in relieved, the overall mobility in holidays significantly increases (14.19%, fig. 11 . the hourly mobility patterns in universities p=0.04) compared to alert and panic. the sharp decrease in morning-and dinner-time mobility observed during panic gets back or even increases in relieved. this could be the case that people who left the city for mid-to long-term come back to the city, and short-term travelers re-start traveling to other cities after observing the golden-cross. healthcare services. there are a couple of general hospitals in the city, such as inha university medical center, catholic university medical center, and gacheon university gil medical center. fig. 10 shows the mobility pattern in the cells with these hospitals. because they are the largest hospitals in the city of incheon and are responsible for taking care of covid-19 patients, their mobility increases for all cases (24.00%, p=6.67e-5). only the holiday mobility in relieved is similar to that in alert, which indicates a decreased number of covid-19 patients. around the golden-cross, the number of daily new patients is no more than 50 nationwide. therefore, it is possible to say that mobility in hospital regions decreases as covid-19 patients decrease after the golden-cross. education. the city of incheon is one of the education-oriented cities in south korea. there are many higher education institutions, such as george mason university korea, the university of utah asia campus, the state university of new york korea, yonsei university global campus, inha university. all those universities except inha university are located close to each other across adjacent voronoi cells. they are not open for spring 2020. fig. 11 shows that mobility decreases slightly during the working days in panic around inha university (-12.07%, p=0.02). however, its holiday mobility significantly increases during panic because this university opens its campus to residents (27.64%, p=0.031). the university campus might have played a role as a park during panic. for other universities located in the songdo district where premium, apartments, and parks are co-located, their mobility patterns do not change much on working days in panic. people visit the campuses on holiday mornings during panic (46.60%, p=0.028). because the songdo district, highlighted in a blue rectangle in fig. 3 (a) , also has accessible parks, recreational zones, and commercial facilities, their working day mobility does not decrease in general. in both figures, one interesting pattern is that the high holiday mobility in panic disappears in relieved. this might indicate that people are getting back to normal. legislative elections. south korea's 21st legislative elections were held on april 15th, a temporary holiday promoting voting. they were the first nationwide event since the covid-19 outbreak in south korea. as shown in fig. 12 , the mobility on the election day significantly increases in all cells related to the events, compared to the mobility in other holidays. fig. 12 (a) shows the mobility pattern in the area with the largest number of voters, and (b) shows the smallest one. their increase ratios are 10.18% (p=0.024) in fig. 12 (a) and 7.03% (p=0.045) in fig. 12 (b) . another interesting finding on the election day is the difference in mobility by wealth. in fig. 12 (c) , people in the top-3 areas (in terms of housing prices) move more actively than those in the bottom-3 areas. this difference might provide important implications for the relationship between socio-economic status and socio-political equity, as discussed in the next section. answering research questions is scientifically meaningful because it can show mobility pattern changes that are different from or similar to countries with different social distancing measures. in addition to this scientific contribution in the context of mild social distancing, the findings provide design implications for future systems in the cscw domain. based on the mobility patterns identified concerning diverse factors, we discuss potential opportunities to design technological interventions that could help flatten the curve and sustain people's daily practices and work during pandemics. as an initial effort to provide such implications, a typology of populations is identified and developed based on their mobility patterns during covid-19 and associated factors, which imply their lifestyles and work conditions in the context of mild social distancing. one of the salient types of people during covid-19 is those who still commute between their homes and workplaces while changing their commuting times, which we call "crowd-avoiding outdoor workers." in the cells that present an increase in mobility (fig. 5 , mobility increased in early mornings and early afternoons on working days in both residential and commercial areas. this may mean many people who had to go outside for their work shifted their commuting times to avoid rush hours. their concerns might be to ensure their safety during commuting times. for this type of worker, congestion-and crowd-monitoring systems or route recommendation/coordination systems could help mitigate their safety concerns during pandemics. this difficulty is observed in cells with low socio-economic status (fig. 7) . while other patterns did not change between alert and panic, cells with low socio-economic status present peaks during morning times and in the afternoons, just like working days. this means many people may have to work more during the holidays in panic than ordinary, maybe because they need to complement decreased income through gigs or part-time jobs. we hypothesize that this pattern is not due to other leisure or religious activities because they are not observed during ordinary. further research is needed to understand the citizen groups who present this mobility pattern through surveys or in-depth interviews. if the reason for the increased mobility is because of extra work, the design of crowd-monitoring systems could be improved by considering the job characteristics of crowd-avoiding outdoor workers. while not designed in this context, there have been relevant geographically-oriented recommendation systems developed in the cscw and related fields. for example, priedhorsky and terveen developed a crowdsourcing system called cyclopath to recommend bicycle routes for cyclists in the city of minneapolis, minnesota, based on people's biking trajectory data [42] . also, quercia and colleagues designed happy maps that recommend aesthetically pleasant routes by using people's ratings of urban scenes [43] . although these systems focus on geographical routes, a similar approach could be used to recommend a route and departure time to help workers safely commute to their workplaces dynamically. related to workers who have to shift their commuting times, old generations in south korea could be another population that needs special consideration from a mobility perspective. one inference that could be made based on the age group observation is that a large portion of the older generations who are more vulnerable to covid-19 than other generations might still need to commute for their work during the pandemic. as we observed in fig. 7 , people who are in their 60s or more present a smaller decrease in mobility during the pandemic compared to people who are in their 20s to 50s. this might be because, in south korea, people have to retire around the age of 60 by law, and many rely on a gig economy or part-time jobs after retirement. studies and news articles show that these generations (usually characterized as "baby boomers" and "korean-war generations") work hard after their retirements but still in poverty [22, 54] . a news outlet reported that 33% of the retired population in south korea still work but remain in a low socio-economic status, which is one of the long-standing social issues [54] . a research article published by korea institute of finance (kif) reports that the proportion of the old generations in the relative poverty level is 43.8% and that in their absolute poverty level is 32.6%, which is a significantly higher percentage than the absolute poverty rate of younger generations at 9.3% [22] . according to this report, the reasons for the low socio-economic status include the massive retirements of people who are baby boomers, a lack of income sources for the old generations, insufficient preparations for retirement life, and insufficient retirement funds. from a technological intervention perspective, providing a crowd-monitoring system is not sufficient for this population. technological designs need to consider not only the safe commuting of this population during pandemics, but also their safe job information and potential digital divides such as technical literacy, data literacy, and physical access to the internet [49] . at the same time, policies and social supports need to be combined for the welfare of the old generations because of their double hardships during the pandemic: both old generations' medical vulnerability and work conditions are related to their socio-economic status. health authorities and policy-makers can benefit from this analysis in implementing social support policies by knowing how hardships during covid-19 manifest across generations in people's mobility patterns. the difference between regions with high and low socio-economic status also manifests in the mobility patterns on the legislative election day, as depicted in fig. 12 . in the cells with low socioeconomic status, the mobility change is minimal on the election day compared to wealthy areas, and their peak in mobility is concentrated in morning times. this may indicate that a non-trivial portion of them voted in the morning and moved to other cells to work even though it is an official holiday, or they voted in advance. 8 either way, this phenomenon provides implications for the design of technological interventions for elections during pandemics. on the one hand, the voting, in general, can benefit from a design of technological coordination systems that help minimize the congestion at voting venues by assigning voters to appropriate time slots. in this case, the designers of such systems need to consider existing voting methods and known factors that could shape voting turnouts, such as early in-person voting and voters' demographic characteristics [15] . on the other hand, the mobility-driven characteristics of voters need to be taken into accounts, such as their available times and routes on the election and pre-election days. as the mobility change patterns indicate, there might be many citizens who still need to work even on voting days, e.g., self-employed people. safety issues during a voting process can result in small voting turnouts, particularly in regions with low socio-economic status due to their limited voting time slots. any interventions for voting during pandemics would need to be designed in a way that does not decrease the voting rate among this population. at the same time, policy-makers and national election commission could benefit from the mobility pattern data by choosing appropriate voting locations for the convenience and safety of marginalized populations. a noticeable pattern observed from the data analysis is a decrease in mobility in the afternoons in residential, commercial, and industrial cells on working days (fig. 4) . during the pandemic, people in these cells decreased their outside activities in the afternoons and rush hours. because there is no peak during the rush hours around dinner time, people may not have gone to work during the pandemic. based on these patterns, it is possible to infer that a large group of people are flexible in changing their working times and locations, such as opting to work from home. for this group of workers, their primary focus might be productivity. if so, asynchronous, remote collaboration tools might be helpful. as briefly mentioned in section 1, technological tools for facilitating remote collaboration are among the core topics in the fields of cscw and hci. bjã¸rn and colleagues report, through their ethnographic work, that successful remote collaboration should involve (1) the development of common ground among team members to have a shared understanding of concepts, vocabularies, and norms, (2) collaboration readiness such as languages, necessary skill sets, and peripheral knowledge outside of their core jobs shaped by organizational structure, (3) collaboration technology readiness such as conferencing tools and shared document practices, (4) coupling of work that creates interdependencies among remote workers that facilitate communications with and awareness of each other, and (5) organizational management that tends to be more difficult in a remote environment because of the reinforced power structure driven by the physical separation of teams [5] . in addition to these already complex challenges in remote collaboration, the context of pandemics can make it more difficult to develop any of these components. for example, a sudden change in working environments could result in a lack of preparation time for organizations and workers to develop common ground among team members, equip them with the necessary technology for remote collaboration, and structure the work in a way that creates higher interdependencies among them. also, remote workers could struggle from additional challenges in a home environment if they have family duties, such as taking care of children and helping household work, as reported by many recent studies [9] . accordingly, the design for remote collaboration during pandemics should consider these factors as well as people's daily mobility patterns (i.e., high in the mornings and low in the afternoons) to understand their behaviors and daily challenges better. part of the remote work collaboration is closely related to their socializing and leisure behaviors, because knowing and understanding team members is a good way to develop common grounds. beyond this, socializing and leisure activities with friends and family members is an essential part of life for people's mental/physical health and the development of trustworthiness within a community. according to fig. 4 , people usually hang out with friends and family in the afternoons of holidays in ordinary. however, in the panic period, the peak during dinner times disappears. this change suggests that socializing activities outside of their homes decreased significantly during the covid-19 outbreak. similarly, in ordinary of fig. 10 (b) , bus stations are peaked in the mornings and in the dinner times on holidays. this might be because of day travelers during the holidays. domestic travels from incheon to locations outside of the city are easier with buses rather than with trains due to the location of the city. mobility is decreased during morning and dinner times on the holidays because day travelers who regularly go to hiking and leisure activities outside of the city might have stopped having trips during the pandemic. since socializing and leisure activities are closely related to people's mental and physical health, these mobility patterns suggest a need for technological interventions to help them socialize with each other and enjoy their outdoor activities while ensuring safety. one possible implication might be, similar to that for crowd-avoiding outdoor workers, a consideration of crowdedness in pois or leisure places: systems could be designed by focusing on safe alternatives and times for outdoor activities. also, existing socializing and online networking apps could be re-appropriated by considering their emotional changes and safe times for connecting socializing goers during dinner times on holidays. as with other data-driven studies, this analysis has some limitations. even though spatial and temporal units were aggregated to some degree, there is still uncertainty embedded in the processed data due to the uneven distribution of taxis across times and locations. refining aggregation techniques and other imputation methods could help minimize the spatio-temporal bias. another difficulty is that taxis cannot capture mobility if some regions are not accessible by cars. we overcame this by setting the size of voronoi cells big enough in such areas. however, future studies may need to take this uncertainty into account to identify mobility changes more precisely. also, mixed land-use needs to be considered in future analysis. in this paper, we used the highest-ranking types among the manually-coded land-uses. however, this method still has a limitation from an analytical perspective. developing ways to consider the mixed land-use types would make this kind of study more accurate in interpreting results, especially in cities with a high population density. statistical models could be improved in future studies. this study provides a descriptive analysis of mobility changes, rather than fitting novel statistical models such as event study analysis or hazard models because this study focuses on providing implications for technological interventions during pandemics. analyzing mobility changes with advanced statistical models and spatio-temporal analysis will benefit social scientists and policy-makers with more accurate measures and monitoring technologies. finally, the use of housing transaction data as a proxy of socio-economic status needs more validation. although there is strong evidence that real-estate ownership is a symbolic and material wealth indicator, there might be some discrepancies between housing prices and actual wealth at the mesoscopic region level. measuring and predicting socio-economic status could benefit from machine learning models and large-scale surveys in future studies. also, open data support from the statistical department in the government of south korea will help alleviate this issue. nevertheless, this study provides extensive analyses of human mobility during the covid-19 outbreak, by possibly covering the most pre-and after-pandemic periods in south korea. by analyzing human mobility in diverse regions and times of the day, this paper contributes to the scientific findings on mobility during covid-19 in the context of mild social distancing. also, through the examinations of daily pattern changes in mobility, this paper identifies a typology of five mobility groups who potentially need more attention for their safe navigation of daily practices. we hope that the typology of populations and their discussions provide useful implications for the design of technological interventions to help relieve the on-going challenges and plan for the post-pandemic era. effect of social distancing measures in the new york city metropolitan area how south korea reined in the outbreak without shutting everything down computational geometry : algorithms and applications pattern recognition and machine learning does distance still matter? revisiting the cscw fundamentals on distributed collaboration estimation of risk factors for covid-19 mortalitypreliminary results a timeline of south korea's response to covid-19 contact tracing mobile apps for covid-19: privacy considerations and related trade-offs disparities in mobility responses to covid-19 the livehoods project: utilizing social media to understand the dynamics of a city alexey siretskiy, and marina toger. 2020. effects of the covid-19 pandemic on population mobility under mild policies: causal evidence from sweden 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for severe disease and death socioeconomic status and perception of the quality of life in korea dissonance between formal and informal housing capital: the case of korea assessing changes in commuting and individual mobility in major metropolitan areas in the united states during the covid-19 outbreak press release the effect of human mobility and control measures on the covid-19 epidemic in china the (black) art of runtime evaluation: are we comparing algorithms or implementations? crisis crowdsourcing framework: designing strategic configurations of crowdsourcing for the emergency management domain propagation delay influence in ieee 802.11 outdoor networks covid-19: researchers launch app to track spread of symptoms in the uk identifying urban neighborhood names through user-contributed online property listings a country comparison of place-based activity response to covid-19 policies infrastructures ministry of land and transport. 2020. real-estate transaction data portal south korea shows the world how to hold elections during a pandemic changes in subway ridership in response to covid-19 in seoul, south korea: implications for social distancing covid-19 outbreak response: a first assessment of mobility changes in italy following national lockdown emanuele del fava, sofia gil-clavel, and emilio zagheni. 2020. behaviors and attitudes in response to the covid-19 pandemic: insights from a cross-national facebook survey dealing with mobility: understanding access anytime, anywhere the computational geowiki: what, why, and how the shortest path to happiness: recommending beautiful, quiet, and happy routes in the city social media in emergencies: a representative study on citizens' perception in germany sweden's coronavirus strategy is not what it seems the coronavirus is infecting and killing black americans at an alarmingly high rate who belongs in the family the advantages of a high density the evolution of the digital divide: the digital divide turns to inequality of skills and usage mobility changes in response to covid-19 providing real-time assistance in disaster relief by leveraging crowdsourcing power an interactive covid-19 mobility impact and social distancing analysis platform discharged>new confirmed cases ë¹�ê³¤ì�¨ë�� ì��ë��ì � 1ì�� ì�� (the employment rate of korea's old generations is top-1 in the world key: cord-340848-gdi4c92i authors: moon, m. jae title: fighting covid‐19 with agility, transparency, and participation: wicked policy problems and new governance challenges date: 2020-05-20 journal: public adm rev doi: 10.1111/puar.13214 sha: doc_id: 340848 cord_uid: gdi4c92i governments are being put to the test as they struggle with the fast and wide spread of covid‐19. this article discusses the compelling challenges posed by the covid‐19 pandemic by examining how this wicked problem has been managed by the south korean government with agile‐adaptive, transparent actions to mitigate the surge of covid‐19. unlike many western countries, south korea has been able to contain the spread of covid‐19 without a harsh forced lockdown of the epicenter of the virus. this essay argues that an agile‐adaptive approach, a policy of transparency in communicating risk, and citizens’ voluntary cooperation are critical factors. it also suggests that the south korean government learned costly lessons from the mers failure of 2015. this essay suggests ways that western countries can manage future wicked problems such as covid‐19 without paying too much cost and maintaining quality of life in open and free societies. as the pandemic stage of covid-19 continues to develop, we have observed how governments have responded to the threat and dealt with challenging policy issues in different ways. although many studies have examined crisis management (comfort 2007; comfort et al. 2012; moynihan 2008) , covid-19 appears to present new challenges because of the scale and speed of infections. this study aims to discuss key governance and policy issues that have been revealed in the course of making critical decisions about preparing for, mitigating, and responding to the outbreak. in particular, this essay examines key policy issues identified in the south korean government's initial response to the outbreak, then draws some lessons and policy implications for other countries that have been experiencing the same challenges as the pandemic situation continues. covid-19 was reported to have originated in wuhan, hubei, china. initially, covid-19 appeared to be similar to middle east respiratory syndrome (mers) and particularly severe acute respiratory syndrome (sars). however, it is more contagious and more impactful in provoking economic and social instability and igniting psychological fears of individuals than previous infectious diseases. for example, as figure 1 suggests, the number of infected patients has grown much faster than previous diseases, reaching about 2.5 million (with more than 160,000 deaths) in about four months as of april 19, 2020. 1 in comparison, sars and mers reached 8,096 patients in eight months and 203 patients in a year, respectively (wu and chow 2020) . 2 in addition, covid-19's geographic spread has been much wider, reaching the pandemic stage in about 150 countries as of april 19, 2020, 3 figure 2 active covid-19 cases in south korea the city of daegu and from kyungbook province. the majority (about 60 percent) of the confirmed cases were from these two areas as of the middle of march 2020, as a church member known as "patient 31" (a super spreader) infected many other members during worship in a shincheonji church in daegu, which suddenly became the epicenter of the covid-19 outbreak in south korea. with the unexpected spike in covid-19 cases in daegu and kyungbook province, the south korean government raised its alert to the highest level and took a series of actions ranging from full-scale epidemiological investigation of infected patients to medical and economic policy packages. of course, the government experienced obstacles in negotiating with the religious group to acquire necessary information such as church members' contact information and the locations of church facilities in order to identify possible infected patients and to prevent possible future infections. thanks to agile, adaptive, and transparent actions by the south korean government, along with citizens' active participation in figure 1 comparison of covid-19, sars, and mers social distancing, the rate of infection began to drop dramatically. as figure 2 shows, the number of infected patients under treatment was reduced to 2,484 (out of more than 10,000 total confirmed patients) as of april 18, 2020, and the number of recovered patients began to outnumber new confirmed cases on march 14, 2020. the number of new cases dropped to fewer than 10 on april 19, 2020. the following section will examine how the korean government responded to the sudden surge of covid-19. while the south korean government has been considered an exemplary case in demonstrating effective and innovative responses to the covid-19 outbreak, it experienced a painful failure in its initial response to and mitigation of mers in 2015. according to a mers white paper published by the ministry of health and welfare (2016), south korea had 186 infected patients and 38 deaths between may 20 and december 23, 2015, when the south korean government officially declared the eradication of the outbreak. south korea was second only to saudi arabia in terms of the number of infected patients. the first patient was reported to have been infected during a two-week trip to the middle east at the end of april 2015. the patient visited several medical clinics before he was later diagnosed with mers. later, the number of confirmed cases began to increase through hospital infections as infected patients visited the hospital and were treated. despite the surge of infected cases, the south korean government initially did not disclose necessary information to the public, such as where the patients were hospitalized, to avoid any unnecessary fear among citizens and potential reputation damage to the hospitals. 4 this position of nontransparency caused public outcry as well as tensions with local governments that wanted to disclose related information. for example, the mayor of seoul metropolitan city criticized the central government's nontransparent stance and held an emergency briefing to release information about the infection paths of patients and exposed hospitals. though this caused much friction between the central and local governments, this open information position of the seoul metropolitan government was source: modified from wu and chow (2020) . source: worldometer, https://www.worldometers.info/coronavirus/country/south-korea/ (accessed april 18, 2020). later accepted by the central government, and it allowed individual citizens to identify and assess their possible exposure to infected patients. in addition, many managerial and policy limitations were identified in the course of fighting mers until the last quarantined patient was released on july 27, 2015. later, the mers white paper (ministry of health and welfare 2016) was published to document key lessons and policy recommendations from the mers experience so as not to forget the failure and to turn the painful experience into useful guidance in handling future similar cases. based on these policy recommendations, the south korean government upgraded the korean centers for disease control and prevention (kcdc) to a deputy-ministerial-level agency and strengthened its autonomy and professional specialties by increasing the number of epidemiological surveyors (ministry of health and welfare 2016). the mers experience was costly, but it provided a great organizational learning experience for the south korean government, as the government acquired "puzzling" and "powering" capacities from the accumulated experience of managing the mers outbreak under uncertain, urgent, and complex circumstances (moynihan 2008) . the south korean government's institutional learning was primarily based on reevaluation/assessment (puzzling) and reform (powering) (moynihan 2008) , which enhanced the kcdc's autonomy and capacity and established procedural protocols to control and prevent new infectious diseases such as covid-19. the south korean government learned costly lessons from the mers failure 5 that became the foundation for the current policy actions against covid-19 (normile 2020). the next section will discuss how the south korean government responded to the covid-19 outbreak and mitigated its unexpected surge. in particular, agile, adaptive, and transparent actions by the south korean government, as well as evidence-based policy decisions and collaborative governance, were emphasized. this section also examines how citizens' participation in social distancing campaigns and voluntary quarantine was effective at mitigating covid-19. the south korean government introduced agile responses to possible infected cases based on thorough epidemiological surveys of each possible case. while some medical specialists argue that we should recognize that covid-19 may eventually become a seasonal infectious disease like influenza, others claim that governments should take more aggressive measures to suppress transmission of infectious disease as much as possible. the former often supports a soft and somewhat passive approach, including moderate mitigation measures. for example, the u.k. prime minister at one point suggested that the country might need to wait until 60 percent of the people had been infected and obtained so-called herd immunity (costello 2020) . japan also appeared to take this approach. the latter is a hard approach, which often requires forceful and aggressive measures such as lockdowns, travel bans, and curfews, as was done in china. many countries initially positioned themselves somewhere between two approaches but changed their positions as the situation worsened. for example, many european countries such as italy and france shifted from a soft and passive approach toward a hard and aggressive approach. the south korean government took a unique approach, which i call an agile-adaptive approach. south korea proactively identified each infected case and exposed potential cases as fast as possible. this approach requires not only massive testing and quarantine of infected patients but also technological support to track their movements. in fact, the south korean government tested more than 4,099 people per million from the beginning of the outbreak, while the united kingdom, japan, and the united states tested 387, 76, and 26 people per million, respectively, as of march 9, 2020 (mccarthy 2020; worldometer 2020). as of april 18, the south korean government was testing about 10,000 people per million. 6 this massive preventive testing relied on a systematic epidemiological survey of each infected patient, which enabled governments to emulate the contagion speed with its suppression capacity by isolating and treating infected patients. of course, this is only a feasible alternative in the early stages of a covid-19 outbreak because it is almost impossible to have a complete epidemiological survey once the outbreak becomes a community contagion. such a massive scale of testing was possible because the south korean government was well prepared to conduct a large-scale epidemiological survey and quickly develop infectious disease testing kits by increasing the number of epidemiological professionals in the kcdc and local governments, as well as by promoting infectious disease research and development among academics and related medical communities in post-mers policy actions. several innovative practices, such as drive-through and walk-through testing stations, were quickly adopted, which helped not only shorten the testing time but also reduce potential infections in medical facilities, enhancing national testing capacity (normile 2020) . this approach allowed the government to slow down the contagion speed and ease the spike of new infected cases. similar to the notion of agile government (deloitte 2017; deseve 2020; moon 2017 moon , 2019 , agile actions often require flexible organizational structure, increasing involvement of stakeholders and resources, and efficient decision-making processes for timely and transparent results. the south korean government was adaptive and flexible in handling new situations and receptive to new ideas and alternative solutions under the uncertain circumstances, particularly in the course of the rapid surge of infected patients. for example, the south korean government quickly sought alternative ways to handle new situations by using training centers and public institutions' facilities to accommodate infected but light-symptom patients and by adopting new methods to minimize hospital infections, such as drive-through and walk-through testing stations. this adaptative approach was largely possible because the south korean government attempted to put "science" over "policy" (comfort 2007 ) by making key initial disinfection decisions primarily based on scientific evidence and standard operating procedures established after the mers incident of 2015, then adjusting its decisions based on inputs from the fields rather than political calculations. countries that did not take an agile-adaptive approach later decided to increase testing and often introduced a hard approach such as lockdown, which was initially adopted by china and later by western democratic countries such as italy and france as they experienced uncontrollable massive surges. unfortunately, countries often missed the golden time for the necessary thorough epidemiological survey-based effective mitigation, which forced them to take a hard approach. this indicates that south korea's agile and adaptive approach with massive testing was an appropriate action to control the outbreak without extreme intervention measures such as aggressive lockdowns that forcibly constrained citizens' mobility. the majority of respondents to a national survey by the institute of future government (2020) indicated that they felt positive about the south korean government's action and preferred it to that of other countries. one of the crucial lessons from the mers failure was that governments should be open and transparent to the public. to actively communicate with citizens to increase their awareness of and engagement in anti-covid-19 measures, the government provided all necessary information, including up-to-date statistics on infected cases and the fatality rate, as well as details of the movement path of each individual infected patient prior to being quarantined. in fact, citizens frequently received notifications from the government on where a new infected case was found and where the patient had been. in addition, apps were developed by the government as well as citizens that allowed citizens to track where the infected patients visited (e.g., corona map). 8 this was made possible thanks to many technological and legal supports that permitted data mining of cctv footage, credit card use, and gps information from the mobile phones of infected persons. as the country experienced a shortage of face masks, apps were also developed and provided to give information regarding the locations of drugstores and the number of face masks available in nearby drugstores. it should be noted that active information provision often raises concerns about infringement on the privacy of infected patients, even though their identities are not revealed. this is part of an ongoing debate on the trade-off between privacy and public safety. regarding this debate, a recent national survey suggested that a majority of south koreans (84.4 percent) preferred having transparent information provided by the government on the details of the movements of infected patients to withholding the information for the purpose of privacy protection (institute of future government 2020). the survey also showed that a majority of respondents checked covid-19 information multiple times a day: about 62 percent answered that they checked the information more than three times, and 34.3 percent answered that they checked one or two times a day. despite the favorable reception of governments' uses of private information for the sake of public health interest, governments and citizens should constantly revisit the privacy-public interest trade-off and figure out how possible abuse of public authority and infringement on privacy can be monitored, prevented, and managed. this is an important issue whenever new technological solutions for covid-19 tracking systems, such as google's social distancing tracking systems, are developed and adopted. in fact, the privacypublic health interest trade-off was an important consideration when the south korean government decided to introduce electronic wristbands to effectively enforce quarantine policies by monitoring and preventing violations of mandated quarantines. while the openness and transparency of the south korean government about covid-19 has been well received and trusted by citizens in general, it stirred citizens' fears and outrage in the initial stage. when a sudden surge of confirmed cases began with the shincheonji-originated spike in the daegu and kyungbook regions, citizens were extremely disturbed, as they were shocked by the daily updated statistics showing the abrupt rise in the number of infections and deaths. many were disappointed by the poor judgment and performance of the government, because president moon jae-in had mentioned that the covid-19 was likely to be controlled sooner or later and asked citizens to prepare to go back to their routine life and socioeconomic recovery right before the unexpected surge in the daegu and kyungbook regions. it seemed that transparency initially caused some disturbance, fear, and distrust, but eventually it helped regain public trust and reduce unnecessary fear in the long run. figure 3 shows the hypothetical effects of transparency and nontransparency policies on public trust in government (moon 2020) . for example, a transparency policy might result in a trust deficit in the short run because the growing number of new infected patients is likely to cause citizens to experience fear and frustration about poor performance on infectious diseases, which tends to lower public trust in government. however, a policy of transparency eventually leads to a trust surplus in the long run because the public will then accept the government as a reliable source of information and come to trust government actions (moon 2020) . many believe that the south korean government's position on transparency was effective risk communication because it helped build the credibility of the kcdc and filter fake news and rumors around covid-19. in fact, 74.4 percent of respondents to a national survey answered that government information about covid-19 was transparent, and more than 60 percent replied that they trust the government (institute of future government 2020). in fact, the increased public trust in government, coinciding with president moon's higher approval rating, eventually helped the ruling party clinch an unprecedented landslide victory in the national assembly election on april 15, 2020. it should be noted that the transparency policy and trust surplus in korea helped to facilitate citizens' cooperative participation in fighting against covid-19 which is discussed in the following section. according to the u.s. centers for disease control and prevention (2017), nonpharmaceutical interventions (npis) are critical source: moon (2020, 81) . in the effective management of any infectious diseases like influenza or covid-19. in fact, npis such as social distancing and individual sanitization are considered the best ways to slow and prevent the spread of a virus when no vaccines or medicines are available (cdc 2017). the south korean government also referred to public information campaigns (pics) to promote npis for personal sanitization and social distancing through various channels, including conventional posts and placards, mass media, and new media. as noted by weiss and tschirhart (1994) in their analysis of 100 campaigns, pics are an increasingly important and often very effective policy instrument, particularly when a government aims to communicate with a large target population without having any alternative forceful and regulatory measures or monetary incentives. referring to massive pics, south korea effectively enhanced the level of awareness of covid-19 and promoted voluntary actions for personal and public health. with the massive social distancing campaign and transparent policy stance by the south korean government, the public was extremely cooperative and participated in social distancing as well as personal sanitization practices such as hand washing and wearing masks in public places. voluntary quarantines of low-risk patients also helped reduce the number of new infected cases. government actions could not have been effective if the public had not voluntarily cooperated with the npis. in particular, voluntary social distancing and selfquarantine of people in the daegu-kyungbook region enabled south korea to effectively manage the massive regional cluster without lockdowns. this is an exemplary case that demonstrates the significance of citizens' voluntary participation and engagement in social distancing for effective covid-19 mitigation. in fact, citizens' engagement and mature citizenship is as important as agile and adaptive actions of the government to the successful management of covid-19. however, it is fair to note that south korea, like many other countries, cannot always expect voluntary and mature citizenship. for example, south korea initially experienced an unexpected shortage of face masks amid the covid-19 outbreak, mainly because of rapidly growing fears of covid-19 and illegal stockpiling, 9 similar to the stockpiling of toilet tissue, food, and hand sanitizer in many other countries. responding to the great disturbance from the face mask shortage, the south korean government decided to ration them to citizens, as had been done in taiwan, which later helped alleviate citizens' outcry. pics for social distancing and disease awareness are effective only when citizens are cooperative with responsible engagement and voluntary participation in campaigns that put temporary and reasonable constraints on individual freedom, such as quarantines. covid-19 will remain a challenging problem in south korea, considering the possible resurgence of covid-19 (so-called black swans) through channels such as imported infections, hospital-acquired infections, and public facilities. this was seen in singapore, where the number of confirmed patients dramatically spiked after the government decided to reopen schools and release social distancing guidelines. public administration is being put to the test by covid-19. many countries are struggling with the choices of different approaches (a soft-passive approach based on herd immunity versus a hardforceful approach such as aggressive lockdowns versus an agile-adaptive approach) and policy instruments (testing, tracking, treatment, quarantines, pics, app-based information sharing, social distancing, lockdowns, etc.) to mitigate this unprecedented wicked challenge. there are many alternative policy options on the table, from china's harsh complete blockage of the epicenter using the army and monitoring drones to japan's soft and reactive measures without proactive testing and lockdown. some argue that many western democratic countries are paying a high price for their open and free society, where methods such as china's sudden and complete blockage option are not likely to be easily accepted (perez-pena 2020), while the linkage between culture and quality of government has been studied (porcher forthcoming). as some european countries failed in initial mitigation, they gradually shifted from a soft and reactive approach to a hard and more aggressive approach by increasing their testing capacity, forcing quarantines, and ordering partial lockdowns while they put more emphasis on citizens' cooperation in npis. although there is no perfect policy, the south korean government's agile, adaptive, and transparent approaches demonstrate how the wicked pandemic problem could be mitigated with citizens' voluntary engagement in the fight against covid-19. governments should quickly learn from the initial covid-19 failure. governments also need to build on administrative and policy capacities to minimize any potential damage and to prepare for future wicked challenges with minimal disruption of quality of life in free and open democratic societies, the same way that south korea learned from the costly lessons of the mers failure. covid-19 requires both scholars and practitioners to revisit key public administration issues such as government and market, science and policy, administrative and societal capacities, public leadership and citizen participation, policy instruments and instrument choices, local problems and global problems, and policy failure and organizational learning, heuristics and rational decisions, and agility and effectiveness. we should continue to pay attention to the development of covid-19 and conduct comparative studies of approaches adopted by different countries to the same wicked problem. finally, governments should continue to search for alternative ways of managing uncertainties and complexities through evidence-based heuristics as well as strong governmental and societal capacities to prepare for future wicked policy problems. institutional memories, and standard operating procedures established during the mers case in 2015, enabling swift and decisive action. 6. the data were obtained from our world in data, https://ourworldindata.org/ grapher/tests-of-covid-19-per-thousand-people-vs-gdp-per-capita?country=bhr +bgd+ind+idn+isr+jpn+mys+pak+phl+tha+tur+vnm, accessed april 18, 2020. 7. details of adaptive policies can be found in walker, rahman, and cave (2001) . 8. one of the first covid-19 apps was developed by a college student who wanted to provide detailed information on the movement paths of infected patients based on the data and information released by the kcdc. 9. the south korean government initially failed in risk communication and sent inconsistent signals about wearing face masks. data are based on the world health organization's situation report of most of the patients (90 out of 186 total confirmed patients from mersaffected hospitals) were infected at seoul samsung hospital, which later led lee jae yong, vice president of samsung company director of the kcdc, was one of the government officials who was penalized for poor management during the mers outbreak. director jung and her colleagues at the kcdc heavily relied on their experiences, references centers for disease control and prevention (cdc). 2017. community mitigation guidelines to prevent pandemic influenza-united states crisis management in hindsight: cognition, communication, coordination, and control. special issue emergency management research and practice in public administration: emergency, evolution, expansion, and future directions the uk's covid-19 strategy dangerously leaves too many questions unanswered. the guardian agile in government: a playbook from the deloitte center for government insights agile government and agile governance: we need both institute of future government. 2020. national survey of critical policy issues lags behind other countries in coronavirus testing mers whitepaper: learning from mers experiences the fourth industrial revolution and super-connected intelligent future government trustworthy future government in rapidly changing societies in comprehensive assessment of covid-19 situations and policy recommendations 71-8 learning under uncertainty: networks in crisis management coronavirus cases have dropped sharply in south korea. what's the secret to its success? science virus hits europe harder than china: is that the price of an open society culture and the quality of government adaptive policies, policy analysis, and policy-making public information campaigns as policy instrument worldometer. 2020. coronavirus testing: criteria and numbers by country coronavirus diseases: comparing covid-19, sars and mers by the number. nbc news key: cord-328742-r4ht266w authors: heo, jung yeon; noh, ji yun; jeong, hye won; choe, kang-won; song, joon young; kim, woo joo; cheong, hee jin title: molecular epidemiology of human adenovirus–associated febrile respiratory illness in soldiers, south korea(1) date: 2018-07-17 journal: emerg infect dis doi: 10.3201/eid2407.171222 sha: doc_id: 328742 cord_uid: r4ht266w during january 2013–april 2014, we subjected nasopharyngeal specimens collected from patients with acute febrile respiratory illness in a military hospital to pcr testing to detect 12 respiratory viruses and sequence a partial hexon gene for human adenovirus (hadv) molecular typing. we analyzed the epidemiologic characteristics of hadv infections and compared clinical characteristics of hadv types. among the 305 patients with acute febrile respiratory illness, we detected respiratory viruses in 139 (45.6%) patients; hadv was the most prevalent virus (69 cases). of the 40 adenoviruses identified based on type, hadv-55 (29 cases) was the most prevalent, followed by hadv-4 (9 cases). hadv-55 was common in patients with pneumonia (odds ratio 2.17; 95% ci 0.48–9.86) and hospitalized patients (odds ratio 5.21; 95% ci 1.06–25.50). in soldiers with hadv infection in korea, hadv-55 was the most prevalent type and might be associated with severe clinical outcomes. during january 2013-april 2014, we subjected nasopharyngeal specimens collected from patients with acute febrile respiratory illness in a military hospital to pcr testing to detect 12 respiratory viruses and sequence a partial hexon gene for human adenovirus (hadv) molecular typing. we analyzed the epidemiologic characteristics of hadv infections and compared clinical characteristics of hadv types. among the 305 patients with acute febrile respiratory illness, we detected respiratory viruses in 139 (45.6%) patients; hadv was the most prevalent virus (69 cases). of the 40 adenoviruses identified based on type, hadv-55 (29 cases) was the most prevalent, followed by hadv-4 (9 cases). hadv-55 was common in patients with pneumonia (odds ratio 2.17; 95% ci 0.48-9.86) and hospitalized patients (odds ratio 5.21; 95% ci 1.06-25.50). in soldiers with hadv infection in korea, hadv-55 was the most prevalent type and might be associated with severe clinical outcomes. h uman adenoviruses (hadvs) are considered the most important causative agent of acute respiratory infection in soldiers, particularly in new recruits (1, 2) . a total of 79 hadv types have been documented (3) . the distribution of hadv types differs substantially by geographic region and environmental factors (4, 5) . hadvs are prevalent in training facilities or military barracks for soldiers, but the prevalent types of hadv have changed over time (6) . historically, hadv-4 and hadv-7 have been the most prevalent causes of acute febrile respiratory illness (afri) among us military personnel since the 1950s (7) . vaccination against hadv-4 and hadv-7 has been effective in reducing afri among us military trainees to date (8, 9) . however, since 2007, the emergence of new adenovirus types such as hadv -14, which is distinct from the prototype in the united states, has been associated with outbreaks of afri and severe pneumonia (including several deaths) in military populations (10, 11) . hadv is most prevalent in patients with acute lower respiratory tract infection and is the most common cause of pneumonia among military personnel in south korea (12) . however, studies evaluating the types of hadv in this population are limited because of the lack of knowledge about hadvs among military physicians. in 2012, hadv-55 was identified in patients with severe pneumonia, and an outbreak of afri among military personnel in south korea was recorded (13, 14) . hadv-55, which is a novel hadv type characterized by genome recombination between hadv-b11 and hadv-b14, caused outbreaks of acute respiratory diseases in military camps in turkey, china, and singapore (15) (16) (17) (18) . although cases of pneumonia caused by hadv-55 among military personnel in south korea have been recorded, information on the epidemiology and characteristics of type-specific hadv respiratory infections among military personnel in south korea is limited. thus, our study aimed to investigate the epidemiology of hadv infections and to compare the clinical characteristics by type of hadvs in soldiers in south korea via hospital-based surveillance on viral respiratory infections. the study was approved by the institutional review board of the south korea armed forces medical command. during january 2013-april 2014, we enrolled in the study all new recruits and active duty soldiers with afri who were required to visit the emergency department or to undergo we collected nasopharyngeal or throat swab specimens from the patients with afri within 24 hours after their hospital visit by using a flocked swab. we stored the specimen at 4°c in viral transport media until further testing. within 3 days of collection, we sent specimens to a commercial laboratory center (gc labs, yongin, south korea), where they were subjected to respiratory virus multiplex reverse transcription pcr. we extracted total viral nucleic acid from the specimens by using the chemagic viral dna/rna extraction kit (chemagen inc., baesweiler, germany) and performed cdna synthesis by using the capfishing full-length cdna premix kit (seegene inc., seoul, south korea). we performed pcr by using the seeplex rv12 ace detection kit (seegene inc., south korea), which is used for identifying influenza viruses a and b, respiratory syncytial viruses a and b, adenovirus, parainfluenza virus types 1-3, rhinovirus group a, human coronavirus 229e/nl63, human coronavirus oc43, and human metapneumovirus. we extracted dna from the adenovirus-positive respiratory specimens by using the qiaamp dna blood mini kit (qiagen, hilden, germany). we amplified the partial nucleotides of the hexon gene by using pcr as described elsewhere with some modifications (19) . we amplified viral sequences by using oligonucleotide primers producing a 475-bp fragment: adhex1f (5′-caacacctay-gastacatgaa-3′) and adhex1r (5′-katgggg-taragcatgtt-3′). pcr conditions were as follows: initial denaturation at 94°c for 1 min, followed by 35 cycles of denaturation at 94°c for 1 min, annealing at 50°c for 1 min, elongation at 68°c for 1 min, and final extension at 68°c for 5 min. for samples that tested negative in the first pcr reaction, we performed heminested pcr by using primers (273 bp) adhex1f (5′-caacacctay-gastacatgaa-3′) and adhex2r (5′-acatcctt-bckgaagttcca-3′) with the same temperature and time profiles. we determined dna sequences in both directions by using the applied biosystems automatic sequencer abi 3730xl and abi prism bigdye terminator v3.1 sequencing system (applied biosystems, foster city, ca, usa). we identified the type of hadv by using blast (http://blast.ncbi.nlm.nih.gov/blast.cgi). we generated phylogeny on the basis of the 232-bp nucleotide sequences of the hexon gene of hadvs. for the phylogenetic analysis, we selected the sequences of each type of hadv from genbank. we used mega 6 software to generate the phylogenetic tree and evaluated topologies by performing a bootstrap analysis of 1,000 iterations (20) . we obtained clinical information of the patients with hadv respiratory infection during the study period from standardized case report forms. the case report forms, which included clinical diagnosis, intensive care unit stay, requirement for mechanical ventilation or vasopressor, and symptoms at presentation, were completed within 7 days of the hospital visit by an attending physician. we conducted pearson's χ 2 and fisher exact test for the demographic and clinical variables by using the spss for windows version 20 (ibm corp., armonk, ny, usa). for all analyses, we defined statistical significance as p<0.05. during january 2013-april 2014, we enrolled 305 patients with afri in the study. we detected a total of 157 respiratory viruses in 139 (45.6%) soldiers with afri. hadv was the most prevalent virus (49.6% [69/139]), followed we commonly observed cases of hadv infection during winter and spring ( figure 1 ). among the tested cases of afri, the monthly positive rate for hadv ranged from 0% to 53.8%; average positivity rate was 22.6%. a peak positive rate for hadv infection occurred in soldiers with afri during march-april 2014. the mean age of the patients with hadv infection was 21.7 years. among the 69 patients with hadv infection, 40.6% were new recruits and 75.4% were hospitalized (table 2) . from the 69 patients with hadv infection, 51 respiratory specimens were available for further molecular analysis. for the 51 samples tested, we identified the hadv type in 40 samples (figure 2 ). hadv-55 (72.5% [29/40] ) was the most prevalent type in soldiers with hadv infection, followed by hadv-4 (22.5% [9/40]). we detected hadv-55 and hadv-4 in 2013, but we did not detect hadv-4 in 2014. we detected hadv-5 and hadv-6 in 1 case each. we observed no statistically significant difference in the demographic characteristics or signs and symptoms of the patients with hadv-55 infection compared with those with other types of hadv infection (table 3) . furthermore, we observed no statistically significant difference between the patients in terms of laboratory and radiographic findings. coinfections with other bacteria or viruses were similar in both groups. the patients with hadv-55 infection were more likely to have onset pneumonia (44.8% vs. 27.3% [odds ratio (or) 2.17; 95% ci 0.48-9.86]) and be hospitalized (86.2% vs. 54.5% [or 5.21; 95% ci 1.06-25.50]) than those infected with other types of hadv. in particular, we identified hadv-55 infection in all patients who required hospitalization in the intensive care unit or mechanical ventilation caused by acute respiratory distress syndrome (ards). in our study, hadv was the most prevalent virus detected among soldiers with afri in south korea, representing 49.6% of the cases. hadv-55 was the most prevalent type among the cases that could be identified using pcr. although hadv-55 has recently received public attention as an emerging pathogen that causes outbreaks of respiratory illness and severe pneumonia in the general population and soldiers, acute respiratory illness associated with hadv-55 has rarely been reported in the civilian population in south korea (6, 16, (21) (22) (23) . in children in south korea, hadv-3 and hadv-7 are prevalent serotypes and have also been associated with the outbreaks of adenoviral respiratory illness since the 1990s (24, 25) . severe pneumonia cases associated with hadv-55 infection were recently reported in soldiers in south korea (13, 14) . our finding that hadv-55 was the most prevalent type in soldiers in south korea differs from the epidemiology of adenovirus in children in south korea. another notable finding of this study was the changing epidemiologic trend from the co-circulation of hadv-4 and hadv-55 in 2013 to the predominant circulation of hadv-55 in 2014. hadv-4 was the second most common type after hadv-55 among soldiers with afri in south korea in 2013. however, hadv-4 has not been identified in soldiers in south korea since november 2013. although the shift in the hadv types in soldiers in south korea could not be fully understood because of the relatively short study period, hadv-55 infection has been prevalent among soldiers in south korea since 2014 (14, 26) . pneumonia and hospitalization associated with hadv-55 infection were more frequent than those associated with the other types of hadv infection in soldiers in south korea. in particular, hadv-55 infection was associated with severe pneumonia or ards. nevertheless, we observed no significant differences between hadv-55 cases and non-hadv-55 cases in terms of the frequency of clinical diagnosis of pneumonia, hospitalization, and ards. these findings could be explained by 2 assumptions. first, specific hadv types such as hadv-3, hadv-7, or hadv-14 might be more virulent than other types (25, 27, 28) . considering that the hadv-55 genome is more similar to the hadv-14 genome than the hadv-11 genome, hadv-55 infection could be associated with severe respiratory infection in certain patients (17) . second, the lower levels of herd immunity against hadv-55 could have an influence on the epidemic of hadv-55-associated respiratory infection in soldiers in south korea (29, 30) . severe respiratory illness and outbreaks associated with hadv-55 in soldiers in south korea might be similar to those observed in military personnel in china (13, 14, 21, 22) . in this study, the proportion of new recruits with hadv infection among soldiers in south korea was not as high as expected. more than half of the south korean soldiers with hadv infection were on active duty. these findings contrast with previous data in which hadv-associated respiratory infection has been common among new recruits 1224 emerging infectious diseases • www.cdc.gov/eid • vol. 24, no. 7, july 2018 . the patients included in this study might have had clinically severe illness rather than mild illness because our institute is the only central referral hospital in the military system in south korea. moreover, hadv easily spreads to advanced training sites or military barracks and it can spread in geographically dispersed military barracks by the movement of soldiers because of prolonged viral shedding (31) . in this study, some of the patients with hadv-55 infection who were active duty soldiers were identified in the clusters of patients in 4 military barracks (data not shown). although the outbreak of hadv-55 infection was not directly confirmed in this study, outbreaks of hadv-55-associated respiratory infection might be occurring among active duty soldiers. our study has some limitations. first, the study was performed for a relatively short period (16 months) . although the data might be insufficient to reflect the epidemiology of respiratory hadv infection among military personnel in south korea, the variation of hadv type over time and the impact of the emergence of hadv-55 on clinical severity can be observed. considering the long-term experience of the us military with respiratory hadv infection, the distribution of hadv types might show a substantial difference in the military and community populations in south korea. thus, a surveillance system must be established to detect the circulation of the hadv type among military personnel. second, the study population included patients who needed hospitalization or an emergency department visit. among soldiers in south korea with hadv infection, patients who had severe clinical signs and symptoms might be those who were primarily enrolled in this study. nevertheless, our results suggest that of the several hadv types, hadv-55 and hadv-4 might be implicated in hadv respiratory infections among soldiers in south korea. furthermore, active duty soldiers and new recruits could have a substantial disease burden caused by respiratory hadv infection. third, we could not determine hadv types in 11 cases. the viral titer in the clinical specimen might have been low and the viral dna degraded because some respiratory specimens were not frozen until the molecular experiment. using the 2-step hemi-nested pcr, we did not observe a dna band in 11 samples. this study is important because it is a prospective study on patients with afri. studies on the hadv type in soldiers in south korea since 2012 are limited. however, the previous studies provided data on the epidemiology of the hadv type in patients with severe clinical manifestations or in those with hadv respiratory infection. these conditions might result in bias in the epidemiology of hadv infections among military personnel in south korea. in conclusion, our study found that hadv was the most prevalent virus among soldiers with afri in south korea. in particular, hadv-55 and hadv-4 were the prevalent types in soldiers with hadv-associated respiratory infection. hadv-55 was associated with severe clinical outcomes. further studies are 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and 7 among unimmunized us army trainees: results of a retrospective nationwide seroprevalence survey epidemic of adenovirus-induced respiratory illness among us military recruits: epidemiologic and immunologic risk factors in healthy, young adults spread of adenovirus to geographically dispersed military installations address for correspondence: hee jin cheong similarities of t cell function in cell-mediated immunity and antibody production lymphokines: non-antibody mediators of cellular immunity generated by lymphocyte activation a lymphocyte-stimulating factor produced in vitro virus interference. i. the interferon a factor stimulating dna synthesis derived from the medium of leukocyte cultures interferon-like virus-inhibitor induced in human leukocytes by phytohemagglutinin although the term cytokine had not yet even been defined, interferon-α, the first cytokine known, was identified in 1957 as a protein that interfered with virus replication. activities of interferon-γ and interleukin-2 were identified in 1965. macrophage migratory inhibitory factor was identified in 1966 key: cord-271870-8v9w3sps authors: lee, david; lee, jaehong title: testing on the move south korea’s rapid response to the covid-19 pandemic date: 2020-04-21 journal: nan doi: 10.1016/j.trip.2020.100111 sha: doc_id: 271870 cord_uid: 8v9w3sps abstract the emergence of covid-19 in south korea, and the public and private sector response to it, serves as a valuable case study for countries facing similar outbreaks. this article focuses on how korean health officials implemented drive-through and walk-through diagnostic testing, and extensive movement and contact tracing, to identify and inform exposed members of the public. mobile applications from both government agencies and private developers played an important role in guiding people to testing centers, communicating movement trajectories of confirmed cases on digital maps, and tracking the health and movements of travelers and others at risk of exposure. this case study illustrates the importance of rapid adaptation of transportation infrastructure and location-based information technology to respond to public health crises, and how governments can learn from experimentation and past experience to accelerate these responses. in early 2020, the world watched as a novel coronavirus emerged in wuhan, china, and dramatically transformed the lives and movement patterns of millions of its residents. health officials in south korea recognized the threat this outbreak posed to their nation, a close neighbor and trading partner with china. with constant exchange of tourists, workers, and academics between the nations, it was inevitable that the virus would enter korea through a visitor or returning citizen. however, the strategies south korea employed to control the disease's spread within its borders appear to be effective as of march 2020, and have received much media attention as other nations struggle to manage the crises at home . rather than mobilize its security forces to lock down entire cities and cut off nearly all forms of in-person contact, south korea focused on rapid and widespread testing, and close tracking of all contacts between the exposed. these two pillars, testing and tracking, have allowed the nation to blunt the exponential spread of the disease, without having to halt all internal movement and access between its cities . in this paper, we briefly outline the progression of the outbreak within south korea, local government implementation of low-contact testing to safely and efficiently detect its spread, and nationwide contact tracing and dissemination of individual movement patterns to identify and inform the exposed members of the public. this case study illustrates the importance of rapid adaptation of transportation infrastructure and location-based information technology to respond to public health crises, and how governments can learn from experimentation and past experience to accelerate these responses. the first confirmed case of covid-19 in south korea came on january 19, 2020 . a visitor had arrived at incheon international airport from wuhan, china, and tested positive after being flagged for high body temperature at the entry screening using an infrared sensor. in response, the national government elevated its alert level from "aware" to "care" according to the standardized degrees of risk. the government announced increased entry screening and shared the patient's movement trajectories with the public (kcdc, 2020a). after two additional patients were confirmed within the following week from the same origin point of wuhan, the korean government raised the alert level to "caution" on january 28th, and began to reinforce local response strategies. the korea center for disease control & prevention (kcdc) increased the number of local screening centers to discover potential asymptomatic carriers, and assigned local hospitals as infection control institutes to preserve medical capacity in case of expansion of infection. moreover, the national government started to cooperate with local governments and the national health insurance agency to closely monitor all travelers entering from wuhan. in case any of the monitored people experienced symptoms, they were guided to take the diagnostic test and placed under quarantine. all known contacts with the confirmed patients were also monitored under the same procedures to prevent further infections (kcdc, jan 27-28, 2020) . despite such efforts, the number of confirmed patients grew steadily at the rate of 1~4 patients each day until mid-february. on february 3, the government expanded their search to include people with whom infected patients had even minor contact. in addition, the government approved the use of a diagnostic testing kit (powerchektm 2019-ncov real-time pcr kit) developed by a private company called kogene biotech to facilitate the growing number of diagnostic tests (kcdc, feb 3-4, 2020) . several other private firms also quickly developed covid-19 testing kits and won approval for their use. on february 18th, the 31st patient was confirmed in the city of daegu, and by the next day, a kcdc investigation team discovered that she had close contact with hundreds in a church congregation (kcdc, feb 18, 2020) . in the following weeks, the number of confirmed patients steeply increased from a rate of 20 to more than 200 new cases per day, as represented in the log-scale graph in figure 2 . the government escalated the alert level to "serious" on february 25th, announced guidelines to limit trips and outdoor activities, and imposed emergency safety measures, from basic hygiene rules to self-quarantine and social distancing (kcdc, feb 25, 2020) . the daily rate of new case discovery peaked on february 29, 2020 with 813 patients, and since then has been slowly declining (see figures 1 & 2) (kcdc, 2020b) . in the following sections, we will discuss some of the major strategies used to respond to the outbreak, focusing on lowcontact testing, information release, and large-scale contact tracing. 3. low-contact testing centers 3.1 drive-through testing j o u r n a l p r e -p r o o f of workers, limited space for social distancing, and rapid consumption of personal protective equipment from one-on-one medical consultation within existing healthcare facilities (윤종열, 2020) . the first drive-through test was implemented in goyang, gyeonggi province, at the city hall parking lot. the test, which included registration, symptom check, swab sampling, and car disinfection, lasted 10 minutes on average for each person, whereas previous testing procedures took ~30 minutes (노승혁, 2020) . the test results were delivered directly to the patient via text message within three days . as the number of drivethrough test centers increased, the government announced operating standards for systematic scale-up and management (kcdc, mar 4, 2020) . the standard included the above mentioned four procedures (which could be curtailed depending on the situation), the minimum number of professional personnel with specific responsibilities, space requirements, and visiting vehicle restrictions. a total of 4~8 people are required to operate a drive-through; 1~3 administrators handle registration, vehicle entry/exit management, and education; 1~2 doctors conduct symptom check and sampling; and 1 person disinfects the vehicle. although not strict, the standard required a minimum amount of dedicated space in the form of either shipping/storage containers or medical tents, for maximum space efficiency. lastly, the patient must be the only person in the vehicle and must make reservations prior to visit (kcdc, mar 4, 2020) . figure 3 shows one container-based testing site in south korea, and figure 4 shows screening procedures at a seoul tent-based testing site. in practice, initial attempts to use containers as testing centers were costly, since they required the patient to exit their vehicle and enter the container to be tested. containers had to be equipped with depressurizers to minimize the release of pathogens and exposure of healthcare workers, and disinfected repeatedly. by contrast, when using open medical tents, the doctor could easily stick a swab through the vehicle's open window to take a sample from the patient's mouth or nose. for comparison, one testing center in gyeonggi province with ten containers cost 879 million krw to deploy (roughly 72,000 usd per container), while goyang city installed eight screening tents for only 15 million krw (roughly 1,500 usd per tent) (한상봉, 2020). as a result, most drive-through test centers operated by local governments have employed medical tents, to save on cost and reduce exposure risk. figure 5 illustrates the difference in procedure. illustration of difference between 2 types of drive-through testing centers (above: container-type, below: tent-type) at the time of writing, an increasing number of south korean medical centers, hospitals, public health centers and local governments were adopting drive-through tests using their open spaces and parking lots. however, information on their locations was not easily accessible to the public, because the government had only listed all testing centers without indicating which ones allowed drive-through testing (ministry of health and welfare, n.d.). therefore, the public had to rely on news articles or directly call the centers. for this reason, the mobile application oilnow, which normally helps customers locate gas stations, added a service that mapped all the drive-through test centers. as of march 9, 2020, 45 of the 613 test centers allowed drivethrough (조재환, 2020). table 1 lists the provinces of south korea that deployed drive-through test centers, their respective location types, and number of confirmed patients. while drive-through sites served well for testing patients with private vehicles, they were not optimal in dense urban environments with fewer drivers and less available space for car queues. to expand low-contact testing to these areas, hospitals created "walk-through" centers, rows of plastic booths (roughly the size of a phone booth) fitted with depressurizers, intercoms, and attached gloves for doctors outside the booth to interact with and collect samples from the patient. introduced by h plus yangji hospital in seoul, these booths (named "safe assessment and fast evaluation technical booth of yangji hospital" or "safety") have helped boost their testing capacity from 10 to 70 patients per day (김철중, 2020). subsequent variants have inverted them by placing the healthcare worker inside the booth, while the patient stands outside to be tested; this speeds up the process, since the booth does not need to be disinfected between patients (황선윤, 2020). these booths have made lowcontact testing possible for non-drivers, and their small, mobile footprint allows them to be deployed in dense urban cores nearer to transit and residential areas. figure 6 shows an example of one testing booth with sample collection, decompression, and patient access equipment. j o u r n a l p r e -p r o o f the korea center for disease control & prevention (kcdc) posts the national counts of covid-19 cases daily on its website. it used to update this twice a day, at 8am and 5pm, but switched to once a day at 10am starting from march 10, 2020, to minimize confusion and pursue statistical consistency with local public authorities (뉴시스, 2020) . the briefing information categorizes cases into three groups: tested positive, currently being tested, and tested negative. the group tested positive is further differentiated into three sub-groups: in quarantine, out of quarantine, and deaths; these counts are presented in daily statistics for each major province. any update in response strategies or important regulatory revisions are also posted from the website. this information disseminates through online news, social media, and the local government. figure 7 shows a daily infographic and chart provided by naver, a popular web and news portal in south korea, using the kcdc briefing data. citizens can quickly access information specific to their districts or neighborhoods; this includes the daily count of newly confirmed cases, along with their detailed movement trajectories within the last couple of days. kcdc investigators use interviews, mobile phone tracking (every mobile account in south korea is tied to the owner's national id), credit card transaction history, and video footage from public surveillance cameras, to reconstruct the individual movements of confirmed covid-19 cases in fine detail. they can also find or cross-check other people whom the patient had close contact with, prior to quarantine. through manual effort, these officials can identify potential future cases, and target those people or areas for testing and precautionary self-quarantine (sonn, 2020) . this form of contact tracing was originally meant for internal usage by health officials in tracking the epidemic. however, following the 2015 mers outbreak in south korea, public disclosure provisions were added to the country's infectious disease control and prevention act to facilitate sharing these traces with the public. government officials feared that releasing contact tracing data would negatively impact businesses and hospitals visited by diagnosed cases, but acquiesced to public pressure for more transparency (spinazze, 2020) . this has helped residents understand their personal risk, avoid infection hotspots, or review their own movement history and decide whether to get tested and self-quarantine. revealing the movement trajectories of confirmed patients this way has raised concerns of privacy infringement. the information released to the public often includes the exact names of places and specific timestamps the patients visited. although other personal information such as names and faces are not released to the public, some individuals have attempted to find out their private information for harassment. this is possible because commuting patterns between home and work are clearly revealed in the public movement traces. for example, the 31st patient (whose attendance at the mass church meeting is believed to have caused the daegu outbreak) was exposed to personal information release, public criticism, and direct threats (bbc news, 2020). one of the most effective ways that the korean government rapidly dispersed these daily updates is emergency sms messages. all citizens receive daily alert messages through their mobile phones from their local authorities. the alert message arrives with a 40~60 db alarm sound, and contains information from kcdc about newly confirmed patients and their recent trajectories if available. this alert message system was originally implemented by the ministry of interior and safety (mois) to inform citizens about any disaster, classified by its degrees of risk (전광준, 2020) . these messages are written and sent from provincial governments to anyone within the boundaries of that province, based on their phone's current location. furthermore, if a known case is discovered by contact tracing to have visited clinics or other public locations in a neighborhood, everyone in that neighborhood receives text messages with those details. in the case of the coronavirus outbreak, many people found it useful to be promptly notified of the latest updates in nearly real-time, but some raised concerns about the quality and frequency of these alert messages. because of the loud alarm sound, users reported annoyance at receiving frequent messages, especially when the content is just a reminder of basic safety drills such as "keep your hands clean, wash it thoroughly, or please avoid outdoor activities" (전광준, 2020) . such over-alerting carries risks of reducing user attention or crowding out more important information (national academies of sciences, engineering, and medicine et al., 2018) al jazeera encountered both opinions among south korean citizens, quoted here (kasulis, 2020) : "now, i know which areas to avoid and i do feel like the government is doing a good job at keeping me informed." j o u r n a l p r e -p r o o f 13 "i cannot disagree with the fact that it's good for people to know if there are infected people visiting the same places that they might go to. but i think the government is sending these messages too frequently … i know i stopped reading them." 4.4 digital mapping and alerts figure 8 . screenshot of coronamap.live, one of many web and mobile applications developed during the covid-19 outbreak to map the movement trajectories of confirmed cases in south korea (홍준서, 2020) . since the outbreak, many individuals, private companies, and local authorities have developed various applications to cope with this disaster. a common application type is the real-time exposure map, which visualizes the movement trajectories of confirmed cases (as reported in the government reports), along with timestamps and transport mode. for example, several websites (coronamap.site, coronamap.live, coronapath.info) were independently developed and updated regularly with government info from the early days of the epidemic. a mobile application named "corona 100m" alarms the user when they are within 100 meters from the trajectories of confirmed patients, and reached 1 million downloads by feb 28 . these applications communicate the trajectories in a visual, interactive format, making it easier for the public to digest this information and adjust their own behavior in response. j o u r n a l p r e -p r o o f 4.5 digital diagnosis and self-quarantine while the above applications are focused on disseminating information, the ministry of health and welfare (mohw) developed a mobile app to monitor potential patients with symptoms. every traveler or returning resident entering the country is obliged to install this application, and self-report their health condition and any symptoms using the app for 14 days from entry. in case of fever or respiratory discomfort, the users are required to report their health status and contact kcdc to register for testing. travelers are also required to demonstrate that they can receive calls and be contacted by the government during their time in korea (김아름, 2020) . as of april 1, 2020, to reduce the spread of covid-19 from international travelers, the korean government has mandated 14-day self-quarantine for all long-term residents returning from overseas, using the gps tracking function of the application and the threat of severe legal penalties to enforce this limit on movement. figure 9 shows screenshots from this mobile application. screen 1 provides language options in korean, mandarin, and english. screen 2 is a series of questions on nationality, travel history, and contact information. screen 3 provides links to self-diagnosis questions, clinic locations, and direct chat help channels. screen 4 presents four self-diagnosis questions on fever, cough, sore throat, and dyspnea. the ministry of interior and safety (mois) has also developed an application to monitor selfquarantine and self-monitoring of people's health conditions. people who confirm that they were exposed to the trajectory of a known coronavirus patient should contact kcdc, to be monitored for 14 days. if they have any symptoms, they may receive diagnostic testing free of charge; otherwise, they self-quarantine and regularly respond to monitoring queries. the application also uses the gps sensor to detect whether the user leaves the boundary of self-quarantine. this is intended to help local governments monitor a large pool of potential patients with minimal labor and cost (뉴시스2020; 김아름, 2020). j o u r n a l p r e -p r o o f figure 10 shows screenshots from this application, which closely parallels the mohw app. screen 1 provides links to self-diagnosis, health advice, and contact lines for health officials. screen 2 presents the same four self-diagnosis questions as the mohw app: fever, sore throat, cough, and dyspnea. figure 10 . self-quarantine monitoring application developed by ministry of interior and safety for tracking cases infected through community transmission. however, unlike at an airport's border control where people must install the self-check application to pass through, use of the self-quarantine application is voluntary. the installation rate of the application is approximately 35% of the total number of people under monitoring based on the government's guidelines for self-quarantine. awareness of the application is not widespread given its recent release on march 5, 2020 for android phones, and march 15, 2020 for iphone. users must also carefully review the published movement traces of known infected, and trust in government health procedures enough to voluntarily self-report their condition (yeonhap, 2020; 김아름, 2020) . further outreach, and mandatory screening in certain public places like transportation hubs or government offices, may help increase the use of the application, and reduce the risk of community transmission (virus spread between unconfirmed cases). as the number of active covid-19 cases grew in the country, it became difficult for health officials to manually perform contact tracing for each individual known case. in response, south korea's ministry of land, infrastructure, and transport (molit) developed a "covid-19 smart management system", in collaboration with the kcdc and ministry of science and ict (msit). the system was adapted from an existing "city data hub" platform that molit originally developed for smart cities to analyze their traffic, energy use, environment and safety; it was repurposed to help automate contact tracing by combining data from the national police agency, three telecommunications firms, and twenty-two credit card companies (molit, 2020). at its launch on march 26, 2020, molit claimed the system would reduce the time consumed for contact tracing an individual from one day to under ten minutes. prior to the system, kcdc officials needed to communicate by phone through the police or national credit agencies as intermediaries, in order to receive location trace information from the telecoms or credit card companies (see figure 11 ). the management system allows investigators to request this data directly from the companies, while enforcing security clearance on different types of data and levels of detail. patients are only tracked after being interviewed by health investigators and informed that their phone and credit card usage will be monitored. system user activities are logged and subject to audit, and personal data is scheduled to be deleted at the close of the government's official response to covid-19 (ktv 2020). j o u r n a l p r e -p r o o f in this article, we reported on the circumstances of the covid-19 outbreak in south korea, its implementation of low-contact testing to scale up diagnostics and reduce health care worker exposure, and how mobile apps and online mapping helped to track its spread and alert the public of their risk of exposure. by a combination of design and technological innovation, these steps have enabled the country to quickly detect, track, and quarantine new infections. lowcontact testing illustrates this well; health officials were able to quickly adapt infrastructure like parking lots into experimental drive-through testing sites, then iterate on their design to improve their hygiene and cost-effectiveness. to meet the challenge of extending low-contact testing to korea's dense urban cores, they innovated again by developing compact, mobile testing booths accessible to pedestrians. part of this ability to rapidly innovate stems from preparation. the first mobile apps to map drivethrough test centers and contact traces were created by private developers, highlighting the advantages of a highly-connected population and a thriving local software industry in filling the technology gap left by the public sector. the nation's transport ministry was also able to quickly create an integrated surveillance system for large-scale contact tracing, because it had previously researched and developed "smart city data platforms" meant to handle this sensitive, private information. at a policy level, the national government had already debated and legislated how it would balance patient privacy rights against public demand for contact tracing information years before the covid-19 outbreak; thus, there was no ambiguity about what data local governments could share for the benefit of public health. while it isn't clear how much each step directly reduced the rate of infection, it appears that south korea's overall strategy has been effective in slowing the virus spread. the country faced several potential disadvantages in an outbreak: a highly urbanized population with little room for social distancing, a reluctance to apply complete bans on foreign entry and internal mobility, and unpredictable behaviors from sub-groups that resulted in super-spreading of the virus. these perceived disadvantages may have driven the government to lean on testing and tracking, and improve on its ability to scale up both, in order to maintain a degree of personal freedom in movement and association. as of this writing, the united states, canada, and other nations have adopted their own versions of drive-through testing. singapore and china have implemented similar mobile app and phone tracking procedures for travelers. yet ultimately their success or failure will depend on how wellprepared their societies were to adopt these strategies, and how quickly they can learn and iterate toward better designs. we hope that the south korean experiences we've reported here provide useful knowledge for other countries following suit. in this paper, we did not deeply investigate the rapid development and manufacturing of covid-19 diagnostic tests, which was critical in enabling the government's strategy of widespread testing, and was the result of lessons learned and policy changes after the 2015 mers epidemic (normile, 2020) . we also have not discussed in detail the ethical implications of the government's approach to contact tracing, which was effective in identifying future cases and building public trust, but at significant risk of violating individual privacy rights (sonn, 2020) . also concerning is the disproportionate impact certain individuals or businesses may have experienced by the release of contact tracing information to the public. these issues rightfully invite more scrutiny, as other open, democratic societies grapple with the trade-offs between healthcare regulation vs. private initiative, and individual surveillance vs. privacy protections. for future studies, we hope to gather empirical evidence on these impacts, and take a more critical look at the risks other countries face in adopting south korea's strategy. at a love motel": are s korea virus alerts too revealing? bbc epidemiology and important lessons from the coronavirus disease 2019 (covid-19) outbreak in south korea s korea's smartphone apps tracking coronavirus won't stop buzzing daily briefing report daily government statistics the first case of 2019 novel coronavirus pneumonia imported into korea from wuhan, china: implication for infection prevention and control measures covid_19_walking_thru_screening_center_02. flickr korean statistical information service full] molit & kcdc online briefing on covid-19 smart management system -코로나19 역학조사 지원시스템 외신브리핑 코로나19 선별진료소 및 국민안심병원 현황 (corona 19 screening clinic and national security hospital) ministry of health and welfare molit, msit and kcdc launch the covid 19 data platform. -smart city technology reinvents contact tracing method this is how south korea flattened its coronavirus curve emergency alert and warning systems: current knowledge and future research directions coronavirus cases have dropped sharply in south korea. what's the secret to its success? science potential roles of social distancing in mitigating the spread of coronavirus disease 2019 (covid-19) in south korea drive-through screening stations -. 서울시 영문 coronavirus: south korea's success in controlling disease is due to its acceptance of surveillance. the conversation south korea learned its successful covid-19 strategy from a previous coronavirus outbreak south korea pioneers coronavirus drive-through testing station coronavirus mobile apps are surging in popularity in south korea 정부 "코로나19 자가격리 앱 설치율 35%…아이폰용 오늘 배포 how south korea put into place the world's most aggressive coronavirus testing 원스토어, 코로나19 관련 앱 메인 배치. financial news 질본, "10일부터 '코로나19 발생 현황' 1회 발표…통계 일원화 서울경제 손씻기"까지 재난문자로 보내야 하나요? the journal pre-proof 코로나19 드라이브스루 진료소 43곳 지도로 제공. zdnet korea 코로나맵 라이브 we thank the members of maturepolis lab at kaist for helping to identify sources and review the content of this article. we also thank hee eun kim for helping research and translate news articles and other sources. this research was supported by a grant (20tsrd-b151228-02) from urban declining area regenerative capacity-enhancing technology research program funded by the ministry of land, infrastructure and transport of the korean government. it is the sole work of the authors, and we report no conflicts of interest. key: cord-329953-8nq7fvfh authors: le grange, lesley title: covid-19 pandemic and the prospects of education in south africa date: 2020-10-19 journal: prospects (paris) doi: 10.1007/s11125-020-09514-w sha: doc_id: 329953 cord_uid: 8nq7fvfh the covid-19 pandemic has caused havoc in the world, radically changing our lives and raising new and old questions, both existential and educational. this pandemic has revealed the underbelly of south african society in general and its education system more specifically—it has laid bare the gross inequalities that are the legacies of apartheid and the consequences of neoliberal capitalism. drawing on ideas articulated in the four introductory chapters of the international handbook of curriculum research, edited by william pinar in 2014, this article discusses covid-19 and the prospects of education in south africa. the article shows how understanding the wisdom of indigenous traditions along with the moral dimensions of education, race, and the new technologies of surveillance, neoliberalism, and education can provide a nuanced awareness of the nature of the covid-19 pandemic. it then explores the implications of such insights for the field of curriculum studies and, where relevant, for the school curriculum. it concludes by showing how these broad themes intersect and gel around the notion of ubuntu-currere. time. and also, the enduring curriculum question, first raised by herbert spencer (1884) : what knowledge is of most worth? other education questions that we could invoke are: how ought we to teach/learn? what are the prospects for education during and after the covid-19 pandemic? what is education for in troubled times? is knowledge enough? we are witnessing emerging responses to these questions, and i shall touch on these questions in various ways in this article. for the most recent international handbook of curriculum research, pinar (2014) commissioned four introductory chapters to challenge accounts on curriculum studies presented by authors from different nations. in the first chapter, autio (2014) highlights the moral dimension of education and makes the point that it is education's implicit morality that makes it educative. autio's use of "morality" is not meant in a didactive sense but is more akin to ethics: a commitment to engage, in an ongoing basis, with the worthiness of knowledge-that is, with the worthiness of what education programmes include and/or exclude. according to pinar (2014, p. 2) , it is this sense of the moral that informs our "profession's ethics, our commitment to study, and teach as we engage in academic research to understand curriculum". moreover, it also involves understanding curriculum as a complicated conversation that occurs among scholars of the field and between scholars and students. in the second chapter, mccarthy, bulut, and patel (2014) discuss the reconfiguration of power that globalization accelerates, with a particular focus on race. they point out that race cannot be viewed in isolation but needs to be understood in contemporary times as structured through contradictory processes of globalisation, localisation, migration, and technologies of surveillance. the technologies of surveillance that the authors refer to are biometric technologies of information: face scanning; finger printing; dna sampling; and so on. mccarthy et al. (2014) focus particularly on race, but their discussion can be extrapolated to other forms of discriminations that globalizations and new technologies hasten or reconfigure. in the third chapter, smith (2014) assesses the influence of neoliberalism on education, which includes, among other things, privatization, standardized assessments, and the use of technologies to make teaching/learning more efficient. he asks a pertinent question: how might we reimagine education given that neoliberalism brings into question the very assumptions that education is based on? smith (2014) suggests that we need to analyze and interrogate neoliberalism on an ongoing basis in order to work through it, and that the inspiration for this ongoing examination could be drawn from the wisdom traditions, be they indigenous, religious, or philosophical. in chapter 4, wang (2014) focuses on nonviolence, which she explicates as an embodied sense of interconnectedness among humans, affirming compassion and a positive affiliation with others-in other words, our common humanity. she finds support for her argument from several philosophical, religious, and ethical traditions, including the african notion of ubuntu, the chinese notion of tao, and indigenous peace-making traditions in north america. in this article, i use the ideas articulated in these four chapters as a broad frame for advancing my thoughts. accordingly, i divide the rest of the article into the following sections: the moral dimension of education; race, technologies of surveillance, and bio-informationism; neoliberalism and the prospects of education after the covid-19 pandemic; and why we need ubuntu-currere. although my focus here is on the scholarly field of curriculum studies, i do at times explore implications for the school curriculum. when referring to the school curriculum, i make reference to the school subject that i know best, school biology. education is by definition a moral enterprise, but the covid-19 pandemic has given rise to particular moral dilemmas for all people involved in education. governments had to make decisions on school closings and also on when to reopen them. these are not easy decisions, and neither are the consequent choices that those impacted have had to make. in south africa, schools are more than places where knowledge is exchanged between teacher and learner. for children from vulnerable communities, they are also places of safety and security: among other things, more than 9 million children receive 2 meals per day at school as part of the national school nutrition programme (nsnp). but during the lockdown period and level 4 of the government's risk-adjusted approach, the nsnp was temporarily suspended. this left these children at risk of being underfed and/or malnourished during periods of school closures. gontsana (2020) reports that during the lockdown period the government of the western cape, one of the nine provinces in south africa, made emergency funding available to provide meals to children in vulnerable communities. (the western cape is the only province not governed by the ruling party, the african national congress [anc] . it is governed by the nation's official opposition, the democratic alliance [da].) thus, some schools opened their gates, arranged for learners to sit in open fields at a distance from one another, and gave them meals. however, the country's largest teachers union, the south african democratic teachers union (sadtu), opposed this action. sadtu is affiliated to the congress of south african trade unions, which, together with the south african communist party, is in a tripartite alliance with the anc. sadtu stated that the da was going against the president's plans to curb the spread of the virus, and although the union was concerned about the welfare of working-class learners and their families, it was opposed to learners being given meals on the school grounds because this would place them and their communities at increased risk. in this instance, one might argue that two entities with different political motives were using learners as a political football. the teacher in this situation is faced with a difficult moral dilemma. assuming that the teacher is a member of sadtu and is also acutely aware that learners are not receiving adequate nutrition during the lockdown period, does the teacher support his/her union or does the teacher assist with feeding learners at the school? at the time of writing this article, the south african minister of basic education announced a phased reopening of schools. learners who returned to schools first were those at the exit points of primary and high schools-grades 7 and 12 learners, respectively. this happened in june 2020, which was the beginning of winter in the southern hemisphere, and the disease was predicted to peak in south africa around august/september 2020. thus, learners returned to schools at arguably the most vulnerable time for them in terms of the spread of the pandemic. the government has said that parents can decide themselves whether to allow their children to return to school or to do home schooling. this is a difficult moral decision for any parent to make. it is an even more difficult decision for poor and working-class families, who do not have the facilities and capacity to support their children to do home schooling and who may need to find childcare if they have to return to work themselves. role players in education have only difficult choices, as these two instances illustrate. and decisions of this kind might best be left to parents, free of coercion. but what should the response of scholars who engage in the study of curriculum be at this time? what is their moral obligation during the covid-19 pandemic? autio (2014) refers to the sense of "moral" as a "professional ethics" that relates to our commitment to study, teach, and engage in academic research aimed at understanding curriculum. during the covid-19 pandemic, though we might be isolated and unable to engage with one another through traditional face-to-face means, our commitment to study, teach, and engage in academic research should not weaken. in fact, at this time we need a deeper commitment to this sense of ethics. this means that we should use new technologies to engage in complicated conversations about curriculum-related matters. as with many other conferences, the 2020 annual conference of the south african education research association (saera) was cancelled, but members have been encouraged to engage with one another through their special interest groups (sigs), facilitated through use of technology. members of the curriculum studies sig, for example, have had complex conversations about the curriculum challenges facing south africa during and after the covid-19 pandemic. the sig released a statement that invites a broader audience to take part in such ongoing discussions. these conversations have not been chitchats of the kind aoki (2004) cautions against, nor have they been simple exchanges of information; instead, they have been robust, often involving disagreement, but always with a sense of mutual belonging and a commitment to the intellectual life of the field. i have been privileged to enjoy such exchanges in transnational spaces, in the way in which pinar (2006, p. 178) suggests that such spaces can be productive. he points out that, in transnational spaces, scholars of the field should distance themselves from their own national cultures and politics, and listen respectfully to others, thus creating "a global public space for dissension, debate, and on occasion solidarity". at this time, we need such often-difficult conversations to intensify-we do not need social distancing but social solidarity in national and transnational spaces that new technologies and the commitment of curriculum scholars make possible. in other words, we need physical distancing, not social distancing. again, with reference to the moral dimension of education, autio (2014) also refers to the need for conversations and debates on the worthiness of knowledge. that is, we need to ask critical questions about what knowledge is of most worth when it comes to the school curriculum during and after the covid-19 pandemic. here, i turn to school biology as an example. since its inception, a feature of school biology has been the debate on whether it is a "science of life" or a "science of living" (le grange 2008). few would disagree that school biology has to include both of these dimensions, but the pendulum has swung back and forth over the years concerning where we should place the emphasis. from the last half of the twentieth century to the twenty-first century, school biology has been largely characterized by the force-feeding of learners of a diet of "theory", regurgitated on tests and examinations-content is often irrelevant to the needs of learners or of society. in other words, during that time schools have emphasized biology as a "science of life" (le grange 2008). less than 2% of south african school leavers continue with careers in biology-related fields. therefore, for the majority of learners who take biology at school, the current subject content is largely unrelated to their lives. this is true despite its potential relevance to many contemporary issues facing society; among them, human diseases, including virus-causing diseases such as covid-19; human trafficking involving the sale of body parts; biodiversity loss; commodification of the genetic code; threats of biological warfare. instead of traditional unifying themes such as "structure and function" or "evolution", the curriculum could revolve around more relevant themes, such as sustainability, for example. such themes also reinforce connections between many other school subjects. here, the notion of sustainability does not have to do with policy goals but with cultivating a frame of mind that enables lifelong learning. to continue with sustainability as an example, using it as a unifying theme in biology classrooms could prove to be productive. instead of learners studying animals only in relation to themes such as structure and function, they could investigate what sustains an animal in fulfilling its ecological role, or occupying its niche, for example. it involves a way of getting learners to think about biology differently, to develop frames of mind focused on sustainability. bonnett (2003, p. 683) avers that a frame of mind is a "general mode of engagement with the world through which the world as a whole is revealed to us. … [i]t is more or less a conscious way of being in the world". this requires a specific cognitive/ conceptual outlook-but also involves our sensing of things and encapsulates the affective, moral, aesthetic, imaginative, and other receptions and responses that bonnett (2003, p. 684) refers to as "a mode of sensibility". it is a mode of sensibility toward sustainability that might be cultivated in biology classrooms after the covid-19 pandemic. not as a quick fix but as a habit of mind that might develop over time as the world of biology is "revealed" to learners through a conscious focus on sustainability. in their chapter, mccarthy et al. (2014) challenge scholars of curriculum to take seriously the reconfiguration of power as globalization quickens, and in particular how technologies of surveillance-such as biometric technologies, face scanning, finger printing, dna sampling, etc.-can be used to advance or sustain racism. subtle forms of racism might emerge as technologies of surveillance are used after the covid-19 pandemic, because these technologies provide fertile ground for racism's growth and consolidation. the pandemic will probably accelerate racism and other forms of discrimination, for several reasons-and there is already evidence of this. but the covid-19 pandemic has also exposed the underbelly of racial inequalities in such countries as the us, the uk, and south africa. devakumar, shannon, bhopal, and abubakar (2020) point out that outbreaks such as covid-19 create fear, and that fear is the key ingredient for racism and xenophobia to flourish. they go on to say that the pandemic has exposed the social and political fractures within communities, with racialized responses, that have affected marginalized groups disproportionately. devakumar et al. (2020) note that we have already witnessed microaggressions or overt violence targeting chinese people and barring them from establishments. moreover, political leaders have exploited the covid-19 pandemic to buttress racial discrimination by hardening border polices and conflating public health curtailments with anti-migrant rhetoric. for example, italy's prime minister cynically linked the covid-19 pandemic to african asylum seekers, and the us president referred to sars-cov-2 as "the china virus" (devakumar et al. 2020 ). these developments create fertile ground for racism, which is now also advanced through the technologies of surveillance that mccarthy et al. (2014) identify. the advances in technologies accelerated by covid-19-and the powers that governments have to subject citizens, and particularly foreign nationals, to a range of tests under the guise of protecting public health interests-could be further aiding and abetting this situation. the covid-19 pandemic has also laid bare racial inequalities in the us, uk, and south africa. in the us, the death rate among african americans is three times that of white americans because of poor living conditions, poor nutrition, lack of access to healthcare facilities, and comorbidities (begley 2020) . moreover, african americans are also bearing the brunt of the devastating economic impact of the covid-19 pandemic (rodgers 2020) . we have also observed this disproportionate negative effect of the covid-19 pandemic on black and asian people in the uk. andrews (2000) points out that this should not surprise us, and that it is a mistake to look at these racial differences through the lens of biology, because the issue is not a genetic but a social one. it is the consequence of sustained discrimination at systemic levels-economic, political, and social. in south africa, this pandemic has revealed the extent of the country's gross inequalities. recent statistics show that 20 million south africans do not have reliable access to running water in their homes (ellis 2020) ; the government had to deliver thousands of water tanks to communities in a desperate attempt to slow the spread of the virus. and in the informal settlements where millions of black south africans live, social distancing is a near impossibility. these vulnerable south african communities are also likely to bear the brunt of the economic impact of the pandemic. mccarthy et al. (2014) have reminded us of the importance of bringing race-and its reconfiguration as globalization accelerates-into our curriculum conversations and actions. race and racism-if they are currently blind spots or blank spots in our work-need to become key concerns in educational arenas. according to wagner (1993) , blank spots are what scientists know enough about to question but do not know how to answer, and blind spots are what they don't care about or know enough about. to return for a moment to school biology: when it emphasizes a "science of life" approach, then race becomes a genetic topic and the conclusion is that there is only one human race, one species, homo sapiens. however, this approach can create a blind spot to race as a social construct and its sustained negative impact on people of colour across the globe. and it is this blind spot that has also made race science endure for more than a century and why we are seeing its growth in contemporary times (for more details, see le grange 2019a). if school biology is to address issues related to race, then an emphasis on a "science of living" approach is more apposite than a "science of life" approach. lastly in this section, i shall turn briefly to the issue of bioinformationalism. bioinformationalism relates to parallels between the propagation of fake news in social media echo chambers, and the evolution and transmission of infectious diseases (peters, mclaren, and jandrić 2020) . peters et al. (2020) point out that the covid-19 pandemic is the first instance in which a biological virus has become dialectically intertwined with nonbiological viral information. what the authors are suggesting is that a biological virus and nonbiological viral information are working in tandem to accelerate the spread the virus. in other words, when fake news about the pandemic goes viral-such as "covid-19 does not affect africans" (a myth circulated across the african continent [padayachee and du toit 2020])-it influences peoples' behaviour in a manner that results in the spreading of the biological virus. and when the viral spread of fake news has racial connotations, such as linking the biological virus to african asylum seekers, then it also spreads racism. the coterminous nature of biological and nonbiological-information viruses adds to the complexity of issues related to the reconfiguration of race that globalization quickens and, consequently, to the complexity of curriculum scholars' work. to return to school biology for the moment: the imbrication of biological viruses and the viral spread of nonbiological information could certainly be a topic for inclusion in school biology classroom conversations, and learners could be asked to generate as many similarities and differences between biological viruses and nonbiological viruses generated through itcs as possible. in his chapter, smith (2014) reminds curriculum scholars of the pervasiveness of neoliberalism in education and emphasizes the need to analyze neoliberalism and its effects on an ongoing basis. neoliberalism can be traced back to seventeenth-century liberal perspectives, which became marginalized as a result of the rise of welfare-state liberalism (late nineteenth century) and keynesian economics (twentieth century). the revival of neoliberalism in the late twentieth century is associated with the emergence of the new right in europe and the us, often referred to as "thatcherism" and "reaganism" after two of its key proponents (le grange 2006). although neoliberalism has different strands, all neoliberals embrace the following three basic principles: a commitment to individual liberty and a reduced state; a shift in policy and ideology against government intervention; and a belief that market forces should be allowed to be self-regulating (for a comprehensive discussion on the ascendancy of neoliberalism, see olssen, codd, and o'neill 2004) . many western governments floundered when covid-19 resulted in a global pandemic because their health systems were unable to cope with the pandemic's demands. governments found themselves in a precarious position because of their underspending on healthcare-consequent on adopting neoliberal policies. moreover, some scholars have gone as far as to link an increase in relatively unknown and highly infectious viruses to neoliberal capitalism. as mckinley (2020) writes: [t]he increased occurrence of largely unknown and ever-more-virulent viruses is directly linked to the nature/character of land use and food production under the neoliberal model of capitalism; to the contemporary dominance of an "industrial model" of agriculture that is umbilically tied to the never-ending search for maximum profits, whatever the human, social and/or environmental consequences. just as the covid-19 pandemic as a public health crisis needs to be understood against the backdrop of neoliberalism, so, too, does the education crisis that has deepened during the pandemic in south africa. in the late 1980s, the outgoing apartheid government of south africa adopted neoliberal education policies and introduced new models for white schooling that involved the semi-privatization of these state schools under the guise of racially integrating them. the school model that survived into south africa's democratic dispensation was the model-c school; today, many elite and middle-class public schools in south africa are commonly referred to as "former model-c schools". at their inception, the model-c schools were fee-paying schools, and they were allowed to sell excess land, which enabled them to accumulate capital. these resources enabled these schools to appoint additional teachers to their staffs and, by doing so, improve the quality of education provided. after 1994, south africa's democratically elected government continued the neoliberal trend and maintained what has become a grossly unequal public school system. the government's attempts to make the schools in economically poor communities non-fee paying-by dividing them into different quintiles-have done little to arrest the inequalities that characterize the south african schooling landscape (see le grange, reddy, and beets 2012). when south africa went into lockdown during the pandemic and closed its schools, the unequal education system in south africa was exposed even further. learners in private schools as well as in affluent and middle-class public schools migrated relatively easily to emergency remote learning, because these learners had access to devices and connectivity, as well as support from teachers and parents. access to any form of online learning for the majority of school learners remains a pipedream; thus, the covid-19 pandemic has likewise laid bare the severity of the digital divide in south africa (davids 2020) . moreover, when schools reopen as the country moves to lower levels of its risk-adjusted approach, learners who attend schools in economically poor communities will be at greater health risk. such schools lack basic sanitation and water infrastructure; moreover, their inferior facilities will make physical distancing a challenge. although learners in south africa's bimodal schooling system have the same explicit curriculum, the curriculum-as-lived by the two sets of learners is radically different. the covid-19 pandemic will further reduce the life chances of a learner from a school in an economically poor community relative to those of a learner in a private or affluent public school. additionally, as affluent and middle-class schools pivot toward online learning and governments invest in technology infrastructure to make online learning more widely available after the covid-19 pandemic, we must be aware of the dangers regarding these developments in the context of neoliberal capitalism. it is my contention that we should view new technologies (and in the context of education, online teaching/learning) dialectically. in other words, we need to recognize both their productive potential to advance the goals of social justice and the dangers of their consolidating inequities. in the context of neoliberal capitalism, not only will the digital divide widen, as noted, but also the migration to online learning could result in greater privatization of schooling as for-profit intermediaries become involved in developing online programmes/courses. this is because public schools do not have the capacity to develop such programmes or courses-platform pedagogy morphs into platform capitalism (for a more detailed discussion on such developments, see hall 2016; le grange 2020). in this context, instrumentalist approaches to education would thrive and policy makers would cement standardized tests to improve efficiencies. performativity regimes-including surveillance of both teachers and learners-are likely to increase. if there is a lesson to be learned from the covid-19 pandemic, it is that communities in south africa radically reconfigure and resource their schools. such a reconfiguration needs to make those who inhabit schools (learners and teachers) the central concern, and to open up the pathways for the becoming of their lives (in relationship with one another). it is with this in mind that i turn to a discussion of the notion of ubuntu-currere. the covid-19 pandemic will probably not be the last global crisis facing humanity in the twenty-first century. if another virulent virus is not the cause of such crisis, then the cause could be an environmental catastrophe-that is, if humanity continues on its unsustainable course and neoliberal capitalism continues to thrive. it is sobering to note that global crises have not led to the weakening of neoliberal capitalism, as evident in the case of the 2008/2009 financial crisis. hall (2016) points out that it was not surprising that uber and airbnb had their genesis during that financial crisis, in the years 2008 and 2009, respectively. these for-profit, "sharing"-economy, platform-based companies have taken neoliberalism to an ideal form. customers benefit from the services offered, but, for the on-demand worker in these industries, rights and benefits have become eroded as these businesses escape state regulation (see hall 2016; le grange 2020) . and so, there is a danger that, in the wake of the current pandemic, we might see greater privatization of several sectors, including healthcare and education. smith (2014) , in his chapter, averred that, to get beyond neoliberalism, we need to analyze it on an ongoing basis. he goes on to say that in our critical engagement with neoliberalism we might find inspiration in wisdom traditions, be they indigenous, religious, or philosophical. it is this part of smith's chapter that connects to wang's (2014) -the fourth introductory chapter in pinar's (2014) edited handbook-where she promotes nonviolence through the invocation of indigenous and peace-making traditions such as the african notion of ubuntu and the chinese notion of tao. given the violence perpetrated against humans (particularly those on the margins of societies) that the covid-19 pandemic has laid bare, we could find inspiration from the traditions that wang (2014) refers to. therefore, following on from smith (2014) and wang (2014) , i propose that the notion of ubuntu-currere might provide the inspiration and motive force for ridding ourselves of the shackles of neoliberal capitalism and its effects on education. i invoked the idea of ubuntu-currere in a keynote address at the fifth triennial conference of the international association for the advancement of curriculum studies (iaacs) (le grange 2015). the idea brings together insights from the african value of ubuntu and william pinar's (1975) autobiographical method currere, which was extended by wallin (2010) . ubuntu, derived from aphorisms in the nguni languages of southern africa, means that our being and becoming is dependent on others. in contrast to descartes's cogito ergo sum, "i think, therefore i am", ubuntu means "because we are, therefore i am". some have misconstrued the meaning of ubuntu, arguing that it is, by definition, speciesist. however, what we need to understand is that relationality between humans (ubuntu) is emblematic of the relatedness of all things in the cosmos. i point out that ubuntu is the concrete expression of the shona concept ukama, which mean relatedness of all things in the cosmos (le grange 2012). in other words, ubuntu is a microcosm of ukama. moreover, ramose (2009) has argued that ubuntu is antihumanist and involves the ongoing unfolding of the human in relationship with the other-that the human being is in-becoming. forty-five years ago, pinar (1975) first invoked the etymological root of "curriculum": the latin currere, "to run the course". in doing so, he refocused curriculum on the significance of individual experience, "whatever the course content or alignment with society or the economy" (pinar 2011, p. xii) . currere privileges the individual and pinar (2011, p. 2) argues that it is a complicated concept, because each of us is different in our genetic makeup, our upbringings, our families, and, more broadly, our race, gender, class, and so on. put simply, currere shifts the attention away from the concept of a predetermined course to run, to a focus on how the course is run by each individual, given each one's unique makeup, context, hopes, aspirations, and interactions "with other human beings and the more-than-human world" (le grange 2019b, pp. 221-22). in other words, each person has her or his own life story, and the understanding of one's own story through academic study is at the heart of curriculum. pinar (1975) develops currere as an autobiographical method with four steps or moments-regressive, progressive, analytical, and syntheticalthat depict both temporal and reflective moments for autobiographical research of educational experience. both ubuntu and currere affirm the importance of human experience-the being and becoming human-and the unfolding of the human as the world is revealed to it. but le grange (2015, 2019b) brings the two notions together to shift the emphasis from the individual to a subject that is ecological-a subject that is embodied, embedded, and enacted. i invigorated lines of connections between emerging (post)human theories to create a new concept: ubuntu-currere. i wrote: ubuntu-currere shifts our registers of reference away from the individual human being to an assemblage of human-human-nature. in other words, subjectivity is ecological. moreover, the subject is always in becoming and the becoming of a pedagogical life is relational-the subject becomes in relation to other humans and the more-than-human-world. the notion in-becoming ensures that the human cannot be defined nor have fixity and therefore ubuntu-currere is anti-humanist. put differently, ubuntu-currere negates the construction of a molar identity that is a screen against which anything different is othered in a negative sense. ubuntu-currere has resonance with new materialist post-human theory in that it embraces an ontology of immanence-that there is a material immanent plane that connects everything in the cosmos and from which all actualised forms unfold/become. ubuntu-currere opens up multiple coursings for developing post-human sensibilities driven by the positive power of potentia that connects, expresses desire and sustains life. … but, it also makes possible conversations with the more-than-human so that we can listen to the rhythm and heartbeat of the earth-so that our conversations do not happen on the earth but are bent by the earth. (le grange 2019b, pp. 221-222; italics in original) ubuntu-currere affirms the importance of caring for other humans beings-"humanness" does not mean humanism and is antithetical to it. the subject of education informed by ubuntu-currere is not egoistic and holds no ontological privilege, but is placed on an immanent plane with all living beings. the actions (ethics) of this subject in the world are to release the power that is within-in contrast to the power that imposes or acts upon the other. this power of potentia is within all life and connects all modes of life. it is this same power that we see when humans perform generous acts of caring for others during the covid-19 pandemic, when they unselfishly give up their lives to save or feed another. this power is counter to the negative power of postestas that imposes, that engages in othering, that colonizes, that controls, etc. if we are to have a different post-covid-19 world, then its actualization depends on invigorating potentia. education informed by ubuntucurrere involves supporting learners to release potentia so that actions in the world are about enhancing life. the ideas advanced in the four introductory chapters of the international handbook of curriculum research that frame this article are connected to one another and crystalize in the notion of ubuntu-currere. the moral dimension of education speaks to our sense of belonging to something bigger than our individual selves and the need for our ongoing commitment to engage in complicated conversations with one another, and more so in troubled times. and in such conversations, we should understand and investigate how the ongoing discriminations of all kinds that continue to plague us are amplified and accelerated. the covid-19 pandemic has laid bare how those on the margins of society bear the brunt of the pandemic-and that the underlying cause of much of this reality of inequality is the dominance of neoliberal capitalism. if we are to avoid the damaging effects of crises such as the current one, then we need perform currere to free ourselves from the fetters of neoliberal capitalism. and if we are to live in harmony with one another and the more/other-than-human world, then we need to fuse currere with ubuntu. ubuntucurrere makes possible an education that is a life-long affair of experimentation with the real-experimentation constrained only by life itself. put differently, our experimentation with life should be curtailed only when we hurt other humans or the more/other-thanhuman world. under covid-19, racism in britain and the world is a matter of life and death. daily maverick layered understanding of orientations in social studies program evaluation the internationalization of curriculum research to understand who's dying of covid-19, look to social factors like race more than pre-existing diseases education for sustainable development: sustainability as a frame of mind maybe the coronavirus will set sa on a path to a more equitable education system racism and discrimination in covid-19 responses covid-19: exposing a water crisis in the making. daily maverick lockdown: school feeding scheme reopens in western cape to assist "desperate communities the uberfication of the university quality assurance in south africa: a reply to john mammen the history of biology as a school subject and developments in the subject in contemporary south africa ubuntu, ukama, environment and moral education keynote address delivered at the 5th triennial conference of the international association for the advancement of curriculum studies a comment on criticisms of the article "age-and education-related effects on cognitive functioning in colored south african women currere's active force and the concept of ubuntu could the covid-19 pandemic accelerate the uberfication of the university? socially critical education for a sustainable stellenbosch by 2030 race and education in the age of digital capitalism coronavirus and capitalism: structural foundations and opportunities for systemic change. daily maverick education policy: globalization, citizenship and democracy debunking nine common covid-19 myths doing the rounds in africa: some of the false claims being made about the coronavirus are harmless. others can be potentially dangerous a viral theory of post-truth the method of currere. paper presented at the annual meeting of the american educational research association (aera) the character of curriculum studies: bildung, currere and the recurring question of the subject international handbook of curriculum research african ethics: an anthology of comparative and applied ethics black americans bearing the brunt of coronavirus recession: this should come as no surprise. the conversation wisdom responses to globalisation what knowledge is of most worth ignorance in educational research: or, how can you not know that? educational researcher a deleuzian approach to curriculum: essays on a pedagogical life a nonviolent perspective on internationalising curriculum studies publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.lesley le grange is distinguished professor in the faculty of education at stellenbosch university, south africa. he is also vice-president of the international association for the advancement of curriculum studies (iaacs), a fellow of the royal society of biology (uk), a member of the academy of science of south africa, and rated as an internationally acclaimed researcher by the national research foundation in south africa. he has published more than 200 articles and serves on editorial boards of nine peer-reviewed journals. he has delivered more than 170 academic presentations and is recipient of several academic awards and prizes; the most recent is the south african education research association (saera) honours award (2019) for outstanding contribution to educational research in south africa. key: cord-016593-t0dn27bc authors: spring, úrsula oswald title: food as a new human and livelihood security challenge date: 2009 journal: facing global environmental change doi: 10.1007/978-3-540-68488-6_33 sha: doc_id: 16593 cord_uid: t0dn27bc as a result of a process of “regressive globalization” (kaldor/anheier/glasius 2003; oswald 2008b) and of an increasing concentration of wealth in few hands, the economic gap has widened between north and south and within the countries between rich and poor, which has often affected the survival of social groups. as a result of a process of "regressive globalization" 2 (kaldor/anheier/glasius 2003; oswald 2008b) and of an increasing concentration of wealth in few hands, the economic gap has widened between north and south and within the countries between rich and poor, which has often affected the survival of social groups. this inequality is one of the core elements of failure in the eradication of hunger and poverty. therefore, many multilateral organizations, such as the world bank (wb), the international monetary fund (imf), and regional associations like the economic commission for latin america and the caribbean (cepal), the inter-american development bank (idb), the asian development bank (adb), and the african development bank (afdb) and the east african development bank (eadb), have recommended to the governments to reduce the internal gap and to dedicate more resources for human development. they should address basic food production systems with job creation, increase low salaries and subsidies for the marginalized and promote cheap prices of basic food for the urban poor. these recommendations have directly linked 'food security' 3 to the wider concept of 'human security' 4 (brauch 2008; oswald 2008b, 2008d; brauch/oswald/ mesjasz/grin/dunay/behera/chourou/kameri-mbote/ liotta 2008). 'freedom from want' requires sufficient food ('food security') and water ('water security'), and both are key demands of any human security concept as a necessity for survival, and thus it has become a basic human right. human security requires not only a quality of life and a decent livelihood, but also health and stable productive conditions for almost half of the world population living in marginal rural and urban areas (see part ix and chap. 74 to 96). in the early 21 st century, more than 2 billion persons depend on food self-sufficiency and another billion peasants suffer from eroded and polluted land, are unable to satisfy basic human needs, and are often forced to migrate to shanty towns or to cross illegally the borders to industrialized countries in search of jobs and quality of life (schteingart 2006; oswald 2006a). thus, in this author's understanding 'food sovereignty' goes beyond the physical conditions of production and market, and involves social (campos 1995; strahm/oswald 1990), cultural (arizpe 2004), economic (calva 2008/a; martínez 2003; cadena 1 this article has been substantially improved as a result of an international cooperation. i want to thank two anonymous reviewers for helpful comments and hans günter brauch for his critical input to the first draft. he also compiled box 33.1 and systematized important parts of box 33.3. i am immensely grateful for his careful editing and style correction and to ronnie lappin for his language editing. 2 regressive globalization is understood in this context as a doctrine, rooted in the confidence of the efficacy, institutional building and moral authority of us power, allied with transnational capital in the sphere of communication, military, commerce, finance, and productive system. using the term democracy and progress it is promoting a liberal global world order, favouring international capital and transnational productive systems. in the poor countries this process creates greater poverty, technological dependency, debts, massive rural migration and often loss of food sovereignty, while a small elite benefits from this alliance. 3 for the definition of and the scientific debate on the term 'security' in english and spanish see albrecht/ brauch (2008 , 2008a ; brauch (2002a brauch ( , 2003 brauch ( , 2008 brauch ( , 2008a brauch ( , 2008b brauch ( , 2008c ; and oswald/ brauch (2008, 2008c) . the author will not use the term 'food security' developed during the past four decades (see part 34.2, where the debate in the fao and world bank has been briefly documented and criticized as a too technological and top-down approach), but will developed a wider concept of 'food sovereignty'. 4 the author has developed in chap. 90 her proposal for a new and wider policy-relevant security concept that combines human, gender and environmental security (huge) dangers and concerns. on this dual political and conceptual background, this chapter addresses the following research problem: food represents not only a security issue of intake of nutrients, but it forms part of a holistic understanding of life and a constituting element of any civilization. thus it includes networks of connectedness (vertical: patron-client, and horizontal: social groups), belonging, relationship of trust, reciprocity, cooperation and exchange. it creates social benefits and risk reduction, but also innovative activities through a wider access to information and learning. it is a process of anchoring of personal and group identity (see chap. 90 by oswald on huge), where social relations reaffirm the integration of a person inside a community with clear rights and obligations, such as access to land, credit, technology, training, market, life quality and rituals. besides guaranteeing the physical and cultural survival, food also creates new opportunities for people-centred poverty alleviation and new understanding of 'rurality'. it represents a critical response to the past development and modernization paradigms and opens ways for diverse rural life processes, where agricultural activities and environmental services coexist with services, technology, and industries. in addressing this research question, this chapter links the concept of food security with food sovereignty, a term developed by peasant movements, especially via campesina 5 that was later also taken up by fao. it first reviews basic concepts such as food security, food sovereignty, survival strategies, self-sufficiency, and livelihood (33.2). then it scrutinizes the contradiction that in a world with increasing production and a diverse offer of food, hunger is still one of the most important causes of illness and death, because an important part of food is used for livestock and for industrial purposes. recently, biofuels have aggravated the scarcity of food worldwide and regionally, affecting above all vulnerable groups such as poor peasants and marginalized urban people in the south and north. this part reviews the internal food intake not only globally, but also for latin america and in a case study of mexico that focuses on the remote indigenous regions of chiapas, oaxaca, and guerrero where undernourishment is still high and one of the causes of child mortality (33. 3) . part 4 explores three global models of food production: a) the productive paradigm, represented by the 'green revolution' that emerged in mexico; b) the new paradigm of the 'life sciences', where transnational enterprises (tne) have converted food not only into a commodity, but also into health and medical items; c) the third paradigm refers to 'organic agriculture' that cannot be globalized. it uses traditional agricultural methods developed in each region; recycles organic waste, produces soil enrichment with compost and uses biopesticides and natural seeds. the transformation of food uses long-established techniques and avoids the use of chemicals for conservation. this production system not only conserves the natural nutritional values of food and soils, but it is also an alternative for the self-sufficiency of poor peasants worldwide (33.4). in the concluding part these three models are compared and related to its repercussion on environmental, gender, and human security (oswald 2001, 2006a and chap. 90 below on huge). it links 'food security' with some traditional models of self-sufficiency that were proposed by julius nyerere in his 'ujamaa' philosophy and by ecofeminists (mies 1998; shiva/mies 1997; d'eaubonne 1974). it was taken up by via campesina, the most important world peasant movement and developed into a 'food sovereignty' paradigm. this approach is able to link up small producers from south and north, east and west, and to produce enough food for a livelihood with dignity. this approach integrates democratic land reforms, local market structures, green agriculture, and natural seeds as the patrimony of peasants and communities, with a culturally diverse livelihood (shiva 2008, see preface essay in this vol.). why is food important for humans? food, water, and air are the crucial elements of survival for humans. food creates energy required for growth, sustenance, and biological and physical activities; it acts within the cells and it purveys the structural and catalytic components to build anabolism. 6 whenever one of these 5 vía campesina is a world organization of peasants and small producers and fishermen from the south and north with sub regional association such as latin american peasant organizations (cloc in spanish), in latin america, north america, europe, asia and africa. their goal is to defend an integral process of rural livelihood including agriculture, livestock, orchards, fishing, hunting and recollection, including direct producers, rural workers, women, elders and the young. their executive committee is democratically elected and regionally representative, caring about gender and youth equity. functions fails, organisms substitute it with another process (oswald 2006: 663 -664). food is the generic term used for vegetal and animal nourishment as a whole, in parts or its different versions (flowers, fruits, leaves, roots, milk, eggs, muscles, kidney, blood, etc.). it can be distinguished from nutrition, which is the process through which food is absorbed and transformed. food intake is a biological necessity, determining the quality of life and health of a human being, and its nutritional requirements vary according to age, sex, physical activities, climatic factors, and health conditions. nutrition refers to the process of absorption of food by living organisms'. 7 it starts with ingestion, continues with digestion, where the proteins are transformed into amino acids and keeps on with the absorption of nutrients in the intestine. once integrated into the blood, they are assimilated by the body and transformed metabolically in each cell. the last phase is the excreta of faecal material and urine, where also toxins are eliminated from the body. nevertheless, food cannot be reduced only to this physiological process. it is a holistic experience where different senses intervene (smell, flavour, touch, view). each civilization has developed a culture of tra-ditional, ritual and food specialties linked to religious and civil events. different diets and food preparation, but also taboos, ceremonies and rituals, are able to reinforce the cultural and territorial identity of people. maxwell and smith (1992) had counted more than 200 definitions of 'food security' (fao 2003a (fao , 2005c . within the food and agricultural organization (fao) the food security concept has gradually been developed as a guiding concept for fao's evolving food policy (box 33.1). the general definition of 'food security' that was inspired by fao is related to the personal right to sufficient food for a person and a nation, discounting nofood uses. 8 the us department of agriculture (usda) evaluates national food security by measuring the gaps between actual food consumption, domestic production, plus commercial imports, minus unused food and consumption targets. sometimes, nutrition gaps are also measured by the minimal daily nutritional requirements in relation to age, sex, and activities. thus, food security is assuring the physical availability and the economic accessibility to enough food in an environmentally and socially sustainable manner, where adequate quantity and quality, but also culturally acceptable food for everybody at any time is able to guarantee a healthy and active life. quantity refers to amount, distribution, calories and proteins, and quality to safe, innocuous, nutritious balanced, good and culturally accepted food. among the many 6 anabolism is the process which builds up complex molecules from smaller units, able to give the body the required energy that is coming from glucose and fatty acids. therefore, it refers to chemical reactions that produce a combination of different molecules. the result of anabolism is the creation of new cellular material (enzymes, proteins, cells and its membrane, organs and tissues). thus, anabolism is crucial for growth, maintainance, and reparation of tissue. 7 an optimal functioning of an organism or of its cells requires about a hundred different substances located in the environment. their function is to maintain the structure and to control the metabolism. metabolism means the sum of chemical changes taking place inside an organism by which food is transformed and utilized by the organisms, and water products are eliminated. according to fao (2003a) the food security concept gradually emerged in the mid-1970's when the initial focus was on: food supply problems -of assuring the availability and to some degree the price stability of basic foodstuffs at the international and national level. that supply-side, international and institutional set of concerns reflected the changing organization of the global food economy that had precipitated the crisis. a process of international negotiation followed, leading to the world food conference of 1974, and a new set of institutional arrangements covering information, resources for promoting food security and forums for dialogue on policy issues (odi 1997). focus was put on productivity, within a frame of green revolution, independent of social, environmental, and political costs. the problems of famine, hunger, and food crises were analysed in detail, resulting in a "redefinition of food security, which recognized that the behaviour of potentially vulnerable and affected people was a critical aspect" (fao 2003a). the insight that the green revolution "did not automatically and rapidly lead to dramatic reductions in poverty and levels of malnutrition ... were recognized as the result of lack of effective demand" (fao 2003a). food security was defined in 1974 as: 'availability at all times of adequate world food supplies of basic foodstuffs to sustain a steady expansion of food consumption and to offset fluctuations in production and prices' (un 1975) . in 1983, fao expanded its concept to include securing access by vulnerable people to available supplies, implying that attention should be balanced between the demand and supply side of the food security equation: 'ensuring that all people at all times have both physical and economic access to the basic food that they need' (fao 1983a) . the commoditization of inputs and food markets widened the existing social gap, giving support to large-scale industrial agriculture and expelling millions of peasants from their land. an influential world bank (1986) report on poverty and hunger addressed the temporal dynamics of food insecurity and introduced the "distinction between chronic food insecurity, associated with problems of continuing or structural poverty and low incomes, and transitory food insecurity, which involved periods of intensified pressure caused by natural disasters, economic collapse or conflict" (fao 2003a). the food security concept evolved to: "access of all people at all times to enough food for an active, healthy life" (world bank 1986: chap. 2). in the mid-1990's, this definition was widened: to incorporate food safety and also nutritional balance, reflecting concerns about food composition and minor nutrient requirements for an active and healthy life. food preferences, socially or culturally determined, now became a consideration. the poten-tially high degree of context specificity implies that the concept had both lost its simplicity and was not itself a goal, but an intermediating set of actions that contribute to an active and healthy life. in undp's (1994) human security concept, food security was one of its seven aspects. in 1996, the world food summit adopted an even more complex definition: food security, at the individual, household, national, regional and global levels [is achieved] when all people, at all times, have physical and economic access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life (fao 1996b food security … as a phenomenon relating to individuals. it is the nutritional status of the individual household member that is the ultimate focus, and the risk of that adequate status not being achieved or becoming undermined. the latter risk describes the vulnerability of individuals in this context. … useful working definitions are described below. food security exists when all people, at all times, have physical, social and economic access to sufficient, safe and nutritious food which meets their dietary needs and food preferences for an active and healthy life. household food security is the application of this concept to the family level, with individuals within households as the focus of concern. confronted with new models of fast food, people began to suffer more from obesity, cardio-vascular accidents, diabetes and cancer. thus the concept of food security shifted again, now to healthy and innocuous food, able to maintain a person vigorous and active by reducing the intake of animal fat, sweet beverages, and junk food. but when confronted still with 825 million hungry people, food insecurity was addressed, together with the fact that 80 per cent of the poor live in rural areas and agriculture employs almost 50 per cent of them: rural development is critical for improving food security. the traditional agriculture sector has low productivity due to the lack of investment, inadequate water supply and scarce arable land. rapid depletion of groundwater resources may be the most serious problem facing the countries (fao 2006: 20) . definitions of 'food security' used in the scientific and policy oriented food discourse those selected here indicate its scope: • "when people do not need to live with hunger or fear starvation" 9 ; • "physical and economic access, at all times, to sufficient, safe and nutritious food to meet dietary needs and food preferences for an active and healthy life" 10 ; • "the ability of individuals to obtain sufficient food on a day-to-day basis" 11 ; • "the notion that all people, especially the most vulnerable, have dignified and unthreatened access to the quality and quantity of culturally appropriate food" that will fully support their physical, emotional, and spiritual health (wolfe/frongillo/valois 2003); • "state in which all persons obtain a nutritionally adequate, culturally acceptable diet at all times through local non-emergency sources" (riely/ mock/cogill/bailey/kenefick 1999); • "condition of having enough food to provide adequate nutrition for a healthy and productive life" (usaid, bureau for africa 1986a). usaid defined 'food security' as: all people at all times have both physical and economic access to sufficient food to meet their dietary needs for a productive and healthy life. achieving food security requires that the aggregate availability of physical supplies of food is sufficient, that households have adequate access to those food supplies through their own production, through the market or through other sources, and that the utilization of those food supplies is appropriate to meet the specific dietary needs of individuals. achieving food security requires that the aggregate availability of physical supplies of food is sufficient, that household have adequate access to those food supplies through their own production, through the market or through other sources, and that the utilization of those food supplies is appropriate to meet the specific dietary needs of individuals (riely/mock/cogill/bailey/kenefick 1999: 2 -3). the us food and drug administration (fda 2003) defined 'food security' as the daily balanced intake of proteins, carbohydrates, vitamins and minerals re-quired for a healthy life. the disequilibrium in quantity and polluted food, or with toxins, could generate illnesses and limit the physical and mental development of children. finally, food security is also related to food safety such as hygiene and prevention of illnesses caused by food in bad conditions or foodborne sicknesses. 12 according to who, bacteria are the main threat for innocuous food that are present in the domestic and professional food chain. food security, as defined by fao, does not include social and cultural factors of food and nutrition, nor land rights, seeds, credits, family ties, social relations of productive and consumption pattern together with communitarian cohesion. therefore, via campesina understood 'food sovereignty' as "the right of peoples, communities, and countries to define their own agricultural, labour, fishing, food and land policies, which are ecologically, socially, economically and culturally appropriate to their unique circumstances. it includes the true right to food and to produce food, which means that all people have the right to safe, nutritious and culturally appropriate food and to food producing resources and the ability to sustain themselves and their societies" (food sovereignty: a right for all, political statement of the ngo/cso forum for food sovereignty, rome, june 2002). thus important elements of food as a cultural and not only as a technical process are lacking in the fao definitions. the concept of "food sovereignty represents both a social and a personal right of individuals and communities to healthy, culturally appropriate and permanent food" (oswald 2006: 664), but includes also the process of production, land tenure, local native seeds, access to water and to other natural resources, storage processes, transformation of food, eating, fiestas and rituals in which women play a key role. social movements such as via campesina have used in their daily struggle the concept of food sovereignty, including geopolitical, socio-economic, identity and cultural aspects (box 33.2). this new concept of 'food sovereignty' that differs significantly from the concept of 'food security' (box 33.1) that is being used by fao and the food aid community has been taken up by the un forum for indigenous peoples during its sixth session, 14 -25 may 2007 that defined food sovereignty as: the right of peoples to define their own policies and strategies for the sustainable production, distribution, and consumption of food, with respect for their own cultures and their own systems of managing natural resources and rural areas, and is considered to be a precondition for food security. 13 this concept has also been discussed by several ngos, such as the africa europe faith and justice network (aefjn) that adopted a food sovereignty document in september 2005 that points to many shortcomings of the food security concept (box 33.3). these definitions on food sovereignty by social movements representing the interest of farmers in the south (via campesina, box 33.2) and of an african-european catholic group (box 33.3) are just two exemplary snapshots that point to major shortcomings of the debate on food security during the past three decades. they are also responsible for the lack of progress against hunger since until today 25,000 people, above all small children, die daily of hunger. the next two concepts of 'survival strategies' and 'livelihood' that have been developed in the south address different means for the marginalized poor to achieve 'food security' with 'food sovereignty'. vía campesina, social movements, ecofeminists and indigenous organizations define food sovereignty as an integral process of production, commercialization, transformation and intake related to the family and community culture of food, proper of any region, social class and nations. their understanding of food sovereignty includes: a.) local production and trade of agricultural products with access to land, water, native seeds, credits, technical support and financial facilities for all participants; b.) women are the main food producers worldwide 1) and they are often in charge of transformation and local trade; c.) therefore, access to land, credit and basic production means for women and girls at home and in the community is a guarantee of food security, but it is also able to overcome the violent and unjust patriarchal structures within families, communities, social organizations, countries, and global economic systems; d.) inclusion of the indigenous, women, and peasants in regional and national rural policy and decision-making processes related to agriculture and food sovereignty; e.) the basic right to consume safe, sufficient, and culturally accepted non-toxic food, locally produced, transformed and sold, since food is more than intake of proteins and calories: it is a cultural act of life; f.) the rights of regions and nations to establish compensations and subsidies to get protection from dumping and artificial low prices as a result of subsidies in industrialized countries; g.) the obligation of national and local governments to improve the food disposal of its citizens through stimulus of production and transformation of food, subsidies, and economic programmes to achieve food sovereignty in basic crops; discounts in urban poor regions, able to guarantee the basic food basket; popular kitchens; breakfast in schools, and special food for undernourished babies and pregnant mothers; h.) governments should guarantee an adequate nutrition above all for babies, infants, and pregnant women, offering food supply for poor people; i.) during bad harvests the importation of basic crops from the world market, and when countries are threatened by famine, with the advice and support from the world food programme; j.) clean water and sewage facilities to eliminate parasites, viruses, helminth and protozoa 2) ; k.) links among environmental services, agriculture, territorial planning and democratic participation in the decision-making process to guarantee the livelihood and dignity of the most vulnerable in rural areas. they create opportunities for rural population to stay on their field without pressure for migration. the sum of these processes reinforce for each citizen the basic rights of life, but also the right of non-migration, thanks to sustainable life with dignity in its own communities and countries. on 7 july 2005 some representatives of aefjn met … to discuss the principles of food sovereignty as a possible framework for the work of aefjn. the discussion stimulated interesting reflections about the definition of the term, the difference with other mainstream concepts such as the right to food and food security, weaknesses and strengths of this paradigm, and the specific aspects that can relate food sovereignty to catholic social teaching, human rights and policymaking. we would like to summarize here some of our findings. life is the most precious gift. the right to life is therefore the most fundamental right for any human being. an essential condition to sustain life is food. access to food is recognized as a basic human right. the right to food was recognized in the universal declaration of human rights in 1948. it is also included in the international covenant on economic, social and cultural rights of 1976: "everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food…" (universal declaration of human rights, art. 25.1) therefore the right to food is an integral component of human rights, based on existing international law and protected by a legally binding framework in international law. also important are the fao "voluntary guidelines " (november 2004) formally accepted by fao members states as a useful tool to challenge unwilling governments to take their internal and external responsibilities serious. the concept of food security has long dominated the discussion about the question how to diminish and eliminate poverty and hunger. coined in the context of the un specialized agencies, such as fao, the term has been used since the 1970's. although there is a definition agreed by all, the 1996 world food summit defined food security as 'the situation in which all people, at all times, have physical and economic access to safe and nutritious food that meets their dietary needs and food preferences for a healthy life'. though it refers to having enough food to eat, it doesn't talk about where the food comes from, who produces it, how and under which conditions it has been grown. food sovereignty is a global or national vision oriented towards production, rather than access to food by deprived persons and groups. the way to have access to food can be different: to grow food, to have paid work to buy food, or to receive welfare in case of inability. this allows the big food producers both in the north and south to argue that the best way for poor countries to achieve food security for their people is to import cheap food from abroad rather than trying to produce it themselves. it does not question the existing relations of inequality and processes that increase these social gaps, within a country by landlords and outside by tne. in spite of the green revolution, improved productivity and tremendous efforts to provide food security, the number of hungry people in the world has been growing. surprisingly, the very people who grow food, the small peasant farmers, particularly women, are afflicted by hunger and can no longer make a living on their land. to speak only of food security is no longer enough. we have to look at the question of what kind of food is produced, how it is produced, for whom it is produced. food security is a definition of a goal rather than a programme with specific policies that aim at the eradication of the causes of hunger and malnutrition. therefore a more comprehensive notion is under discussion today to ensure the daily food for all through food sovereignty. there are several definitions of 'food sovereignty': food sovereignty is the right of people, communities, and countries to define their own agricultural, pastoral, labour, fishing, food and land policies which are ecologically, socially, economically, and culturally appropriate to their unique circumstances. it includes the right to food and to produce food, which means that all people have the right to safe, nutritious, and culturally appropriate food, and to food-producing resources and the ability to sustain themselves and their societies. food sovereignty also refers to the right of states to protect their population by restricting the dumping of products in their markets and through the control of the domestic market. the notion of food sovereignty has not been invented by intellectuals. it comes from the grassroots, from peasant farmers and indigenous people in latin america who started to reflect on the root causes of their misery and to look for a way to live a dignified life. farmers associations in asia took up the concept. today farmers in europe are threatened as well in their existence by the effects of globalization. they, too, begin to accept food sovereignty as a revolutionary alternative to the dominant neo-liberal model, which tends to look at reality exclusively from an economic and a commercial angle. more important, the concept of 'food sovereignty' wants to integrate the welfare of people/human beings as well as/and to integrate the notions of the common good of society and ecological sustainability into concepts of the market economy. the concept of food sovereignty is not necessarily opposed to that of food security, but it goes beyond it. food sovereignty actually expands the focus by looking at the causes of hunger rather than concentrating only on the effects. food sovereignty can be an alternative to the current mainstream thinking on food production. it is people-centred as it looks at people not only as consumers of food, but at active agents in the production of food. there are various definitions of food sovereignty. we want to look at the definition accepted by the forum for food sovereignty in rome in 2002. food sovereignty is the right of people, communities, and countries to define their own agricultural, pastoral, labour, fishing, food and land policies which are ecologically, socially, economically, and culturally appropriate to their unique circumstances. it includes the right to food and to produce food, which means that all people have the right to safe, nutritious and culturally appropriate food and to food-producing resources and the ability to sustain themselves and their societies." let us analyse the most important elements: the democratic principle (who decides what we grow and eat?): at present the decision concerning what is grown on farms and sold in supermarkets is taken by a few powerful transnational companies, which control much of the food production and distribution. their principle aim is to produce and sell as cheaply and as profitably as possible. the concept of food sovereignty wants to give back to states or groups of states and agricultural communities and farmers the possibility to decide what kinds of food they want to grow and how to grow it. states are to remain "sovereign" and need to have a political space in order to implement their own agricultural policies. the question of ownership (who controls the means of production?): with the advance of industrialized farming the means of production (land, water, and seed) are taken over by companies, turning farmers into underpaid slave labour or slum dwellers. in an economy of food sovereignty the state will provide small farmers with the resources needed to grow their own food. agrarian reform and redistribution of land is the most appropriate means to achieve that. in contrast to the social-ist model (state ownership of the means of production) and the capitalist model (the capital is owner) food sovereignty demands that it is the producers who remain in control of their resources. food is a social and personal right. the right to protection: today the political choices made by the multilateral institutions, like imf and wto tend to protect the agribusiness industry both in the north and the south, and to destroy the livelihood of millions of subsistence and family farmers by controlling the food cycle all the way from agricultural inputs and the growing of the crops to the distribution, processing, and selling of food. the dumping of heavily subsidized agricultural products onto the world market thus drives local farmers into bankruptcy. this is the very vision of agriculture that the concept of food sovereignty challenges. not only does this practice constitute a grave injustice, it contributes to the decline in food production and to the increase of hunger, and at the same time creates mass unemployment for millions of people. food sovereignty stipulates the right of peoples to protect themselves against dumping through protective tariffs, to retain the capacity of receiving remunerative prices for their products and so remain masters of their own way of life. the principle of ecological sustainability (who can best produce healthy food without destroying the environment?): the present system of industrial monocultures is economically efficient and profitable. yet, for the environment it is a disaster. biodiversity and the nutritional value of the food are reduced. the destruction of the environment for the sake of profits destroys the irreplaceable richness of animal and plant life for future generations, and is thus a crime against them. food sovereignty favours food production through family units who produce healthy food in respect of natural processes. economic models are based on ideas and a vision of human nature, of the role of society, and of the purpose of creation. the present economic philosophy sees human beings mainly as producers and consumers. the social dimension which used to be part of the 'social market-economy' is gradually eliminated. the long-term ecological cost of our way of producing, transporting, and selling our goods is completely neglected. food sovereignty wants to come back to a holistic view of the world and integrate the different dimensions that make up our reality. economic activities have consequences for social relations and the environment that have to be considered. the scientific modernization theories 14 , the economic recipes of the neoliberal 'chicago school' 15 , and the 'washington consensus' 16 offered by northern theoreticians that have been implemented by many development agencies and international financial institutions (ifis), especially by the bretton woods organizations (wb, imf, ifc), have failed to achieve thier goals in many parts of africa, asia, and latin america. the implementation of these theories by governments in latin america is reflected in three lost decades of development, while the policies have failed to eradicate poverty and to overcome hunger. in many cases these neoliberal concepts have worsened the situation of the rural and urban poor who still experience undernourishment with all the negative human, social, economic, and cultural effects. due to the low income of the marginalized poor as a result of underdevelopment, economic crises, the increase of productive costs and chemical inputs, the rise of prices for basic products when crop prices collapsed, erosion of soils and scarcity as well as pollution of water, the peasants started in latin america in the 1950's to migrate massively to big towns. in marginal slums, they have lived with survival strategies (box 33.4) that are defined by diego palma as "a sum of initiatives able to complement the salary in terms of the reproduction of their labour force" (palma 1986: 28). nevertheless, the origin of the concept started with duque and pastrana (1973) when they described the situation of rural migrants invading urban marginal land in chile, and started to create their new livelihood. susana torado included in the concept "the procreation of family life cycle and labour migrations" and named them "strategies of family life" (nd: 2), a term that was amplified by the group of quito as "strategies of existence" (pispal 1978). thus, 'survival strategies' were consolidated in the socio-economic crises of latin america, when in the 1970's the models of capital accumulation and of import substitution as post-war strategies were exhausted and the neoliberal globalization process was reinforced. on 11 september 1973, chile experienced first with the military coup the neoliberal imposition of the chicago school. argentina followed with a military coup in 1975, and many other countries in south and central america experienced this regressive globalization combined with repression and empoverishment of large social groups. mexico (like venezuela and ecuador) seemed to be exempted from these repressive coups due to its richness in hydrocarbons, however, with the fall in oil prices, and a corrupt financial management of the governments (oil rent), elites were unable to consolidate and distribute profits, and thus crashed the 'mexican wonder'. confronted with the incapacity to pay the debt service, the imf imposed its structural adjustment policies (sap, see figure 33. 1). from mexico the crisis spread all over la, africa, and to several asian countries. the affected nations were obliged though draconic policies to pay back at any cost their debts, and as a consequence public support and subsidies were drastically reduced. the adjustment costs of this failed policy were transferred to the workers and peasants, and later to the middle classes, which resulted in massive unemployment, loss of purchase power, increasing prices of the basic food basket, the elimination of controlled prices in basic products, a growing monopoly in the trade system, and a reduced purchase power parity (ppp) ( members, neighbours, and from the corner shop. soon, these possibilities disappeared due to the persistence of economic crisis, and food became scarce. then, e.g. in mexico city (oswald 1991), women organized themselves, picking up half-perished products from the garbage of the central market and transformed these products into food in collective popular kitchens collective community work (kitchen, child rearing, pressure on public functionaries) was organized through a system of rotation. united, they fought for basic services (electricity, water, roads, security, health and community centres; rosiques 2003) and the legalization of land and services. due to lacking cash and jobs, they struggled also for public subsidies and poverty alleviation programmes (ramírez 1991). besides all these activities, women still found time for some temporary paid work as domestics, washing or ironing; others generated services, handicrafts, food selling, etc. to be able to maintain their families. children, grandparents, and sometimes husbands supported these complex strategies, where poverty of time was the highest cost paid by women (damian 2002) . furthermore, these popular colonies have not only been hazard-prone but also exposed to organized crime and gangs. thus, only a strong social organization permitted them to fight against public insecurity, where often the police was involved in illegal activities. the sum of these complex actions empowered women, and therefore they were also able to fight against interfamilial violence. as a result these women were often abandoned by their partner, and as heads of household they had to struggle for the future of their children (inegi 2005) . after a decade of intensive mobilization and organization, most of these quarters achieved some social and economic consolidation (oswald 1991 (oswald , 2007b , and their living conditions and livelihood improved. when they have been confronted with chronic unemployment, they integrated their microbusinesses vertically and horizontally (cadena 2005) with popular savings banks, collective childhood, prethese are some of the alternatives to avoid perverse poverty and to improve their quality of life. . in india, bangladesh and africa similar processes of survival strategies took place, all of them replete with criticism of the imposed liberal modernization and globalization process. "over the past two decades every issue … what the industrial economy calls 'growth' is really a form of theft from nature and people" (shiva 2000: 1) . after the slogan in seattle "no new round, turnaround", she added that the real challenge is to "turn the rules of globalization and free trade around, and make trade subservient to higher values of the protection of the earth and people's livelihood" (shiva 2000: 127) . the future of the three billion impoverished people in the world lies on small farms, peasant and marginal urban livelihood, able to produce safe and culturally accepted food. this productive process is neither marginalized nor criminalized, and food sovereignty is a secure basis for regional sovereignty. the there exists a vicious circle linking hunger and undernourishment with poverty and ignorance ( figure 33.2) . these authors analysed the food transition in the mexican diet from traditional corn and bean intake to a modern food pattern that is rich in carbohydrates, fat and sugar, thus inducing illnesses, excess of weight, and hypertension which starts in the womb of mothers, creating chronic malnutrition and later obesity and associated epidemics. this phenomenon exists worldwide and has contributed to a deterioration of food, livelihood, and health security. thus, hunger is a complex interrelation where poverty is reinforced by ignorance and propaganda in the mass media, inducing people to buy junk food with their scarce money. unhealthy food creates further health problems above all for children, limiting their brain and bone development and adversely creating modern illnesses and degenerative processes from childhood on. the world the fao (2005a) estimated that there are still 468 million people suffering from hunger in poor countries, implying a loss of gdp of 30 billion dollars/ year. chronic infant undernourishment linked to a lack of iron and iodine reduces the intellectual capacity of infants by 10 to 15 per cent. combining proteincalorie insufficiency with missing micro elements, the economic loss in poor countries affects 5 to 10 per cent of their gdp, equivalent to 500 bd/year. regions threatened by war and internal conflicts are responsible for 10 per cent of deaths limited by famine. nevertheless, malnutrition is basically concentrated in rural areas of poor countries and increasingly chronic undernourishment is present in urban slums, affecting also industrialized countries 20 . the global demand of food is estimated to increase between 70 to 85 per cent between 2000 and 2050, and simultaneously an increase of irrigation water of 15 to 35 per cent is estimated, due to an unsustainable management of aquifers. water withdrawal is regionally limited and it will affect regions that have already today overexploited its reserves. this refers also to areas with high population growth and countries such as india, the south of the usa, and northern mexico, peru, to the south-east of australia, to north africa, spain, the sahel region, the nile basin, east africa, south africa, central asia, the south of china, pakistan and mongolia (millennium ecosystem assessment 2005). thus, the future of food production increase is limited due to the availability of water, desertification processes, and loss of soil fertility, but also due to growing food prices since 2006 because of the promotion of biofuels. the trend towards an increasing undernourishment may grow when natural, population, and economic factors together become more urgent ( figure 33.3) .. in 1996, in countries with a high human development index (hdi) the intake was 3,347 calories (11.6 per cent more than in 1976) and 102.7 g of proteins (a 13 per cent increase); in countries with a medium hdi the intake was 2,696 calories (26.9 per cent increase) and 69.6 g of proteins (33.7 per cent increase) and in countries with low hdi the intake was 2,145 calories (1 per cent less) and 51.0 g of proteins (4.4 per cent less). another indicator of life quality is the birth weight. in industrialized countries in 1997 seven per cent of babies had low weight, 17 per cent in countries with medium development and 20 per cent with low hdi (undp 1999: 172 -175) . according to undp . this process reduced the workers' capacity to negotiate labour conditions and salaries, and the survival problems pulverized the labour struggles of a whole favor of capital. 20 in 1999, when on 1 june the rally against hunger started in the us, 31 million us citizens (12 million children) were exposed to food insecurity, meaning, they suffered from hunger or did not know how to get their next food. hunger increased in african countries affected by war, but also in east and south asia, and an increase of 23 million in latin america. furthermore, regional and social differences exist ( figure 33.4) . food production has augmented, but at the same time poverty, hunger, and preventive illnesses (hiv/aids) increased in several countries, above all in sub-saharan africa (ssa). this region has at its disposal today 20 per cent less food than 25 years ago, despite the population increase (undp 1998 (undp , 1999 (undp , 2000 (undp , 2001 . the ssa countries produced between 2002 and 2003 about 22.89 million tons of cereals; a small increase compared with the 21.55 mt of the previous year. this production is insufficient to feed the population and 15.2 million people are threatened by famine or require international food support (figure 33.5). causes are complex: in the former grain reserve of the region in zimbabwe a corrupt government rules; in congo a civil war is ongoing; and namibia is confronted with a severe desertification process. in general, severe droughts and disasters have affected food production in many countries, but also the international trade rules are unequal for africa (turner 2003). in ssa the fifth poorest segment of the population obtained only 72 per cent of nutritional requirements, in latin america 78 per cent, and in the recent independent countries of the former ussr, 80 per cent. the gap among and within countries in africa and asia is increasing, and only the fifth wealthiest will get their nutritional requirements in the near future. these negative results are reinforced by the present policy of cash crops, the food production, and the policy of biofuel controlled by multinational enterprises (mne). tajikistan and probably azerbaijan will lose their food security without armed conflicts, but the food situation can get worse in the event of political destabilization (chap. 34 by salih). in sum, with the estimated population growth in poor countries and the present policy of food as a commodity, poor countries will be highly affected by the change of food patterns, and therefore more exposed to hunger and famine. these processes are reinforced by propaganda, where occidental introduced values of food patterns are taking away the few resources able to offer healthy food to poor people. with a global population of more than 6.5 billion inhabitants, more than one sixth in 70 countries are suffering from hunger (usda 2005). natural factors such as loss of fertile soils, salinization of coastal areas and deltas, intrusion of salty water into coastal aquifers, and greater droughts will increase food vulnerability in countries that are today food insecure. these processes will be aggravated by climate change and more frequent hazards. the export of primary commodities from the poor countries to the world market equals that of 1980, representing 26 per cent of the global trade. nevertheless, the imports grew from 28 per cent in 1970 to 37 per cent in 1997. the net food imports in the poorest countries have increased by about 50 per cent between 1980 and 1997 (a rise from us$ 3.9 to us$ 6 billion). the increase in 19 medium income countries was 40 per cent (from us$ 9.3 to us$ 13; see: kwa 2003: 24). food distribution is another unequal issue (sen 1995). globally, one fifth of the world population has access to 86 per cent of world consumption, compared with the poorest 20 per cent that obtain 1.3 per cent, and consumption in rich countries is still rising. these data show the concentration of food in industrialized countries and a situation of increasing hunger in the poorest nations as a result of missing money, unemployment, low prices for prime material, unjust terms of trade and trade system, low salaries, population growth and corrupt governments, but also missing land and production means for the poorest. especially women and girls belong to the group of highly vulnerable persons, and are affected by this perverse poverty. 21 the sum of these factors prevents rural people from getting sufficient food to overcome hunger, and thus many are forced to migrate to slums in cities where environmental, social, and economic deterioration affects again the most vulnerable (villareal 2003; schteingart 2006). during 1996/97, 66 low income countries required 8.5 million tons (mt) of grain from food aid, and in 1998 it increased to 11 mt. the usda estimated that this aid covered 85 per cent of the projected needs, and the minimal nutritional requirements are 17.6 mt. the fao (2005b) calculated that the food deficit will grow in 2008, and with the same minimal ingestions, per capita insufficiency will increase by 80 per cent to 19.8 mt, while nutritional deficiency will rise by 65 per cent to 28.4 mt. as a result, 35 poor countries will experience food shortage and 47 countries more must reduce food intake. this implies new subsidies for food surpluses and a greater food power for exporting countries (usa, canada, eu, australia). this power is based on highly subsidized prices affecting poor countries and their rural people. tne obtain a wide with global horizons sufficient, regional horizons limited or missing local horizons gas, gasoline, kerosene gasoline, gas wood, excrement, organic waste high considerable low 21 extreme poverty is better characterized as 'perverse poverty' (oswald 1990). the perversity lies in the fact that a child before being born, is condemned already to becoming a second class citizen due to brain damage, caused by chronic undernourishment and having an anaemic mother. later, the child enters into the 'valley of death' between 1 and 2½ years of age, because of its fragile immune system. if they survive despite chronic hunger, often the growth, intellectual improvement, and motricity of the child is seriously damaged. during the first year of life a child requires 80 per cent of the nutrients for brain development and growth. malnutrition causes irreversible intellectual and physical damage. besides the small size, there are problems for logical learning, altercated micro-motricity, and slow reactions. major part of these subsidies, and gorelick (2000) estimated that profits obtained by big companies in the usa in form of subsidies and external support amount to us$ 2.4 billon dollars, without including environmental costs or health damages. vandana shiva (2003) calculated that each kilogramme of food consumed in the usa travels 1,500 miles, generating 10 kg of co 2 , thus contributing to global warming. these structural inequalities create worldwide prototypes of food consumption, depending on economic possibilities (see table 33.1). it represents a kind of schizophrenic behaviour of upper classes that are damaging to the global environment (see chap. 59 by dalby/brauch/oswald) and their personal health, with their inadequate food intake (murray/lópez 1996). 22 middle classes are becoming aware of their health and consume more locally produced organic food, but they also buy fruit and vegetables from outside. the lower classes struggle not only for their food survival, but also for drinking water and other basic services. these social groups create the lowest environmental impact. this global food pattern is the result of complex and multicausal processes, where local and global activities get negatively reinforced, and where free trade agreements (fta), indiscriminate openness of agricultural markets in the south, sap imposed by imf (strahm/oswald 1990; stiglitz 2002), failed policies by the world bank (mega-projects of dams and irrigations districts, and modernization of agriculture in hands of agribusiness) have created hunger. this critical situation worsened due to subsidies for agricultural products by industrialized countries, corrupt national governments, and local elites 23 , financial monopolies, exports of prime materials at international prices below production costs, debt payments, bank rescues, patriarchal structure inside families and society, lack of peasant support also for organic agriculture, and low agricultural wages. with deteriorated and marginal land, polluted resources and high prices (2005) referred to one billion environmental refugees due to desertification, water scarcity, and soil depletion. the repercussions of the failed development policies in latin america are affecting vulnerable groups, especially indigenous and rural children, the elderly, and women. the causes of chronic hunger in the most biodiverse countries of the world are complex and are directly related to the unequal income distribution, (undp 1990 (undp -2005 . most affected by these developments were peasants and indigenous people during these crises years, which were often pushed from their land and natural resources by tne that imposed a model of capital intensive production when the country had enough human power. as a model of this unsustainable agribusiness a modern chicken farm must produce yearly about 240,000 birds. after paying credit and inputs to the tne "this prodigious (and inhuman) production left the farmer only us$12,000, or five cents/ bird" (gorelick 2000: 5) . mexico is one of the most unequal countries, with the richest man in the world (forbes, 10 august 2007). during the 1980's its model of import substitution and stable development was replaced by a neoliberal globalization process (klein/fontan/tremblay 2003). after joining nafta in 1994, the effects in rural areas and for the peasant economy were disastrous. the wealth has been even more concentrated (table 33. 2). the effects of free trade, promoted by business monopolies, and the rapid openness by government without compensatory processes permitted an evaluation a decade later. the results are complex: economic growth was below one per cent; the employment policy was unable to offer to more than one million young people a job and the new employments are precarious, without social protection, and with 'white' trade union leaderships that are favouring enterprises. about half of the labour force is (self-) employed in the informal, often illegal sector, salaries declined by ures 33.8 and 33.9) . the severe undernourishment hardly declined since 1989 due to inflation and economic crises, while the concentration of wealth owned by a tiny elite has increased dramatically. women have developed survival strategies for their children and elders, and often they have to pay the debt for the illegal crossing of their husbands. also feminization of agriculture rose to 35 per cent (inegi 2006) . food imports affect both countries: the usa due to pollution of agrochemicals to raise yield productivity, and mexico due to payment of us$ 72 billion for food imporation and job creation in a foreign country (inegi 2005) . only a small elite representing 0.23 per cent of the population benefits from this type of modern rape capitalism, owning 40.3 per cent of national wealth and 78 per cent of financial savings (table 33.2) . nevertheless, these global data do not reflect the existing regional disparities. the food perspectives for the future are uncertain, and will most likely get worse due to the massive use of corn and oil seeds for biofuel. furthermore, confronted with climate change, disasters and greater drought, mexico must take its food security problem seriously, especially if the usa and canada that presently provide more than 16 million tons of basic grain should become food insecure. therefore, the term of 'food power', created in 1972 by henry kissinger, may generate structural instability, migration, and social riots (figure 33.6). (innsz 1974 (innsz , 1979 (innsz , 1989 (innsz , 1996 based on global and regional scenarios on temperature rise, precipitation, decline in groundwater, and hydro-meteorological disasters, together with biofuel from cereals, the worldwide supply of basic grain will be reduced drastically. in 2007, still half of the people live in regions with a low level of underground water, including the three large grain producers: china, india, and the usa. countries such as mexico, iran, israel, pakistan, saudi arabia, jordan, and yemen are overexploiting their aquifers and limiting alternatives for the future. due to projected water scarcity in the next 25 years, cheap grain will disappear from the world market and only very few countries will be able to improve their agricultural production due to climate change. in 2005, the world market price of rice, highly vulnerable to water, increased by 30 per cent reaching us$ 260/t (usda 2005). the corn price in mexico rose between september and december 2006 from 1,500 to 3,500 pesos/ton, as a result of the demand for biofuel for corn in the usa, but also due to speculative practices. therefore, the future of the world food system is complex and uncertain, and a new policy of food sovereignty will play an important role in the political stability of many countries. related to the conceptualization of food security and food sovereignty (see 34.2), three models of food production and commercialization have evolved: a) the productivity model based on the green revolution; b) the life science model that relies on modern biotechnology and genetics; and c) the traditional organic or green model. throughout the 20 th century the productivity model tried to homogenize food crops similar to industry, and during the last two centuries the supply of food and agricultural inputs was in the centre. the green revolution promoted monocultures, intensive use of chemicals, veterinarian drugs, improved seeds, machines, fossil energy, and irrigation systems. politically, this system relied on high government subsidies (usa, eu, ocde, japan), offering the consumers cheap products. the production was controlled by agronomists, veterinarians, and the chemical industry. health and environment concerns were marginal. the ministry of agriculture managed natural resources such as soils, water, forests, flora, fauna, and fish. internationally, this model should have eradicated hunger and given the whole world food security. until today it remains the basic tool against hunger (fao 1996a, 2000a, , 2005b, 2005c) . high crop yields and 'free markets' were at the centre of the concern and therefore hunger could not be eradicated, owing to the maximization of profit of agribusiness and governmental subsidies in developed countries. hunger and poverty were considered undesirable side effects for southern countries and for people with a low capacity to modernize. social, environmental, and cultural factors of diverse food production are only marginally considered. food is not treated as a cultural good or as a patrimony of thousands of years of human effort. the limits of this model are imposed by negative effects on health (gallaher 2005) and on the environment (scarcity in water and oil resources). in the 21 st century a new model is emerging that establishes links among health, food production, and dietetic habits. it represents the new health safety and food security concerns where individuals with purchasing power are at the centre of attention. concrete genes were linked to specific illnesses (nestlé 1999), creating a scientific basis for life or a 'life science' paradigm (lang/heaseman 2004). this model is demand-oriented and takes into account the consumers and their needs. productivity is still important. it refers to the balanced daily intake of proteins, carbohydrates, vitamins and minerals, all of them necesary for a healthy life. this life science model integrates the food chain in the form of clusters and relates it to production, transformation, and trade of food. it combines genetic research with field experiments, including biology, engineering, nutrition, pharmacology, health, and mobile field labs. the industries are controlled by multinational food chains. they offer clean, safe, and homogenous products that can stay for weeks on the shelves of supermarkets, thanks to genetically modified genes and organisms (gmo). food is not only modified but also enriched artificially with nutrients to prevent illness, such as enzymes, proteins, minerals, etc. at the centre of concerns is the individual health, improved by technological proceedings in bio-labs, where specialists are in charge of human lives (nestle 2002). these processes of 'healthy' food can only be controlled through sophisticated scientific procedures in well-equipped laboratories in universities or research institutes of mne. the experts are paid by the food mne, which are simultaneously producers, sellers, and supervisors. when nonconformities arise, due to the complexity of the process, governments rely on these institutions, where those who are interested and involved are both judge and arbiter (beck 1998; 2000) . independently of an intensive propaganda in mass media, some undesired effects can not be denied, and ngos are trying worldwide to carefully educate people on these negative effects. most evident are genetic modified crops (gmo), which started commercially in 1995. in 2005 more than 80 million hectares were produced in the usa (68 per cent), 22 per cent in argentina, 6 per cent in canada, and 3 per cent in china. south africa, chile, india, and brazil are joining this production process. on gmo seeds there exists an oligopoly of four main multinational enterprises. one sole holding (monsanto) controls 90 per cent of all seeds with two genetic modified proprieties: a herbicide (roundup) and an insecticide (bt). conclusive results are still lacking whether these seeds are innocuous, but there are risks that the recombinant process could produce unknown effects in human and animal health and environment. unwanted pollution occurred in canada where wind, water, insects, and other animals have polluted natural crops of canola with gmo ties, destroying the great biodiversity and the natural production of this crop (schmeiser 2002). another threat is related to new toxics, new plagues, and insects resistant to gmo and other insecticides. paediatricians have found a high level of food allergy in babies and therefore baby food is produced without gmo seeds. in socio-economic terms, eight mne merged in 2007 into four, able to produce 83 per cent of biotechnological research in the world. this is a threat for the freedom of science and technology in favour of humankind. there is another danger that small farmers may be forced to stop farming due to the expensive productive processes of gmo seeds (40 per cent of cotton production in 2005), what is reinforced through subsidies that are highly concentrated in big enterprises. finally, these gmo seeds are controlled by patents and the wto is the arbiter through trips (heineke 2002; schmid 2000; oswald 2000; 2002) . the study of fao (2005a) in different countries has shown that the income of producers in mexico in-creased by 12 per cent using cotton gm-seeds from monsanto, but the benefits were more than three times as high in china where a national research institute produced their own gm-seeds. the 'life science' paradigm continues with the same model of productivity, but it oriented at the consumers and their health needs. the integration into the food chain is through clusters. this model of production has generated new illnesses (bse 25 ) and could promote new epidemics such as avian flu, since genetically modified organisms work with virus and bacteria that could have their own dynamism when they are modified and inserted into different plants or animals. therefore, the cornucopian vision to resolve by mne environmental, social, and health problems through science and technology shows its limits, but above all poor people have to pay for the mistakes, and biodiversity can get lost for ever. it is horrific that thousands of peasants have committed suicide when gmo harvests failed and credits could not be paid back (shiva 2003, 2008, 2009 ). with regard to food sovereignty there is no doubt. this model of production has enormously increased the costs of production (gm-seeds), and created a monopoly of agrochemicals and the transformation of basic food in the hands of tnes. these processes are able to concentrate wealth within few hands, increasing poverty not only due to more expensive food, but also due to associated health problems. the green model generates symbiotic relations and mutual dependence between nature and food production, and therefore uses soft methods of agriculture. they are regionally diverse and utilize policultivation, association of crops, rotation, mixed agriculture, fixation of nitrogen from air to soil, biopesticides, traditional methods of soil conservation and food, integral management of water, plagues, and environmental services. the combination of traditional and modern knowledge is consolidating food sovereignty in any region. a biodiverse and regionally adapted use of seeds is conserving diversity of species, and therefore is agro-ecological. this mode of production cannot be globalized. the surplus of production is sold in the local markets and thus reduces environmental pollution and global warming linked to transnational agribusiness and global markets. local agricultural production and trade, with access for peasants to water, seeds, credits, as well as technical and financial support could promote this model of agriculture. this green model takes women and peasants as key elements for food issues and agricultural consolidation. it encourages the participation of indigenous, women, and peasants in the national and regional definition of rural policies. it can guarantee women access to land for production and livelihood, and through empowerment they can overcome the violent and patriarchal structures inside families, regions, countries, and the global economic system. it includes the right that peasant organizations have developed their own model of food sovereignty and are now struggling for their right to produce and consume healthy, permanent, and culturally accepted food which is locally produced, sold, cooked, and consumed. governments have the obligation of protecting their economy from subsidized food imports. they have to establish agricultural prices which are able to cover the production costs and to protect the environment. by linking environmental services with farming, land planning, and participative democracy, this paradigm supports a stable rural development and therefore respects the human right for non-migration. when livelihood in villages and countries is guaranteed with public resources for poverty and hunger alleviation, 26 bottom-up efforts can be reinforced. in the medium term, safe ecosystems and stable social relations create synergies and cooperation where safe food and the environment improve public health and cultural diversity at the local level. this third model reflects the food sovereignty debate. it understands food in a holistic way, where livelihood, sustainability, and culture are the driving elements to maintain the genetic diversity for future generations, offering healthy nutrition and establish-25 bse is a result of feeding cows with waste from animals instead of grass. after 15 years research of more than 500 drugs, it was proven that bovine somatropina, an amino acid able to stimulate growth in cows, is responsible for an increase of 180 per cent of breast cancer in pre-menopausal women and the same number of prostate cancer in men (world cancer research fund 1997). confronted with avian flu threats, the same mnes are producing expensive medicaments with dubious results to combat a potential epidemic. 26 foreign food aid from outside has to be targeted to avoid a distortion of non-market items such as equity, corruption, electoral use, etc., but above all it can destroy the local productive systems. thus, it must always be an emergency support, limited in time and for specific events. ing a direct relation among productive, commercialization, and consumption cycles. it represents also an alternative for more than 1.5 billion peasants and small farmers who still depend on their ancient technology. they carefully selected the seeds from the former year that were and are able to guarantee the next harvest. it consolidates the basic right to consume safe, sufficient, and culturally accepted toxicfree food that is locally produced, transformed, and sold. thus, in the green agricultural paradigm food is a cultural act of life and more than the intake of proteins and calories. it is until today the only real possibility to overcome existing famine and hunger and offer humankind an opportunity to create justice and well-being all over the world by fulfilling the universal declaration of human rights in its art. 25.1. food sovereignty within the green paradigm represents the rights of people, communities, and countries to define their own ecological, social, economical, and cultural project of the future. besides maintaining food as a pleasure of life, and not a threat to health and survival, it consolidates the world food culture and consumption for the future. food perspectives: models of production, population growth, climate change, and environmental deterioration 'food security' in the context of the model of agribusiness production or life science has failed to improve the world food situation. it is not a problem of the amount of food and of the knowledge how to produce more, but it is basically a problem of poverty (fao 2006) . therefore the evidence is that in most poor countries the total number of hungry people has not been reduced, except for china and india and the former countries of ussr. rather, new threats of food insecurity are rising. this requires the reformulation of the basic assumption of how to reduce hunger and how to achieve the mdgs. the globalization process in its regressive phase has reversed some advances, but in countries with high population growth that are threatened by severe impacts of climate change and disasters, the eradication of hunger is further limited. both the 'productivity' and the 'life science' paradigms have also led to higher emissions. aquifers have collapsed in india and mexico. through genetic pollution both models have been destroying the biodiversity of southern countries. thus, with regard to food security, but also for the survival of humanity and nature, the present understanding of food security has failed to combat hunger. it has rather increased the threats and risks of more serious famine not only in africa, but worldwide. imposing food security instead of food sovereignty, and destroying the traditional green production, could become a boomerang also for northern and developed countries. from 2000 to 2005 organic food production has grown by 20 to 30 per cent. in germany organic food products grew annually by 15 per cent. a major increase has also occurred in the us where the national organic programme (nop) supports small farmers and promotes the certification of green agriculture where organic products grew from us$ 1 to 13 billion from 1994 to 2003. in 2005 about 26 million hectares of land were certified and 560,000 farmers were affiliated. 27 in most countries, due to the productive model of the political elites, the support for organic agriculture is still limited. nevertheless, the tnes have discovered this green option for supermarkets. they are now charging higher prices for naturally grown products. consumers, confronted with doubts about gmo, are demanding comprehensive labelling, but tnes have tried to influence national laws to avoid or restrict this. propaganda on different products is confusing the consumers even more by letting them believe that they determine their own model of life. via campesina has challenged this tne and has campaigned against gene modified seeds and promoted laws favouring its alternative agricultural model. they insisted that environmental, cultural, and social factors are as important as the economy. further, economic crises and increasing poverty in rural areas have created among peasants, the indigenous, and women a sense of security that they can manage their own food supply with regional resources and local seeds. at the international level, fao has argued that food needs could be linked with a protection of the natural heritage by: promoting market-based incentives that compensate farmers for their stewardship efforts, thus maintaining their economic viability; replacing polluting agricultural practices with approaches that can reverse the dramatic trends in biodiversity loss; thriving on community participation in land conservation. meeting food needs while protecting the natural heritage is a challenge shared by all countries of the planet. organic agriculture can meet this challenge head-on by: promoting marketbased incentives that compensate farmers for their stewardship efforts, thus maintaining their economic viability; replacing polluting agricultural practices with approaches that can reverse the dramatic trends in biodiversity loss; thriving on community participation in land conservation (el-hage scialabba 2003: 15). simultaneously, fao has also promoted gmo seeds in diverse poor countries, and continues to support the 'green revolution' model. many existing contradictions are inherent in the three productive models, and reflect the struggle for hegemony. they can be synthetized as follow: the 'productive' model is unsustainable due to the scarcity and pollution of natural resources (water, soil, seeds, and loss of biodiversity). ministers of agriculture have shifted slowly to the 'life science' model that is supported by ministers of trade who promote free trade and bilateral agreements. health ministers have supported nutria-genomic research, biosecurity protocols and vaccines that are often produced from genetically modified plants. productivity concerns dominate over inherent risks and threats for biodiversity and humankind, due to the uncertainty and insecurity of genetic manipulation and nanotechnology. both could affect the essence of human beings and the future of life (habermas 2001). these two models induce a scenario of a 'food war' 28 (lang/heasman 2004), when multiple factors of aggravation of conflicts intervene: the quality and innocuous food demand, international commerce, governmental regulations, nutritional requirements, control of tnes, anti-monopoly laws in transportation, financial monopsony, security in food chains, supply of safe food products, coexistence of over-and undernourished people, environmental damages, science and technology (s&t). arbitration among these many contradictions are often handled by experts associated with tnes. but despite the unimaginable advances in s&t; hunger is still increasing and far from being eradicated. why is this so? there is a second related factor. the model of transnational agribusiness is oriented at the individual, considering his or her consumption and ppp. as with the modern health system, the individuals become victims and objects of persuasion for food recipes to strengthen their health that are often counterproductive. these two realities have opened for social movements, ngos, and critical scientists a space for struggle. confronted with the nutritional and health deterioration, they have denounced these tnes and often corrupt government allies which try through early alerts and catastrophic predictions about epidemics 29 to push the errors and possible consequences of this erroneous productive system to various 'natural' causes. the global deterioration of life quality and limited progress in hunger alleviation in most developing countries, as well as high levels of obesity and cancer 30 in industrialized countries, offer organic agriculture an option for the future. social movements understood these opportunities and are promoting food sovereignty with native seeds and organic input as a real alternative against hunger and malnutrition. table 33 .4 summarizes, contrasts, and compares the many advantages and disadvantages of the 'life science' model with those of the 'sustainable organic agricultural' model. in synthesis, the paradigm of 'science of life' relies on governmental financial resources; however, the consolidation of this model depends on the acceptance by consumers who are induced through advertisements to buy these products. therefore, the competition among some tnes could leak information about damages in health through this model of food intake, and strict governmental control can avoid a manipulation of consumers. but often the same pharmaceutical holdings are also selling medicaments, control hospitals through the stock market, and often repel demands to pay compensation for damages caused by unhealthy food. their treatment (chemo value of change, with maximization of profits and socialization of losses value of use with maximization of social relations and collective livelihood therapy and radiotherapy) creates further collateral effects compensated with other expensive drugs. their goal is only the maximization of profits by taking away the surplus created by society. 31 these contradictions in the health, education, and food system were exposed by ivan illich (1976). on the other side, there is the small green production for poor people, peasants, women and minorities. organizing production and transformation, food diversity, and local markets increase local food security. more governmental support is still lacking, and also scientific and technological efforts to combine traditional and modern knowledge has to be developed, e.g. in new zealand. there are enough universities that could support green models of production able to facilitate the creation of local jobs and offer young people an opportunity for employment and a decent life. however, the political and economic elites that benefit from the other two productive models are preventing an enhanced 'food security' combined with 'food sovereignty' and a dignified livelihood (nord/andrews/carlson 2004). conclusions: food security with self-sufficiency, food on this dual political and conceptual background, this chapter addressed the following research question: food represents not only a security issue of intake of nutrients, but it forms part of a holistic understanding of life and a constituting element of any civilization. thus, food includes networks of connectedness, belonging, and relationship of trust, reciprocity, cooperation, solidarity, care, and exchange. it creates social benefits and risk reduction, but also innovative activities through the wider access to inforartificial international prices due to subsidies, generating dumping in the world market local, interchange of products and services fixed by the economy of solidarity and support for the vulnerable monopolies, oligopolies and monopsonies local chains of integrated micro-business monopsonies integrated in fta, wto controls through gats, trips and international arbitration family unity and local market with incipient household transformation, local non-violent conflict resolution food disposal world supply-demand, depending on available capital and prices, speculation with crops, increase of hunger proper system of production for local food, family and regional storage 31 the case of old people is often dramatic. they loose their savings for medical treatment and hospitalization. once without resources they are abandoned and in the best case they go back to the traditional medical sector. however, governmental controls can further limit this alternative. mation and learning. it is a process of anchoring of personal and group identities (see chap, 88 by oswald on huge; oswald 2008 a), where social relations reaffirm the integration of a person inside a community establishing rights and obligations, such as access to land, credit, technology, training, market, life quality, and rituals. besides guaranteeing physical and cultural survival, 'food sovereignty' creates also new opportunities for people-centred poverty alleviation and new understanding of rurality as a complex social network. it represents a critical response to the accepted development and modernization paradigms, and opens ways for diverse rural life processes where agricultural activities and environmental services coexist with services and industries. thus, food is part of a holistic model of life and a constituting element of any civilization. networks of interrelationships, and processes of identity and social belonging, create relationships of trust, reciprocity, cooperation and exchange. they are at the basis for 'food security' which could evolve into an integral 'food sovereignty'. confronted with new threats of global environmental change, 'food sovereignty' represents social benefits and contributes to risk reduction through innovative creativity where instant world communication helps to establish new learning processes. during this process of achieving 'food sovereignty', personal and group identity is anchored and social relations may overcome stereotypes by reaffirming the integration of a person or a group within a community. such a wider understanding of rurality that includes non-agricultural activities facilitates critical responses to historical injustice, abuse and environmental changes, and opens ways for diverse ruralurban life processes, where agricultural activities and environmental services coexist with other services and non-contaminating industries and transportation systems. the future is getting complex and the world is confronted with unexpected climatic events, generating massive migrations, chaotic urbanization, pollution of natural resources, and loss of biodiversity. the ecological footprint and the size of the 'food footprint' is converted from food consumption by this equation: where crop yields are taken from the fao database (friends of the earth 1997). population growth creates new challenges when billions of young people ask for dignified employment. on the contrary, the lack of jobs could create complex emergencies. in this multifaceted panorama new agreements among governments at all levels with business and organized civil society should be negotiated where public well-being has to prevail over private interests. this implies to transform through creative activities related to food production, transformation and consumption, the existing monopolies into local chains of micro-enterprises that are able to offer cheap, healthy and, culturally accepted food in a framework of an economy of solidarity. but market forces are pushing in a contrary direction. the future food sector will experience a competition between the 'life science' and 'sustainable small production' model. new food-related illnesses (e.g. bse) have created a greater awareness among people, what they are eating. in europe, some 20 per cent of the population is familiar with the associated risks of agribusiness by tnes and 80 per cent reject gmo food. increasing degenerative illnesses and obesity have forced the tnes to focus on new products, and the culture of 'light' food has been their response. however, only a comprehensive approach with preventive health, vitamins, proteins, iodine, flour, and other microelements for the undernourished will be able to alleviate hunger and create livelihood for all with a distribution of profits. the future will show if the public relations activities by tnes will be able to counter a wider public awareness on the risks associated with the life science approach or whether small green food production will slowly replace big food monopolies. however, there are some global decision-making processes that may contribute to and speed up a strategic shift aiming at 'food sovereignty' (cloc 2004): tries women produce most of the local food (fao 2002; 2005b) . 4. regional food sovereignty: via campesina, cloc (2004) , mst (2005) , and the peasant university of the south (unicam) are promoting an integral model of food with democratic landreform, credits and local savings, green agriculture, chains of integrated local micro-businesses, an economy of solidarity, and traditional medicine. 5. food policy to alleviate hunger: brazil proposed a model of food support for popular sectors linking the small production system with an offer of healthy food, increase of minimal salary of workers, and an urban offer of cheap food for the poor (figure 33.10). 6. a well developed system of periodic measurement of basic indicators of undernourishment is needed, above all for children below five years, including anthropometric measurements of weight and size related to their age. unicef, who, and innsz have proposed six steps with minimal costs to avoid premature deaths, slow development, and brain damage in infants: vitamin a complements; a complete scheme of vaccines; nutritional supplements to overcome severe undernourishment; periodic elimination of parasites, complements of iron, iodine, and other minerals (such as flour against caries) depending on the water composition, floors covered with cement, latrines, clean water access, and nutritional education and care (álvarez/oswald 1993). furthermore, the metabolic syndrome of undernourished children with small size should be addressed. they of32 1. improvement of local food through a mixed agriculture of fruit trees, plants able to fix nitrogen from the air to the soil, rotation of crops, organic composting, and bio-pesticides; 2. community health centres able to treat the most common gastro-intestinal illnesses, malaria, dengue, reproductive health and campaign for vaccination, undesired pregnancy, and sexually transmitted illnesses; 3. basic education: training in simple technologies for production, and conservation of safe food at the community level, especially for women; 4. renewable energies: solar systems, biogas, oil and other energies able to give children light for studying, energy for water pumps, machines for grain mills, and refrigeration of medicaments and food; 5. clean water, building of latrines, water harvesting, protection of wells, and other simple techniques to conserve safe water and to avoid water-borne illnesses. ten rely on a diet that is rich in carbohydrates and fat, and are subsequently frequent victims of obesity, later on diabetes and coronary illnesses. 7. education, training, and the rescue of traditional elements of food culture are basic requirements to improve the nutritional situation in poor countries. education and training, especially of women, reduces not only the illnesses in families and premature death, but it opens the cooperation in reproductive health and creates stable livelihood conditions in villages, and colonies, and slums of the urban poor. ) enabling women, indigenous, and peasants to handle food and nutrition for their families in an integral way, improving their quality of life, and reducing premature death and preventing diseases. such a new comprehensive security process that combines 'food security' with 'food sovereignty', and also with 'water' and 'health security', may be better able to resolve the food problems of the other half of the world population for whom food security has been an issue of daily survival of their families that avoids the overconsump-tion and loss of life quality with which the food security problems of the oecd world and the elites in the global south are struggling (see chap. 34 by salih). the discussion has shown that the evolution of the concept of 'food security' within multilateral organizations has failed due to a top-down approach that is neither questioning the demands of the people, nor the interests behind the driving forces of world business. the continuous adaptation of the 'food security' concept and model by fao reflects its basically technocratic approach that is far away from the real problems of hunger and of agribusiness. the fao has tried to resolve a complex health problem with aspirin (preker/feachem/de ferranti 2000). confronted with serious environmental deteriorations and adverse economic conditions resulting from the neoliberal approach, the directly affected people started first with a critical analysis of agricultural and food aid policies from industrialized countries. greater environmental destruction, new threats due to climate change, and deeper ecological footprints forced organization of civil society to create the new paradigm of 'food sovereignty' as a holistic life concept. that there "are no secrets how to eradicate hunger. there are no new technologies necessary. simple political will is required to change the existing policies which make the rich richer and the poor poorer or 2005) linked the multidimensional roots of hunger to poverty. in the kenyan village of sauri he tried 'the big five' with us$ 70 per person and year women are not only more affected by modernization, they represent also an alternative for self-sufficiency and to the food supplies by tnes this understanding could overcome the limited productive approach, but also the behaviour of converting poor people into victims of their circumstances, when the real causes of their situation of marginalization are precisely the forces of the free market, the political domination and the exploitation of humans and nature for profit. the future is complex and the situation will probably get worse. then biodiverse and culturally determined approaches to food sovereignty could foster solidarity among human beings and protect their remaining common natural and cultural capital. key: cord-353867-617f90wq authors: ory, marcia g.; lee, shinduk; towne, samuel d.; flores, starr; gabriel, olga; smith, matthew lee title: implementing a diabetes education program to reduce health disparities in south texas: application of the re-aim framework for planning and evaluation date: 2020-08-30 journal: int j environ res public health doi: 10.3390/ijerph17176312 sha: doc_id: 353867 cord_uid: 617f90wq health disparities in diabetes management and control are well-documented. the objective of this study is to describe one diabetes education program delivered in the united states in terms of the re-aim (reach, effectiveness, adoption, implementation, and maintenance) planning and evaluation framework. questionnaires, clinical data, and administrative records were analyzed from 8664 adults with diabetes living in south texas, an area characterized by high health disparities. the diabetes education program delivered was a professionally led 12-month program involving 8 h of in-person workshop education followed by quarterly follow-up sessions. changes in average blood glucose levels over the past 3 months (e.g., a1c levels) were the primary clinical outcome. descriptive and multiple generalized linear mixed models were performed. this community-based initiative reached a large and diverse population, and statistically significant reductions in a1c levels (p < 0.01) were observed among participants with type 2 diabetes at 3 months. these reductions in a1c levels were sustained at 6-, 9-, and 12-month follow-up assessments (p < 0.01). however, considerable attrition over time at follow-up sessions indicate the need for more robust strategies to keep participants engaged. for this diabetes education program, the re-aim model was a useful framework to present study processes and outcomes. health disparities are often geographically bound and occur more frequently in impoverished populations characterized by low socio-economic status and a dearth of available healthcare resources [1] [2] [3] [4] . the u.s.-mexico border is impacted by extremely high disparities in income, education, and healthcare access, and these social determinants of health make this region among the nation's figure 1 illustrated the 27 counties formally included in the healthy south texas initiative [30] , and the counties in which the diabetes education program was offered were marked with a red dot. counties along the us-mexico border were included, as well as areas adjacent to border counties, which were all referred to as south texas. including urban, small town, and rural areas, the overall estimated population in these counties in 2015 was approximately 2.8 million, and these areas were among the most impoverished in the nation in terms of socioeconomic status and lack of healthcare services [31, 32] . as a community-driven initiative, inclusionary criteria were broad with the intent of serving those both directly and indirectly involved in a person's diabetes prevention and management. while the focus was on adults with type 2 diabetes, persons with pre-diabetes and type 1 diabetes were invited, as well as family members or friends providing care for persons with diabetes. as indicated in figure 1 , the formal diabetes education program was offered in 14 of the 27 south texas counties in two primary hubs clustered around nueces and hidalgo counties. given the community-based nature of this initiative and the desire to reach as many participants as possible to show widespread program penetration, participants were recruited from a variety of sources including screenings at health fairs, referrals from healthcare facilities, outreach to community partnerships with flyers and other social media, and self-referrals. although there was no attempt to standardize referral sources, which differed by organizational sponsorship and location, promotional materials (e.g., flyers) were standardized with a uniform healthy south texas brand. the diabetes education program was a recognized american diabetes association (ada) program that was professionally led but also included community health workers for outreach and programming assistance [27] . all ada-recognized programs provided quality education for people with diabetes and followed the national standards for diabetes self-management education and support (dsmes) guidelines [33] . ada-recognized diabetes education programs were eligible for reimbursement through many federal and private u.s. insurers [34] . offered in both spanish and english, the program consisted of 8 hours of face-to-face educational workshop sessions led by at least one trained health professional (e.g., registered nurse (rn), registered dietician (rd), pharmacist, or certified diabetes educator). workshop sessions were followed with brief (e.g., 15-30 min) in-person individualized follow-up educational and support sessions offered on a quarterly basis for a year. focal workshop topics included a discussion of, as well as hands-on experiential learning about what diabetes is, blood glucose monitoring, given the community-based nature of this initiative and the desire to reach as many participants as possible to show widespread program penetration, participants were recruited from a variety of sources including screenings at health fairs, referrals from healthcare facilities, outreach to community partnerships with flyers and other social media, and self-referrals. although there was no attempt to standardize referral sources, which differed by organizational sponsorship and location, promotional materials (e.g., flyers) were standardized with a uniform healthy south texas brand. the diabetes education program was a recognized american diabetes association (ada) program that was professionally led but also included community health workers for outreach and programming assistance [27] . all ada-recognized programs provided quality education for people with diabetes and followed the national standards for diabetes self-management education and support (dsmes) guidelines [33] . ada-recognized diabetes education programs were eligible for reimbursement through many federal and private u.s. insurers [34] . offered in both spanish and english, the program consisted of 8 h of face-to-face educational workshop sessions led by at least one trained health professional (e.g., registered nurse (rn), registered dietician (rd), pharmacist, or certified diabetes educator). workshop sessions were followed with brief (e.g., 15-30 min) in-person individualized follow-up educational and support sessions offered on a quarterly basis for a year. focal workshop topics included a discussion of, as well as hands-on descriptive statistics (mean and standard deviation or frequency and percentage) were used to describe the characteristics of participants. not all implementation sites collected the exact same set of variables; thereby, the descriptive statistics reflected available data (i.e., not all variables had the same number of missing cases). bivariate analyses (e.g., independent t-tests or chi-square tests) were performed to compare the characteristics of participants recruited during the first biennium and second biennium. next, retention rates were estimated for each follow-up session. as a part of retention analysis, characteristics of participants who attended and did not attend each follow-up session were described and were then compared using bivariate analyses. this study used data collected between september 2015 and december 2019. although having four additional data collection months after the second biennium ended in august 2019 allowed for more follow-ups, not all participants had an opportunity to complete all their follow-up sessions. intervention delivery dates were used to identify and exclude participants from the retention analyses based on their eligibility to participate in the follow-up. for example, participants who participated in the workshop after june 2019 were excluded from the retention analyses for the 6-month follow-up. similarly, participants who participated in the workshop after march 2019 were excluded from the retention analyses for the 9-month follow-up; and those who participated in the workshop after december 2018 were excluded from the retention analyses for the 12-month follow-up. multiple generalized linear mixed models with participant-level random intercepts were fitted to examine changes in a1c level over time among participants with pre-diabetes or type 2 diabetes. persons with type 1 diabetes (n = 221) or gestational diabetes (n = 12) were not included in the regression models due to small sample sizes. separate models were performed for the first and second biennia. the first set of models examined changes in a1c levels over time in participants with type 2 diabetes (n = 1922 in the first biennium and n = 2733 in the second biennium). the second set of models examined changes in a1c level over time in participants with pre-diabetes (n = 380 in the first biennium and n = 482 in the second biennium). the third set of models examined any differences in the changes in a1c levels over time based on diabetes type (pre-diabetes or type 2 diabetes) (n = 2302 in the first biennium and n = 3215 in the second biennium). the next set of models examined changes in a1c level among participants with type 2 diabetes by their baseline a1c level (i.e., 4.0-5.6%, 5.7-6.4%, 6.5-7.9%, 8.0-8.9%, 9.0-9.9%, 10.0-11.9%, and 12.0% or higher) (n = 1912 in the first biennium and n = 2722 in the second biennium). in addition, a separate regression model was used to examine any racial/ethnic differences in changes in a1c level (n = 2302 in the first biennium and n = 3215 in the second biennium). all regression models controlled for covariates including age, sex, race/ethnicity, education, language, and baseline bmi category. given that there were only 5 participants reported speaking "other" as their primary language, they were excluded from the regression analyses. a significance level of 0.01 was used. this study involved retrospective reviews and analyses of limited data, and this study was reviewed and approved by the institutional review board at texas a&m university (irb2019-0225d). results were presented based on the five re-aim elements to provide a case study of this applied research about diabetes self-management education [29] . reach was defined as "the absolute number, proportion, and representativeness of individuals who are willing to participate in a given initiative, intervention, or program, and reasons why or why not" [36] . the number of persons who participated in the program and their general characteristics were tracked (table 1 ). the majority of program participants were aged between 45 and 64 years (55.3%), female (61.6%), hispanic (68.6%), and had high school or less education (72.2%). most participants reported english as their primary language (89.5%) ( table 1 ). the intervention could be attended by individuals with pre-diabetes or diabetes as well as their family and friends. among the program participants with a recorded diabetes type, nearly 15% had pre-diabetes and more than 80% had type 2 diabetes. the mean a1c level was 6.2% among those with pre-diabetes, 8.7% among those with type 1 diabetes, and 8.6% among those with type 2 diabetes. * p < 0.01; ** p < 0.001; a . p-values from bivariate analyses (e.g., independent t-tests or chi-square tests) comparing the characteristics of participants recruited during the first biennium and second biennium; b . chi-square comparison was performed after excluding "other" language (n = 8650); c . in total, 21.7% of diabetes type records were missing, and frequency and percentage were calculated based on available data (n = 6788); d . mean and standard deviation of baseline a1c percentage measures were estimated among those with pre-diabetes and type 1 and type 2 diabetes. bmi, body mass index. a1c, average blood glucose level over the past 3 months. there were statistically significant differences in characteristics of the participants recruited during the first and second biennium (table 1) , indicating changes in program participant profiles and expanded program reach. compared to participants recruited during the first biennium, those recruited during the second biennium tended to be younger (22.0% vs. 17.1% aged 18-44 years), normal or overweight (32.4% vs. 29.6%), and not knowing their diabetes type (2.0% vs. 0.4%) ( table 1) . in addition to considering initial recruitment, it was important to assess population representativeness over time. the program consisted of an educational session and four quarterly follow-ups to track behavioral goals and clinical outcomes. however, less than 50% of participants attended the first scheduled quarterly follow-up session at 3 months, and the attendance rate for the subsequent follow-up sessions further decreased to 30.5% at 6 months, 23.0% at 9 months, and 18.4% at 12 months. the attendance rates at 9 and 12-month follow-up sessions were higher during the second biennium than during the first biennium (24.8% vs. 21.0% at 9 months and 21.1% vs. 15.9% at 12 months). table 2 shows the number and characteristics of overall program participants who attended and did not attend at each follow-up assessment. for all four follow-ups, retention rates were higher among those in the older age group, females, non-hispanic individuals, those with more than a high school education, and those whose primary language was spanish ( table 2) . retention rates tended to be lowest for those with bmis classified as being underweight (table 2) . among participants with type 2 diabetes, those not attending a follow-up session at any given time point had significantly higher baseline a1c levels than those who attended the follow-up session ( table 2) . among participants with pre-diabetes or type 1 diabetes, no statistically significant differences were observed based on baseline a1c level attending a follow-up session at any given time point (table 2 ). at the 3-month follow-up, the retention rate was significantly different based on participants' diabetes type ( table 2 ). the retention rate was highest among those with pre-diabetes (54.9% at 3 months) and type 2 diabetes (51.3%), followed by those with type 1 diabetes (44.3%) and those who were unaware of their diabetes type (35.5%) ( table 2 ). however, the association between retention rates and diabetes type was not statistically significant at subsequent follow-ups (table 2) . effectiveness was defined as "the impact of an intervention on important individual outcomes, including potential negative effects, and broader impact including quality of life and economic outcomes; and variability across subgroups (generalizability or heterogeneity of effect)" [36] . this study evaluated changes in a1c level among participants from baseline to each follow-up time point. in both the first and second biennium, a statistically significant reduction in a1c level was observed among participants with type 2 diabetes at the 3-month follow-up (b = −0.97, p < 0.001 in the first biennium and b = −1.13, p < 0.001 in the second biennium), and this a1c level reduction was sustained at the 6-month (b = −0.98, p < 0.001 and b = −1.20, p < 0.001), 9-month (b = −1.10, p < 0.001 and b = −1.19, p < 0.001), and 12-month (b = −0.95, p < 0.001 and b = −1.32, p < 0.001) follow-up. for example, for participants with type 2 diabetes who joined during the second biennium, the average a1c level dropped from 8.6% at baseline to 7.5% at 3 months, and this a1c level reduction was sustained at subsequent follow-ups (7.4% at 6 months, 7.3% at 9 months, and 7.3% at 12 months). on average, participants with pre-diabetes had a1c levels that remained controlled (<6.5%) from baseline to the subsequent follow-ups. for example, in the first biennium, a statistically non-significant reduction in a1c level was observed among participants with pre-diabetes at all follow-ups (b = −0.12 and p = 0.06 at 3 months; b = −0.13 and p = 0.07 at 6 months; b = −0.12 and p = 0.13 at 9 months; and b = −0.12 and p = 0.19 at 12 months). participants who had type 2 diabetes showed significantly greater reductions in a1c level than those with pre-diabetes (p < 0.001 for the interaction term between time and diabetes type in both the first and second biennia) ( figure 2 ). table 2 . characteristics of the program participants who attended and did not attend 3-, 6-, 9-, and 12-month follow-up assessments. p-values from bivariate analyses (e.g., independent t-tests or chi-square tests) comparing the characteristics of participants who attended and did not attend the follow-up session; e . excluded 5 participants who reported "other" primary language to prevent possibility of identifying the individuals; f . excluded 12 participants who reported having gestational diabetes to prevent possibility of identifying the individuals; g . high missing response rates and frequency and percentage were calculated based on available data (n = 6776 at 3 months, 6400 at 6 months, 5834 at 9 months, and 5288 at 12 months); h . mean and standard deviation of baseline a1c percentage measures were estimated among those with pre-diabetes, type 1 diabetes, or type 2 diabetes. bmi, body mass index. a1c, average blood glucose level over the past 3 months. significant reduction in a1c level was observed among participants with pre-diabetes at all followups (b = −0.12 and p = 0.06 at 3 months; b = −0.13 and p = 0.07 at 6 months; b = −0.12 and p = 0.13 at 9 months; and b = −0.12 and p = 0.19 at 12 months). participants who had type 2 diabetes showed significantly greater reductions in a1c level than those with pre-diabetes (p < 0.001 for the interaction term between time and diabetes type in both the first and second biennia) (figure 2 ). (a) (b) figure 2 . estimated changes in a1c from baseline to 3, 6, 9, and 12-month follow-up after adjusting for age, gender, ethnicity, education, language, and baseline bmi category, by diabetes type and biennia: (a) first biennium; (b) second biennium. a1c, average blood glucose level over the past 3 months. bmi, body mass index. changes in a1c values over time among participants with type 2 diabetes were also examined based on baseline a1c values. estimated changes in a1c by baseline a1c values show similar trends over time among the participants enrolled during the first biennium ( figure 3a ) and second biennium (figure 3b ). for both biennia, there was a statistically significant modification effect of the baseline a1c level on changes in a1c values over time (p < 0.001 for the interaction term between time and the baseline a1c level in both the first and second biennia). participants with high baseline a1c values (e.g., 8% or higher) achieved a decline in their a1c values at the 3-month follow-up assessments and maintained during the subsequent follow-ups. the estimated a1c level decline was most pronounced for those with highest baseline a1c values (e.g., 12% or higher). on average, participants with controlled diabetes at the baseline remained in control during the subsequent follow-ups. level on changes in a1c values over time (p < 0.001 for the interaction term between time and the baseline a1c level in both the first and second biennia). participants with high baseline a1c values (e.g., 8% or higher) achieved a decline in their a1c values at the 3-month follow-up assessments and maintained during the subsequent follow-ups. the estimated a1c level decline was most pronounced for those with highest baseline a1c values (e.g., 12% or higher). on average, participants with controlled diabetes at the baseline remained in control during the subsequent follow-ups. in a separate regression model, which included the interaction term between time and race/ethnicity, there was no statistically significant differences in changes in a1c values over time among participants with pre-diabetes or type 2 diabetes (p = 0.11 in the first biennium and p = 0.25 in the second biennium). adoption was defined as "the absolute number, proportion, and representativeness of settings and intervention agents (people who deliver the program) who are willing to initiate a program, and why" [36] . in lieu of being able to quantify adoption, the general adoption approach was described. the coastal bend health education center (cbhec) in corpus christi served as the healthy south texas regional headquarters. the texas a&m south texas center, mcallen campus, served as a second regional hub. while planning the intervention roll-out, a hub-and-spoke model was determined to be the most effective strategy in which a central "hub" supports multiple "spokes" in communities to provide a range of services. with this approach, cbhec and the mcallen campus identified other regional partners to help recruit and deliver the program. due to the staffing requirements (e.g., needing a health professional to lead the educational workshops and sessions), the program was not delivered in all counties; rather, it was more selectively offered around the two hubs-with the spokes representing adjacent service areas. in accordance with ongoing collaborative health promotion activities in their respective local communities, both cbhec and the mcallen campus were able to call upon their extended healthcare and public health networks for program delivery assistance. regional partners that helped deliver the program represented diverse community and clinical entities including community-based organizations, federally qualified health centers, hospitals, clinics, pharmacies, school districts, academic institutions of higher education, state agencies and not-for-profit social service organizations, behavioral health organizations, and city and county government offices. partnerships varied with some organizations assuming a fuller responsibility for delivering courses on their own, some helping with overall recruitment, and some solely offering physical space for classes. implementation was defined as "the intervention agents' fidelity to the various elements of an intervention's key functions or components, including consistency of delivery as intended and the time and cost of the intervention. adaptations are also included in this re-aim element" [36] . as an ada-recognized program, there was a need to demonstrate that ada principles of diabetes education were being followed. this involved an annual review by a designated quality control coordinator to review delivery processes, certify them as compliant, or note aspects to be corrected. program standardization across sites was facilitated by having a centralized hub for training and data reporting, in coordination with the scientific-administrative oversight functions provided by healthy south texas leadership. cbhec trained staff in program delivery using a standardized program manual and holding periodic problem-solving feedback sessions with regional program managers and implementers. adaptations to the program were discussed with the evaluation team to enhance program reach and retention. for example, program staff reported that many participants found it difficult to attend a single-day, 8-h workshop. therefore, other options were offered such as spreading the workshop over multiple days in two 4-h sessions or four 2-h sessions. program costs were not tracked in the first biennium, but efforts were made to retrospectively estimate actual program costs based on personnel, supply and space costs toward the end of the second biennium. the program was estimated to cost between usd 800 and 1200 per participant, albeit with substantial variation based on how established the program was delivered at different sites, methods of recruitment, and the number of participants in each class. a major indicator of program implementation was how many participants engaged in all program activities (e.g., the initial educational workshop plus four quarterly follow-up sessions to track behavioral goals and clinical outcomes over time). as seen in table 2 , only about 50% of participants attended the first quarterly follow-up session at 3 months, and attendance rates decreased for the subsequent follow-up sessions. given that process evaluation activities were initially built into the program evaluation, program staff were made aware of this issue concerning attendance. subsequent action was taken in an attempt to bolster follow-up rates. retention rates at 9 and 12-month follow-up sessions during the second biennium were significantly higher than the rates during the first biennium (i.e., 24.8% vs. 21.0% at 9 months and 21.1% vs. 15.9% at 12 months). maintenance was defined at the individual level as "the long-term effects of a program on outcomes after a program is completed" and at the setting level as "the extent to which a program or policy becomes institutionalized" [36] . at the individual level, the trajectory of a1c level change over time during the 12-month intervention period has already been reported in the effectiveness section (figures 2 and 3) . at the setting level, programs included within the healthy south texas initiative were intentionally designed to be housed within and delivered by established community partners who could draw upon their existing networks to facilitate programmatic spread and sustainability. for legislative feedback purposes, the amount of actual and in-kind dollars the health science center leveraged during the first two biennia was calculated. from private and public sources, over usd 15,000,000 was identified in direct support and in-kind dollars for the healthy south texas initiative (including delivery of the diabetes education program, as well as other disease prevention and health promotion activities) by governmental and nongovernmental entities. the program is still ongoing with a legislative commitment for a third biennium (september 2019-august 2021), and program delivery remains a core function of the two regional hubs. the healthy south texas diabetes education program reached and benefitted large numbers of participants in a region with documented health inequities that have perpetuated health disparities [13] . utilizing the re-aim framework for both planning and evaluation enabled the study team to describe this diabetes program in terms of its reach, adoption, implementation, effectiveness and maintenance [37] , and explore the unique challenges faced when applying and assessing re-aim elements in community settings [38, 39] . this community-based initiative reached a large and diverse population in this region, thus supporting the external validity of the positive results observed. the hispanic population accounted for over two-thirds of the total population in the service region [40]; hence, the ability to provide the program in spanish was a critical element that enabled the program to reach this population. an estimated 65,000 persons were served in the first two biennia across a broader range of diabetes outreach and education activities implemented by the texas a&m health science center healthy south texas initiative, in which the diabetes education program was a single component. this initiative capitalized on its understanding of the local community and organizational context, which has been deemed critical for the implementation and dissemination of other health promotion programs [41] . this enabled the implementation sites to draw upon highly visible stakeholders and their diverse relationships with community and clinical organizations for outreach and delivery. culture, language, and access to resources are known barriers to access to care in the hispanic population with type 2 diabetes [42] , and collaboration with diverse local community and clinical entities enabled recruitment of culturally competent staff and facilitators to reach the hispanic population, who are likely to be an underserved population in the region. this study has generated several general take-home messages to be considered before implementing future health promotion initiatives. foremost, program planners should conduct community needs assessments and/or engage stakeholders from the communities they wish to target during initial planning, when assessing feasibility, and when deciding which components to include (e.g., considering potential cultural competency considerations and the need to tailor materials). while research studies typically need to offer incentives for participant recruitment [43] , the healthy south texas initiative promoted program adoption by providing sites with necessary materials and/or subcontracted for services, which allowed programs to be offered free to participants who may have otherwise lacked resources to pay for such services. this was a critical component that helped alleviate or limit the participants' financial burden as a major barrier to participation, particularly among the socioeconomically disadvantaged population. when considering the generalizability of this evaluation in future settings and populations, program implementers and other key stakeholders should consider this option, where possible, as it may determine whether or not participants can access similar services in other initiatives. balancing fidelity to program implementation with the need for adaptation remains challenging in translational research [44] . over the past two biennia, many of the recommended re-aim strategies for improving the implementation processes were implicitly followed and should serve as explicit guideposts in future studies [29, 37] . for example, some sites adapted intervention delivery modes and routinized follow-up reminder contacts. other sites switched the health professional type needed to lead workshops to accommodate local needs and preferences. for example, one hub determined that in their setting a registered dietician was preferable to a registered nurse, and the ada offered some latitude when selecting the specific type of health professional used to lead workshops without jeopardizing the ada-recognized status or program fidelity. of particular note, the high attrition rates for follow-up visits raises issues about the feasibility and appropriateness of the current diabetes education program structure. the first biennium was a learning curve for the problem facilitators and implementation sites, and additional activities (e.g., reminder calls) were considered and conducted to enhance follow-up rates in the second biennium. reviewing other successful chronic disease self-management programs [45] , the difficulties of expecting the targeted population to consistently engage in intervention sessions over a 12-month period were recognized. hence, one major adaptation for future programming is to consider modifications of the current diabetes education program and/or the development of a new iteration of such a program with a shorter active intervention period. long-term supports are still valuable for participant success and should still be incorporated in some capacity (e.g., by their healthcare provider, virtually, telephonically). the effectiveness of the diabetes education program demonstrated significant decreases in a1c levels over time which were clinically meaningful [46] . however, a closer look provides guidance for future targeting, which is a major concern in intervention research [47] . while reducing a1c levels is a clinical goal for persons with elevated a1c levels, targeting those with a1c values of 8 and above has greater potential to be most cost effective, given these a1c levels are associated with the most diabetes complications and need for costly medical care [19] . findings from our study indicate that self-management programs adhering to ada best practices can achieve large decreases in a1c levels among this population. maintenance of individual and system-level outcomes is often the most challenging re-aim element to achieve [36, 48, 49] . it is critical to be aware of how context can influence outcomes at both levels. the practical robust implementation and sustainability model (prism) framework, which is now an integral part of the re-aim framework [50] , helps us understand the contributory role of recipients, implementation and sustainability, infrastructure, and the external environment. one successful maintenance strategy at the individual maintenance level was to pair the diabetes education program with opportunities for class-based exercise programming throughout the year. based on feedback from program managers, participants seemed to enjoy these sessions and kept them engaged in the diabetes education program. additionally, the diabetes education program was seen as a core component of the two healthy south texas regional hubs, and organizational efforts are underway to build capacity and support for continued delivery through a network of concerned partners. in the current third biennium of state funding (september 2019-august 2021), program staff are fully aware of the importance of context during these unprecedented times. thus, different options for long-term sustainability are being explored, noting that the current covid-19 crisis may make future state support less likely due to budgetary considerations [51] . toward this end, strategies for defining and promoting the value proposition of this and other health education programs are being formulated. for example, fee-for-service options, seeking insurance reimbursement for recognized diabetes management programs, and/or providing the program for a modest charge to community or healthcare organizations as a community benefit are being investigated. to assist in making a value proposition based on the potential return on investments made, economic evaluation studies that can demonstrate objective value in multiple ways (e.g., monetary outcomes, measures of gains in quality of life, reductions in years of potential life lost, reductions in potentially preventable hospitalizations) are recommended. such studies are important to inform local, state, and national stakeholders about the potential return on investment for these and similar studies and should complement other evaluation activities of similar initiatives to reach a broader audience. while there were many strengths in this community-based study, there were some limitations that must be acknowledged. this is a case study of a single diabetes education program in a geographic area. hence, the findings, while promising, may not be generalizable to all community diabetes prevention and control programs or to other areas with differing population characteristics, settings, or varying levels of baseline risk (e.g., a1c level). additionally, in contrast to academic-based research studies, service delivery often has priority in community-driven programs relative to data collection and management processes, which can limit the types and quality of data collected. for example, although there was a record of engagement by partnering organizations, there was no record of the extent to which organizations agreed to participate when asked. furthermore, while a large sample size was used, lack of randomization in community settings could be impacted by selection bias. the re-aim model provided a general framework for reporting the planning and evaluation of this initiative. as such, full measures on all re-aim dimensions were not collected. while this is a potential shortcoming, it is also aligned with the recognition that applying the re-aim model in "real-world" studies does not depend on the assessment of all five dimensions [39] . despite the relatively large numbers of community residents served by the diabetes education program, the proportion reached relative to people with diabetes residing in these south texas counties was still minimal, given the high rates of adults with diabetes in the south texas region [52] . further, the large attrition rate for follow-up sessions was considerable, which may highlight recruitment or fidelity issues and introduce self-selection and/or a healthful bias (i.e., participants with type 2 diabetes with lower a1c levels had better retention rates at all follow-up sessions). finally, data were not collected longer than 12 months following the diabetes education program workshop; therefore, an assessment of long-term clinical control and management among participants was not possible. similarly, as the healthy south texas initiative is still ongoing, long-term program delivery and institutionalization post external funding could not be assessed. however, lessons can be learned from this initiative that advance knowledge about research translation. in line with guidelines for implementing evidence-based diabetes prevention and control programs [53] , two successful strategies were employed to enhance reach with the ultimate goal of reducing health disparities in underserved populations. first, community health workers were integral to participant recruitment because they were seen as trusted members in the community [54] . another successful strategy was establishing and using diabetes health champions [55] (i.e., persons in the program who had successfully lowered their own a1c levels) to serve as program promoters who could engage populations typically characterized as "hard to reach" and who were unaware of, or previously uninterested in, participating in health promotion programs [56] . the diabetes education program provided an example of dedicated effort to meet the overall public health goal of diabetes prevention and management for all americans, especially among those experiencing a multitude of social determinants of health inequities [57] . offering the diabetes education program through two regional hubs was a major advantage for program reach and adoption as well as launching the initiative quickly. overall, the diabetes education program, as part of the healthy south texas initiative, made a substantial impact on the target area reaching diverse and potentially at-risk populations with measured benefits as evidenced in the current study. for long-term programmatic sustainability, such programs will need to be viewed as essential to routine diabetes regional risk: mapping single and multiple chronic conditions in the united states regional differences in rural and urban mortality trends; nc rural health research program: chapel hill trends in socioeconomic status-related differences in mortality among people with chronic obstructive pulmonary disease understanding associations among race, socioeconomic status, and health: patterns and prospects healthy border 2020: a prevention & health 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health champions approaches to recruiting 'hard-to-reach' populations into re-search: a review of the literature this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors would like to thank the healthy south texas team within the texas a&m health science center for their work to deliver and evaluate this program. a special thanks is given to the diabetes education program trainers, educators, and staff in corpus christi and mcallen who are continually dedicated to improving lives in south texas. additionally, the authors would like to thank carrie l. byington, former senior vice president of the texas a&m university health science center and vice chancellor for health services of the texas a&m university system (currently executive vice president and head of uc health at the university of california) and susan ballabina, deputy vice chancellor for texas a&m agrilife for their leadership role in the healthy south texas initiative during the study period. the authors declare no conflict of interest. key: cord-345662-vm5btiue authors: walwyn, david r. title: turning points for sustainability transitions: institutional destabilization, public finance and the techno-economic dynamics of decarbonization in south africa date: 2020-10-03 journal: energy res soc sci doi: 10.1016/j.erss.2020.101784 sha: doc_id: 345662 cord_uid: vm5btiue existing socio-technical systems tend to be intransigent to change. decarbonisation, on the other hand, is an imperative, leading to an obvious conflict between the need for, and highly effective resistance to, change. moreover, the abandonment of fossil fuel-based technologies in favour of more sustainable alternatives will require substantial reallocation of government’s operational expenditure, particularly in countries like south africa with high per capita greenhouse gas emissions and low per capita income. in this article, it is argued that reallocation will require more than niche experimentation and destabilisation of the present socio-technical regime. based on a study of south africa’s budget processes, it is concluded that change will only occur when four separate pre-conditions converge, namely a rapidly growing environmental problem capable of leading to civil unrest, a supportive and recently developed policy framework, decreasing techno-economic costs for its solution, and strong political support from an effective ministry or minister. turning points for transition, although infrequent, can be reached through strategic attention to these pre-conditions. a modified kingdon multiple streams approach, which introduces the additional dimension of techno-economic feasibility, is proposed as a useful framework for anticipating when and how to act in order to mobilise sufficient public resources for decarbonisation. the decarbonisation of energy and other systems is essential for the transition to a low-carbon future [1] . many countries have committed to binding targets for greenhouse gas (ghg) emissions, including the attainment of net zero emissions by 2050 [2] . the paris agreement is clear on what countries need to achieve in terms of such emissions, and over what time period these nationally determined contributions (ndcs) must be realised [3] . however, the costs of decarbonisation have not been similarly specified in the agreement. individual countries are only now beginning to fully understand and quantify what investment will be required to reach the ndcs, and how these funds might be secured. some initial assessments have been reported in the literature [4] [5] [6] [7] . for the united kingdom, it has been estimated that the plan to reach net zero ghg emissions by 2030 will cost $1.3 trillion or $3,571 per metric tonne (mt) carbon dioxide equivalent [8] . a similar value has been estimated for the united states of america, where the cost of replacing fossil fuels in the energy sector is estimated at $4.7 trillion or $2,666 per mt carbon dioxide equivalent [9] . these values can be more easily comprehended by firstly calculating a total cost based on the present carbon emissions, then annualising this cost by assuming that the transition to low-carbon will take place over a 30-year period (2020 to 2050), and finally expressing the annual cost as a proportion of gross domestic product (gdp). the normalised costs of decarbonisation for the united kingdom and the united states of america are estimated at 1.3% and 2.3% of gdp respectively, whereas for south africa the value is about 12%. the issue of cost will be particularly acute for south africa [10] . it is an upper middle-income country, heavily dependent on coal as a source of both electricity and liquid fuel [11, 12] . decarbonisation of the energy sector will be a formidable undertaking, whose solution is made more difficult not only by the extent of the economic disruption and social dislocation that may result, but also by the constrained resources with which to address the issue [13, 14] . a similar conclusion about the limited readiness of south africa for a low-carbon future has been reached by the world economic forum, which has placed the country in the 114th position out of 115 countries based on the energy transition index [14, 15] . already south africa has been criticised for its insufficient progress towards the attainment of the country's ndc targets [16] . there is concern about its renewable energy programme, including ongoing delays [17] , a poor outcome relative to the intended targets for economic development [18] , and general deficiencies in the implementation of off-grid solar home systems [19] [20] [21] . the government has also significantly alleviated the impact of a recently introduced carbon tax, and is failing to adequately resource the realisation of its ndcs [10] . moreover, the covid-19 pandemic has caused a massive shock to the economy, reducing tax revenue collection by 20% and cutting at least 6% from the gdp [22] . in short, the south african government appears unwilling and increasingly unable to resource its low-carbon transition. the issue of public sector resource allocation is critical for sustainability transitions. budget decisions within governments have direct and often irredeemable consequences. once such decisions are made, the resultant allocation of funds allows some programmes to be pursued and compels others to be halted. although there are several publications on green financing within south africa, such as its broader challenges and necessary design features [23] and the role that public financial intermediaries have already played in the country's energy transition [24] , there have been no specific studies on how to mobilise and reorient government expenditure for sustainability transitions, and particularly the decarbonisation of its energy sector. the unique contribution of this paper is its analysis of budget processes, leading to the proposition that four preconditions should be met before a significant reallocation of government's operational budgets, in support of decarbonisation, can be achieved. notably, in addition to the three factors of problem, policy and politics, which are central to kingdon' s multiple streams approach (msa) and are already welldescribed [25] , the techno-economic value of the proposed solution must be addressed. the analysis in this paper seeks not only to support its claim for the four streams approach, but also to recommend ways of dislodging lock-in and re-directing government expenditure. the study was exploratory in its approach. it drew on interviews with ex-government officials, examples of previous re-allocations and government documents relating to the budget process. its objective was to identify the causal factors that could lead to profound changes in these budgets, and then to present these factors as preconditions that should be concurrently fulfilled. in its analysis, the study uses a theoretical framework which combines msa [26] with historical instutionalism [27] , as explained in the second section. the third section presents the relevant background on south africa's budget processes. the methodology, results, discussion and conclusions follow in sections 4, 5, 6 and 7 respectively. kingdon's msa postulates that change happens at single points in time or 'policy windows', when a number of causal chains or streams converge [25, 26] . typically, the three streams comprise of the problem itself, a relevant policy framework and the political process through which change can be realised. msa further stresses the importance of policy entrepreneurs, who must attempt to couple the three streams through process of power brokerage and manipulation of problem contexts [28] . msa specifically acknowledges the complex and chaotic nature of policymaking, and the difficulty of operating within an environment of ambiguity, irrationality and unpredictability [25] . changes in policy are seen in msa to emerge spontaneously and stochastically, and can be missed by policy entrepreneurs due to the absence of well-developed policy solutions [29] . msa's emphasis on windows of opportunity and convergence is also a central aspect of historical institutionalism, which refers to windows of opportunity as critical junctures and convergence as a process of conjuncture [30] . historical institutionalism emerged in the 1980s as a means of conceptualising and theorising how reform takes place at the meso-level, introducing such terms as path dependence and selfreinforcing processes, whose identification are critical to understanding and hence overcoming intransigence to transition and change. it adopts a longitudinal approach, perhaps over several decades, the analysis of which is used to identify the relationships of lock-in and dependence that comprise the socio-technical landscape [27] . the hierarchies of micro, meso and macro, as developed within historical institutionalism, have become widely accepted and applied in the sustainability transitions literature [31, 32] , as exemplified by its adoption of the multi-level perspective (mlp). the latter defines the three levels as the socio-technical landscape, consisting of government policy and inter/national systems, the socio-technical regime and the niche level, the latter including firms and networks of individual actors. although arguably a simplification of the broad diversity of individuals, collectives, organisations and systems, this layered hierarchy is fundamental to an understanding of transition, and how different processes take place within each level. in much of the mlp literature, change is considered to begin through niche innovations and policy experimentation, undertaken by an array of minor actors. the efforts of these actors may eventually become aligned and sufficiently powerful to destabilise an extant socio-technical regime, which has been wellestablished at the meso-level over a long period [33] . a possible weakness of this model in the context of a developing country is the extent to which agency is possible within a highly resource-constrained political system. indeed, in the wider debate about structure vs agency, it can be argued that individuals and small networks of actors are disempowered by the broader structural context. it is precisely this consideration which makes the use of historical institutionalism, with its focus on the meso-level, as a highly relevant analytical framework for a country such as south africa. although operating as a democracy, it is clear that the societal environment in south africa still acts as a major constraint on the micro-level actors, given the low level of education and human capability [34] . furthermore, the highly rigid approach of the pre-1994 system of apartheid resulted in an extensive entanglement of the technological systems and the state, creating an almost irreversible degree of lock-in [35] . in some senses, historical institutionalism is about theories of continuity, providing an explanation for why regimes remain stable, even though they are contested, rather than why they change. in order to address this gap, roberts and geels [36] supplemented the insights of historical institutionalism with those of mlp as a means to further develop a theory of change. in their analysis of conditions for politically accelerated transition, informed by two case studies in the united kingdom, they argue that conditions for change must include both a weakening of the socio-technical regime, which they refer to as a push factor, and a strengthening of niche actors, which they label as a pull factor. following the insights from historical institutionalism, in which major policy change arises from struggles for power at the meso-level, they conclude that at least one mechanism of change is a macro-or landscape level shock. this severely disrupts the incumbent regimes and allows the emergence of niche actors as a new socio-technical system [36] . in summary, historical institutionalism has two specific advantages when used to understand sustainability transitions, firstly its focus on meso-level institutions and policy regimes, and secondly the recognition that power struggles between political collectives or groups over scarce resources lie at the centre of politics and are critical to policy change [36, 37] . institutional structures and arrangements, typically referred to as a political community or polity, engage in power struggles through the process of politics. in this sense, historical institutionalism is more appropriate in understanding south africa's budget processes and has been used in this study. it is argued that important decisions relating to resource allocation, which have the capacity to alter the course of sociotechnical systems, are the consequence of conjunctures taking place at critical moments. such turning points have a low probability of occurrence, given the dominant approach to policy stability and lock-in. the state can play an important role in transitions, either through exogenous changes at the level of the socio-technical landscape, or by strategic and planned initiatives to change the institutional environment [38] . it is precisely the issue of the role of the state, and how it can be internally directed, that is the subject of this article. the study considers the separate roles of the executive, the administration and the legislature. the nature of the power balances between these three arms is explored by analysing their relative roles with respect to a core public sector process, namely the allocation of funds from the national fiscus to individual departments. an overview of this process, as it normally takes place, is presented in the next section. the adoption of south africa's new constitution in 1996 necessitated a comprehensive reform of the management of public finances, including its budget procedures. the latter were amended in several respects, such as strengthening the link between policy and budget allocations, the introduction of systems to address fragmentation and lack of clarity, and measures to improve transparency and re-establish fiscal stability [39] . although the new processes were more top-down, the changes improved the alignment between post-1994 priorities and actual public expenditure [39] . a core feature of the revised budget process was the introduction of the medium-term expenditure framework (mtef), which was intended as the means by which government could ensure budget stability and predictability while allowing changes "at the margin" [39, p3] , thereby managing the "tension between competing policy priorities and budget realities" [40, p49] . the mtef was positioned as a first step in the "wider overhaul of the budgetary process, emphasising transparency, output-driven programme budgeting and political prioritization", that provided the link between the "technical preparation of budgets and the need to reflect political priorities in expenditure plans" [41 p1 ]. its key features include rolling baselines, which are the core budgets for each department and are substantially unchanged within a single mtef, and a contingency reserve, which is intended to cover unforeseen expenditure. a detailed review of the timeline for the budget process is not possible in this article. in summary, the process is initiated by a cabinet lekgotla, which takes place in february to march of each year (see fig. 1 ). at this meeting, the cabinet reviews the macroeconomic and fiscal policies, and the extent of the required budget cuts, or the additional funding that may be available for new priorities. these changes are then incorporated in a set of mtef budget guidelines [42] , which are issued to the various national departments and provinces. in response to the guidelines, the departments prepare budget proposals, which are then submitted to national treasury, where they are consolidated into an overall budget estimate. based on the alignment between the estimates and the guidelines, national treasury provides feedback and, if necessary, requests revisions from the departments. the adjusted budgets are then assessed in the ministers' committee on the budget (mincombud) technical committee (mtec), which is composed of senior officials from national treasury (nt), the department of planning, monitoring and evaluation (dpme), the department of cooperative governance (dcog) and the department of public service and administration (dpsa). mtec then prepares recommendations for mincombud and cabinet regarding budget allocations in the mtef, taking into account government priorities, funding available, exchange rates, alternative funding sources and the division of revenue amongst the three spheres of government [42] . once mincombud has approved the budgets, the minister of finance tables the medium-term budget policy statement in the whole process intentionally reinforces a central design principle of the post-1994 reforms, namely the establishment and maintenance of a stable public finance environment, otherwise stated as a predictable expenditures and policies [39] . one effect of this approach is that it severely limits the available funding for new policies or initiatives and reinforces a pattern of lock-in or pathway dependence within the budget allocations. however, there are two mechanisms through which small amounts of money can be sourced for new policies, if there is sufficient political support. before the estimated income is divided between the different departments and spheres of government, a contingency reserve is 'top-sliced' and retained by national treasury for emergency needs or novel policy instruments. this reserve provides a level of flexibility to the budget allocations, although, as shall be discussed later, it is a small amount relative to the demand for new funding from the various departments. the other mechanism, known as virement, involves the shifting of funds from one subdivision of a budget vote to another. there are a number of restrictions to this practice, including the requirement that it may not exceed 8% of the total allocation in the source subdivision (from which the funds are taken), that it may not involve the shifting of funds from capital to recurrent expenditure and that it cannot be used to increase remuneration without special approval from national treasury. clearly, expenditure predictability and budget stability are important objectives, especially in respect of financial markets and the cost of borrowing. however, both elements act against the needs of transition or change, particularly where the change has a significant cost or budget implication. the prospects of sufficient allocations for major new policy directions are limited by the mtef and the system weakens the role that government can play in enabling such changes. this imbalance has led to the growing realisation by south africans that reform can only take place in response to external pressure, widespread protest, and even violence. the 2015/2016 student protests regarding "free" higher education are an illustration of this perspective. provoked by a statement from the department of higher education and training (dhet) on transformation in higher education [43] , the students embarked on nationwide protests, demanding that promises of free education be fulfilled. after a number of incremental changes, president zuma finally announced on 16 december 2017 that higher education for the poor and working class students would be free [44] . the president's decision was taken against the advice of national treasury, especially since it ran counter to the agreed budget processes and mechanisms [45] . moreover the impact was profound; funding for the national student financial aid scheme (nsfas), the primary vehicle for the implementation of the new policy, a 'mere' r7.2 billion in 2015/ 16, increased to r40 billion in 2021-2022 [46] , as shown in fig. 2 . certainly, in respect of this decision, it can be concluded that the executive directed, the administration was out-manoeuvred and the legislature side-lined. the intent that such decisions should be the outcome of evidence-based information and a collective consensus between the three arms, as stipulated by a range of policy documents, was over-ruled. thus, issues of policy conflict and priorities are often resolved through a political process which may relate to the power or influence of key positions within the executive arm of government (cabinet), or to the ability of the operational and legislative arms to determine the expenditure allocations. despite such processes being of critical importance to an understanding of how decisions on resource allocation are made, there is little published research in south africa on this topic. as illustrated by the earlier example of the nsfas, budget re-allocations are possible and do take place. accelerated sustainability transitions, as will be necessary for the timely implementation of the paris agreement, will require significant government investment, especially in new systems of transport and energy. to disregard or overlook these outlays under the pretext of lacking the necessary funds, appears disingenuous. it is a matter of priority and policy, and of avoiding the disrpution of existing, exclusive institutions [47] . in summary, the analysis of budget processes leads to the following propositions about how change, and in particular realignment to operational budgets in favour of sustainability transitions, could take place. • for change to take place, the problem must be highly visible, a coherent and aligned policy framework must be in place, the solution should be affordable, it must require a political intervention, and failing to act must have severe consequences (such as social unrest). • the dynamics of each aspect are the problem must be accelerating in its severity; the solution must have falling cost implications; the window of change is generally very brief, opened by the sway of politics and rising popular dissent; and the political response must be rapid and effective. • the simultaneous convergence of these four aspects, described as a process of conjuncture resulting in a turning point or critical juncture, is essential for change to take place. in order to explore the validity of these propositions, a research project, involving a series of interviews over an 18-month period, was designed and initiated. the overall objective of the study, as already noted in the introduction, was to identify the factors that can lead to profound changes in government expenditure, and hence how greater priority can be mobilised for the support of sustainability transitions. further details of the research method are provided in the next section. the research followed a qualitative, inductive and exploratory approach with a purposive sampling strategy [48] . the population consisted of ex-members of national treasury, and other departments, who had occupied senior positions within government in the recent past, including director-general, deputy director-general and chief director, and had more than 5 years' experience of budget processes in the public sector. approval of the project by the faculty ethics committee was subject to two explicit conditions, namely that only exmembers could be interviewed and the responses had to be anonymised. the latter is a standard requirement and was fulfilled by following the normal procedures. however, the former condition added lengthy delays to the project due to the difficulty in identifying suitable respondents meeting the two criteria of having recently left a senior post in government. altogether, six interviews were completed. the respondents were interviewed using a semi-structured questionnaire in order to understand, primarily, how policy priorities are assessed and balanced within the public sector. the questionnaire was divided into four separate sections, with the first section covering the participant's view on the role of the state with respect to the environment and how this is presently being fulfilled, followed by three sections on the process of budget allocations and determination of funding priorities, the resolution of cases involving competing priorities, and general recommendations on accelerating support for sustainability transitions, respectively. in each case the interviews were recorded, transcribed and then analysed using atlas.ti. the coding structure was developed based on the research questions, with the coding groups covering the core questions of role, examples of policy conflict, the determination of priorities, details of the budget process, moments of change and lessons for sustainability transitions. it is acknowledged that the small sample size limits the external validity or generalisability of the results [48] . the credibility and exclusivity of the data is, however, robust in that the respondents had all occupied senior positions and accumulated more than fifteen years of experience in budget processes within the public sector. although there were differences in perspectives, mostly there was agreement on the main determinants of the central question that this article seeks to address, namely how to influence such budget processes. as a result, it has been possible to extract a set of useful insights from the data. as mentioned earlier, south africa faces a huge decarbonisation challenge. its electricity sector is the most carbon intensive of all the g20 countries, it has a bankrupt power utility without resources to finance its normal operations, let alone decarbonisation, and it has a high level of unemployment, which places even more pressure on the imperative for a just transition [49] . the global decarbonisation imperative will place huge financial pressure on state income. it has been estimated that the cumulative impact on south africa of a low-carbon transition, referred to as the 'transition risk' will be $120 billion, which includes the loss of export revenue, and the loss of local markets for coal and liquid fuels [14] . in addition, south africa will need to invest in new energy infrastructure, the extent of which can be illustrated by considering investment cost normalised for gdp. using data for carbon emissions and gdp data from the world development indicators database [50] , and assuming that the average investment cost will be $2,500 per mt of carbon, it is calculated that south africa must source $44 billion, or 12% of the gdp to finance the transition, as shown in fig. 3 . it is clear from this comparison that the cost of decarbonisation will be more acutely experienced by countries with lower gdp and higher carbon emissions. for instance, iran, russia, india and saudi arabia have high relative ghg emissions and can expect a larger cost, normalised to gdp, than other countries. the combined impact of this investment cost and the transition risk, which represent a major challenge to the south african government, has a number of budgetary implications. as will be the case in many countries, the public sector will be required to implement mitigation strategies, such as the retraining of mining sector employees, introduction of new policy instruments to support the renewable energy sector, changes to legislation, interim approaches to reduce the impact of revenue changes on municipalities, measures to build resilience to climate change, programmes in research and development focussed on the necessary diversification of the economy and the remediation of environmental damage from fossil fuel usage. although several departments will be affected by transition risk, this study has looked specifically at the department of environment, forestry and fisheries (deff), which has overall responsibility for environmental management and is represented at executive level by the minister and deputy minister. the department has an annual budget of about $500 billion, an amount which has not changed much over the last seven years, and under the medium-term expenditure framework allocations is projected to stay at a similar level in the immediate future (see fig. 4 ). allocations to the department were considered by the interviewees to have grown from a low base, with the department being one of those to have benefitted from the growth in overall government revenue over the period 2003 to 2008. opinions as to the adequacy of the present budget in meeting the department's responsibilities were mixed, although it was generally considered that the major constraint was not funding, but capacity to deliver. this sentiment is not echoed by the present minister, who indicated a need to leverage the resources of other sectors in order to ensure that the department could deliver on its present mandate [51] . the respondents agreed that deff's role is to ensure the protection and preservation of the environment, or in broad terms 'environmental sustainability', and that this role was being fulfilled through the combined actions of regulation and enforcement. however, it was noted by the respondents that the department's efforts can be compromised by the very nature of public policy, which is to represent a broad range of interest groups, and the diversity of government's activities, some of which can impinge on the environment and have direct environmental costs. for instance, the granting of coal mining or fishing licenses was cited as an example of the tension between protection of the environment and economic development. in the case of fishing licenses, the desire to ensure the economic livelihoods of small fishing enterprises was considered to have led to over-harvesting of fish stock, with subsequent depletion, and in some cases collapse, of fish populations. similarly, the granting of additional coal mining licenses as a means of transforming the sector, or the use of pesticides to control malaria, had led to significant degradation of the environment in the affected areas. it can also be argued that environmental protection through restrictions on mining and other resource extraction activities can be justified economically, and that defining sustainability vs. development as a dichotomy is unproductive and misleading. longer term economic development is about environmental sustainability, a perspective which is expressed by the present minister, barbara creecy, who stated [51] : "what i want to bring to this portfolio is the understanding that caring for the environment, caring about climate change and threats to biodiversity may well be an emotional concern for some people, but 2-million south africans are directly dependent on our natural resources." it is clear that conflict between the mandate of deff and other departments arise on a regular basis, and that in some cases, the deff is successful in preventing decisions leading to adverse environmental impacts. although no clear pattern emerged from the discussions, the interviewees were questioned about how such tension was managed, and, typically, which areas were prioritised. the results of these questions are presented in the next section. disagreements on government choices are generally resolved through the existing policy framework, which forms the blueprint for government action. however, in ambiguous situations, where proponents of each position can find relevant policies in support of their perspectives, decisions are taken based on the power of coalitions, politics, the charisma of individuals and the strength of lobby groups. such decisions often take place in the executive, which, in the view of one respondent, is a forum with weak environmental representation, given that there is one minister of environmental affairs, but five or six economic ministries, and eight or nine social ministries. in order to ensure a positive result for the environmental portfolio, it is therefore essential that the minister attempts to build an alliance with other ministries and civil society, and is then able to depend on this alliance in supporting a particular issue. as noted by one respondent: [19:51] "a flat-footed environment ministry that refuses to play the politics that is required ain't going to get anywhere." (respondent 2) the choice of alliance partners is one of several important components in the construction of such a coalition. it was indicated that likely partners for environmental issues included the security cluster (defence, police, justice) and one or several of the cross-cutting departments (finance; foreign affairs; public service and administration; and planning, monitoring and evaluation). it was noted that the former was often supportive of longer-term perspectives as a means of averting social unrest and inter-nation conflict. apart from being a forum in which the environmental mandate is outnumbered, the executive is also a constitutional body which lacks a referee, particularly if the president does not assume at least some responsibility for non-partisanship. this one-sidedness is especially relevant in decisions relating to the construction of infrastructure or the expansion of one of its public enterprises, where the government acts as both the regulator and the player, and may too easily be able to bend the rules in its favour, or make a trade-off, as described by one respondent: [9:24] government always has to make trade-offs between various sectors and importantly with respect to the environment it is constantly making trade-offs between environmental and economic/social objectives, and really that is its function. so, it is not just a regulator of the environment. in regulating the environment, it balances multiple competing objectives …. i think that is just the hierarchy of decisionmaking that it needs to do (follow). (respondent 2) it is not clear how such a hierarchy of decision-making is established, other than that it is political and highly contextual. a propensity for persistent and patient negotiation is an important prerequisite for the minister of environment, forestry and fisheries, especially in pursuing a pro-environment agenda which may be perceived as anti-employment or economic growth. in the next section, the respondents' comments on how such agendas have evolved, and particularly the reasons for any successes, are discussed. during the interviews, several incidents of decisions relating to significant policy changes were discussed, including the implementation of the sugar tax, the introduction of plastic bag regulations, the proposed carbon tax and the reforms on student fees. in the earlier discussion on historical institutionalism, it is argued that such moments of change require, inter alia, strong political support. one important strategy for obtaining this support, which emerged from the discussions, is the inclusion of revenue collection, which predictably secures agreement of arguably the most powerful government department, the department of national treasury. according to the respondents, the ability to extract additional fiscal revenue accounts for the relative ease with which changes such as the sugar tax were introduced, compared to other policy initiatives. the respondents noted, however, that even in the case of additional tax revenue, obtaining consensus from the executive always required a great deal of finesse. the nature of this 'footwork' is central to this study, but inevitably the most elusive aspect to define. it depends on the issue, the context, the personalities, the relevant institutions, the affected sectors, and a number of other factors. it is what distinguishes an effective from an ineffective minister, a progressive from an intransigent or reactionary administration. the respondents noted that in government change generally takes place with difficulty, if at all. the processes and systems are designed to maintain the status quo, perhaps for important reasons. policy stability, particularly macro-economic, is both a desire and a goal in governments, and change, especially when it is driven by narrow political interests outside of established governance processes, can be damaging to countries and economies. such momentum in government action is reflected acutely in budget allocations. the respondents commented that these allocations are mostly unchanged from one year to the next, giving little flexibility to the executive in being able to implement new initiatives. for instance, [5:50] "… every now and then there are some shifts, but those shifts might be fairly significant in the context of one particular department, but i'm not sure that they are significant in the context of an entire sector and usually those shifts are either … i don't think that they are ever more than maybe 5% of any government's allocation from one year to the next." (respondent 4) in other words, there is no new money within treasury and budgets remain substantially unchanged from one year to the next. moreover, the re-allocation of funds from one budget line to another, within the rules of virement, is tightly controlled and requires national treasury approval. individual line managers are able to re-allocate unspent funds within a programme or line item, such as from one project to another, but these changes are relatively minor and cannot be applied to the funding of new initiatives. the challenge for the funding of sustainability transitions is, therefore, to persuade government departments to redirect their existing budgets over time, and mainstream the sustainability development goals in their daily practices. this challenge is recognised by deff as being central to its mandate and it engages regularly with other departments on the need to include such goals with some success. for example, the establishment of the biodiversity centre of excellence by the department of science and technology (now the department of science and innovation), the creation of the green fund and the implementation of the renewable energy independent power producers procurement programme were mentioned by the respondents as resulting from such inter-departmental discussions. there is one important exception to the overall situation of budget stasis, which is the power afforded to the president of south africa. although not explicitly stated in the constitution or the legal system, it appears that the president is able to circumvent the standard budget processes, as happened in the example of the student fees crisis of 2015 [43] . the appropriateness of this use (or abuse) of power was questioned by a respondent: [35:33] "you know if the politicians don't accept the institutional rules of the game, then it is very easy for them to wreck the institutions. … there has to be a basic acceptance, a collective acceptance that this is the rules and this is how you do things. if people don't accept that, they can just wreck institutions very, very easily." (respondent 3) in summary, the interviewees concurred on the budget situation as being highly constrained with the opportunity of finding new funding to support sustainability transitions (in pursuance of the sustainability development goals) as being not just remote, but impossible. the redirection of existing funds is the only option, although the budget process is ill-suited to such changes and in general only incremental adjustments over a long period are possible. the implication of these results for sustainability transitions are discussed in the next section. decarbonisation of south africa's energy sector is largely a problem for the state. more than 45% of the country's carbon emissions derive from the fleet of coal-based power stations owned and operated by the state-owned power utility, eskom [52] . replacement of these facilities with renewable energy alternatives will require significant new finance. given its present financial circumstances, eskom itself is highly unlikely to be at the forefront of this reinvestment and the reform of the electricity sector. as already noted, the utility is deep in debt, and embroiled in a series of technical and political crises which severely constrain its ability to raise finance from capital markets or the state [53] . this outlook suggests that much of the investment finance for the energy transition will be provided by the non-government sources. however, government will be required to provide financial support for a range of operational activities, including energy research and development, retraining workers affected by the energy transition, building of capacity to manage energy markets, and incentives to support local manufacture of renewable energy equipment. such funding will be mostly additional to the existing budgets of government departments, and will require either new funding or the re-allocation of budgets from other activities. the likelihood of new funding is minimal. government finances, already stretched to the limit before covid-19, are now in a highlyborrowed predicament, with the level of government debt rising to 80% of gdp in the 2020/2021 financial year [54] . the re-allocation of monies from other expenditure items within the operational budgets will be an imperative if government funding for decarbonisation and the energy transition is to be made available. the premise of this article has rested on the assumption that high-level decisions for such changes reflect not only the extent of the need to fulfil each department's public mandate, but also the strength or weakness of the interdepartmental power relationships. an understanding of these dynamics is therefore critical to the implementation of emergent and experimental policies within government, such as policies to support decarbonisation, sustainability transitions and the transformation of socio-technical systems. this study has intimated that the budget process affords limited opportunity for negotiations on departmental budgets. however, there are points in the process, referred to as windows of opportunity, when such changes are possible if a number of preconditions have been met. the concept of a window of opportunity is by no means unique. as already outlined, it is shared by both msa and the multi-level perspective; the latter focuses on the two streams of regime destabilisation and niche consolidation, whereas msa requires the conjuncture of problem, policy and politics. the south african context supports both approaches, but identifies the fourth precondition of an affordable solution. conditions in developing countries are frequently resourceconstrained, implying that regime changes lead to extreme changes for the affected parties. as a result, the conflict can be more apparent, the outcomes more divisive and the moments of change take place more unpredictable. in other words, the higher financial stakes determine the nature of the struggle and the resultant change, should it occur. the critical junctures or windows of opportunity are less frequent, more contested, require more significant alignment of interest groups and are characterised as strong conjunctural processes. the pre-conditions for these windows of opportunity are also different. it is argued here that one further stream is required, namely favourable techno-economic value or improvements in the benefit to cost ratio of the potential solution, as exemplified by the introduction of the sugar tax. this amendment to the msa is essential to understand how change can emerge, and hence to engineer or accelerate sustainability transitions. furthermore, each of the four streams needs to be characterised based on its dynamics or rates of change. the four streams are now discussed in more detail. policy changes rarely seem to take place in response to opportunities. politics is a domain that appears to be mainly reactive, and often takes the form of crisis management. given the multiple demands on the public sector, and the huge scale of the issues, this reactiveness is perhaps not surprising. one general precondition for policy change seems to be clear: there must be a shared understanding of a clearly defined problem for such changes to be considered. the mere existence of a problem is also not on its own sufficient; policy windows are more likely to open when the problem is both growing in scope and the rate of growth is accelerating, to the extent that it is mobilising extensive political support outside of government, most notably in civil society with its ability to mobilise civil unrest. the power of civil society to destabilise the landscape depends on the extent of mass mobilisation and public support for a particular issue, and the degree to which this support is able to gain momentum within nation states. government may then act to repress or outlaw civil society protest, as happened repeatedly under apartheid south africa [55] . the inclusion of regime destabilisation as a necessary step in the processual framework of this model is also part of the msa and also the multi-level perspective. examples of such changes include the occurrence of pandemics, the environmental crisis, the advent of widespread road transport and the rise of wheat mono-culture [36] . opinions on how to change a dominant regime have been offered by many authors. milton friedman, well known for the development of stabilisation policy, surprisingly had a perspective on how to change a socio-technical regime. he considered that only a crisis produces change, and that the most important pre-condition was to be wellprepared [56, p ix] . this requirement of being well-prepared is partly captured in the theories of policy experimentation and strategic niche management [57, 58] . these argue that transition requires initial experimentation with new approaches, some of which may fail, but the successful interventions may eventually gather sufficient momentum to result in changes at the meso level. importantly, there are no clear predictors of success with early experiments, and policy frameworks may themselves not achieve the desired outcomes. it is therefore critical that such interventions be accompanied by a transparent and insightful monitoring and evaluation framework, which can inform whether the policy should be continued, strengthened or withdrawn. the stream of techno-economic value refers to the perceived cost benefit ratio of a public policy or intervention [59] . such analyses are a legislative requirement within the south africa public service, and are typically framed with questions such as "what is the value for money?" or "what is the cost/benefit ratio?" [60] . cost/benefit analysis is used as a means of informing budget decisions based on the economic viability or socio-economic benefit of a particular intervention. there are multiple approaches to the analysis, including the use of standard financial techniques such as discounted cash flows, net present values, internal rates of return and payback periods [61] . mostly, the analysis requires the monetisation of the resultant social welfare and economic benefits of the intervention, the sum of which are then compared to the overall costs. measurement of the net social welfare is complicated by the large variety of possible benefits, the relative value of each intervention and the prediction of its impact. although costs are mostly explicit and relatively straightforward to calculate, the quantification of benefits is subject to assumptions on critical issues such as the contribution of energy to the quality of life, or the magnitude of the social discount factor, or the value of possible externalities (such as an improvement in the quality of the natural environment) which are associated with a particular intervention. some of these limitations can be avoided by applying cost/benefit analysis only as a comparative technique. in this way, the same assumptions apply to all the options being reviewed, and allow for the selection of the most cost-effective alternative amongst a portfolio of analogous projects. a useful example of how the techno-economic value can influence resource allocation decisions is the case of the declining cost of renewable energy technologies. although the cost of electricity from photovoltaic panels and onshore wind turbines was, prior to 2019, generally more expensive than energy obtained from fossil fuels, this situation has now reversed and renewable energy technologies are now consistently cheaper [62] , due mostly to improved manufacturing efficiencies and greater production capacity within the sector [63] . the lower levelised cost of energy has been an important influence on the planning of national energy systems and the decisions to incorporate higher levels of renewable technologies within such systems [17] . as for the problem stream, a positive impact on social welfare is not a sufficient condition; the benefit should have, at least, the prospect of growth. in other words, the potential savings should be increasing, or the cost of implementation should be decreasing, as indicated in the example of renewable energy technologies. accepting the validity of the normative process that policy determines strategy, strategy determines operational plans and operational plans drive budget allocations, it is reasonable to assume that budget allocations match the overall policy framework. however, government as a punctualised actor is in fact not a single entity; it is a loose agglomeration of multiple actors with overlapping but also conflicting policy objectives. for instance, industrial policy may contradict environmental policy, fiscal policy may oppose energy policy, health policy may conflict with trade policy, and defence policy may act against science and technology policy. in terms of decarbonisation, and the likelihood that departments of the environment will be able to secure funds from the national fiscus in support of decarbonisation, it is clear that attention to the politics is critical. for south africa, which faces a 530 million metric tonne per annum decarbonisation challenge with limited ability to raise the necessary resources, this aspect of the environmental campaign will be vital. using the estimated value of $2,666 per mt carbon dioxide equivalent, the decarbonisation cost for south africa will amount to $1,472 billion, or 12% of gdp over a 30-year period (2020 to 2050). in comparison, the decarbonisation costs for the united kingdom will be 1.3% of gdp, as previously indicated in the introduction. south africa, therefore, has limited options in addressing the decarbonisation challenge, other than to consider budget reallocation. the issue of securing resources to support sustainability transitions, and particularly public funding, is also highlighted in the literature on technological innovation systems, where resource mobilisation is identified as one of several critical functions for the establishment of systems to support such transitions [64] . technological innovation systems as a conceptual model for transition is also a processual framework and in its discussion of resource mobilisation, it is argued that this function needs to be sufficiently covered from the early stages in the development of a new system. identifying resource allocation as an important part of the overall transition process is in itself insufficient in supporting the transition. it is equally important to understand the source of the funds and how they can be secured. public funding is critical in such transitions since the initial stages will be characterised by high levels of risk and limited participation from private funders. however, public budgets are subject to intense competition from other priorities including health, security, education and infrastructure, and the prospects of successfully lobbying for the re-direction of public funds from existing portfolios are severely restricted. this article has argued that such moments do exist, but in resource constrained setting such as south africa, they occur only within narrow windows of opportunity characterised by an escalating problem, the adoption of a recent policy framework, the prospects of an improving benefit to cost ratio, and a willingness to engage in realpolitik. previous studies have concluded with a number of policy recommendations for low-carbon transitions including the need for dynamic policy mixes dealing with demand-and supply-side instruments, a focus on politics in addition to policy, and active steps to phase-out existing technologies in addition to supporting niche-innovation [65] . the results of this study suggest a number of more specific recommendations for resourceconstrained countries as follows. low-carbon futures are unlikely to be realised without public funding. as is argued in the case of public-funded research and development, such transitions will be subject to market failure and under-investment in the absence of public support. it is therefore important that government establish dedicated funding for sustainability transitions, in the same way that they have created budgets for industrial development or energy infrastructure. developing the structure and rationale for these budgets is an important step towards securing the actual funding. in resource-constrained settings, it will be hugely challenging to secure funds without re-allocation from existing portfolios, the prospects of which are unlikely on a daily basis. however, there will be windows of opportunity or critical junctures, which will arise when there is alignment between an escalating problem, a supporting policy framework and a rising benefit to cost ratio. an appreciation of such moments, and a mechanism for recognising their opening, is an important insight of this study. although leadership and agency are critical, engaging in politics is more that individual action. all actors, but especially politicians and senior public servants, need to enter into relationships with each other, and with civil society, labour and advocacy organisations. in the final decision on budgets, the most important factor may not be the strength of the evidence for the intervention, but the strength of the alliances which are willing to support the re-allocation proposal. 7 conclusion and recommendations in addition to an overall cultural change, transitions to sustainability in south africa, and perhaps other countries, will require new programmes and projects within government. importantly, these programmes will require new funding. however, the prospects for this are severely limited by the present situation of decreasing government revenues and the overall path dependence of budget allocations. the lack of new funding will hinder such transformation and requires the development of new strategies. this research has sought to define the main components of the budget process in south africa and hence develop a strategy to overcome funding limitations for necessary and important operational programmes. it concludes that the conjunction of four streams is key to successful changes in budget allocations, namely a growing problem, preferably accelerating, a recently developed policy framework, a strong techno-economic justification whose prospects likely to become more attractive, and a strengthening political stream consisting of powerful alliances able to drive budget changes through the executive. these conclusions align with the insights of historical institutionalism, which include the supposition that change takes place as a result of contestation, and at the meso level, the destabilisation of the existing socio-technical regime combined with significant challenge from an alliance of niche players. this result implies that sustainability transitions in south africa will require highly strategic leadership of the environmental portfolio, which can direct the processes of conjuncture and act at critical moments in order to effect transformation. in particular, this leadership needs to sharpen the arguments for public funding to support sustainability transitions, develop the necessary budget structure, learn to recognise critical junctures or windows of opportunity, and network with power actors willing to support budget reallocations. waves of disruption in clean energy transitions: sociotechnical dimensions of system disruption in germany and the united kingdom these countries have committed to a net-zero emissions goal -could it solve the climate crisis? /l.9/rev.1: adoption of the paris agreement the analyses on 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national treasury the views of commerce students regarding "free" higher education in south africa zuma announces free higher education for poor and working class students zuma ignored treasury, nec on higher education s promise of free higher education honoured sustainability transitions in the developing world: challenges of socio-technical transformations unfolding in contexts of poverty promoting novelty, rigor, and style in energy social science: towards codes of practice for appropriate methods and research design brown to green: the g20 transition to a net-zero emissions economy world development indicators bringing a climate of change tensions in the transition: the politics of electricity distribution in south africa south africa sees government debt exceeding 100% of gdp state-civil society relations in post-apartheid south africa capitalism and freedom policy experimentation and innovation as a response to complexity in china's management of health reforms strategic niche management and sustainable innovation journeys: theory, findings, research agenda, and policy applied welfare economics: cost-benefit analysis of projects and policies socio-economic impact assessment system guidelines, department of planning monitoring and evaluation renewable energy gathers steam in south africa functions of innovation systems: a new approach for analysing technological change the socio-technical dynamics of low-carbon transitions the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. key: cord-033714-rz5unqaz authors: gupte, jaideep; mitlin, diana title: covid-19: what is not being addressed date: 2020-10-13 journal: environ urban doi: 10.1177/0956247820963961 sha: doc_id: 33714 cord_uid: rz5unqaz as the number of confirmed covid-19 cases nears 27 million, there is a rush to answer (what next) and a rush to act (to solve the immediate problems of covid-19). this paper discusses, with a specific focus on urban areas in the global south, what is missing to date from this response. that includes an identification of things that there are too much of, things that are not being done at all, and things that are unbalanced. there has been an enormous upsurge of academic research papers and opinions on covid-19. “technological” and “scientific” solutions tend to overshadow other approaches, even if people know that “social is important”. based on our analysis to date, our primary concern is that there is too little understanding about the importance of building dialogue, exploring collaboration and co-producing solutions. there is too little understanding as to why social and cultural responses are important, and how the recognition that they are important can be actioned. over 95 per cent of all covid-19 cases globally occur in urban areas. (1) the very nature of pandemics is that they are dependent on the interactions of humans with their environment and with each other. these interactions can become intensified in the built environment, making epidemic control a key consideration in city making. the indirect and long-term impacts are likely to be more pronounced and protracted, requiring more complex responses, in lower-and middle-income countries (lmics) due to their more limited ability to respond to the risks. globally, almost one billion people live and work in conditions of urban informality and precarity. hundreds of millions more living in lmic cities can just about afford homes with formal services such as piped water, electricity and access to healthcare, but these services are patchy and reliant on deteriorating infrastructure. while these challenges are location-or place-specific, it is misleading to limit the assessment of the ecology of risk, the direct and indirect impacts of the disease, or the implications for long-term responses, to city limits alone. we recognize that urban systems share a deeply symbiotic relationship with peri-urban and rural contexts, not least through their infrastructural links and dependencies, but also more directly as a result of food systems and patterns of human mobility, and it remains important to take account of these wider contexts. take the example of jaideep gupte is a fellow of the institute of development studies, where he co-leads the cities cluster. he is the principal investigator of the smart data for inclusive cities project (european union/european commission), and coinvestigator of the global challenges research fund (gcrf) accountability in urban health (arise) hub. he is currently seconded to lead the cities and sustainable infrastructure portfolio of gcrf, uk research and innovation (ukri). 3. keil et al. (2020) the first human-to-human transmission of the coronavirus in germany, which reportedly occurred in january in a car parts company in bavaria, when a worker asked a colleague to pass the salt. (2) however, as roger keil and colleagues point out, the coronavirus had travelled to this distant bavarian suburb from the periphery of wuhan, where 1.6 million cars were produced last year. (3) hence the spatial analysis of risk has to include the very local as well as the global. as two urban scholar-activists, we are motivated to write this paper because we are concerned that covid-19 will exacerbate existing inequalities and absolute deprivation and disadvantage, while fuelling a misinterpretation of the nature of societal relationships that produce and sustain agglomeration. we have observed this happening both through the movement of the epidemic on the ground in the context that we know (i.e. low-income neighbourhoods), and through the ways in which local and national governments, as well as external agencies, are responding to this situation. we take note of a misconception that covid-19 is caused by agglomeration and therefore requires "dedensification" (4) or heightened surveillance (5) in cities -it is not. it is a global health crisis, whose impacts on urban populations are exacerbated by debilitated -or outright nonexistent -health infrastructures and, as we expand upon in this paper, the unequal nature of socio-political and economic relationships that categorize the circumstances faced by the lowest-income urban residents. in this context, there are implications for the local actions global compacts aspire to in order to achieve sustainable development, as well as for our understanding of urban living itself. the impacts will be most dramatic where health systems are inadequate, unreliable, under-resourced and mismanaged. while most reported covid-19 deaths have occurred in europe and north america, there are numerous concerns about the accuracy of global estimates of both mortality and infection. the data that we do have suggest that latin america, where the number of deaths surpassed 100,000 in june and the number of infections doubled to 2.2 million in less than a month, (6) and increasingly south asia, (7) are particularly badly hit. guayaquil and rio de janeiro illustrate why we are concerned. low-income residents are unable to protect themselves. overcrowding and lack of access to basic services prevent the implementation of two key measures that populations are being urged to adopt: social distancing and increased hygiene, particularly handwashing. in terms of state interventions, curfews and lockdown make income generation difficult to impossible. informal traders have been stopped from operating, while formal shops selling food and sometimes other goods are allowed to be open. formal manufacturing businesses have closed, laying off workers, and subcontracting is not taking place. low-income households face acute difficulties with limited savings; the need to pay for food, rent and services; and limited access to social protection. given what feels to be a rapidly moving set of activities and reversals, we wish to contribute our reflections on current debates. the required speed of our response means that this contribution is not based on a methodologically robust research design carried out in multiple locations in a comparative analysis. rather, we draw on our research network and our research experience to survey the information available to us, test out emerging observations and lessons, recraft our conclusions and test them again. this means that we are reading, analysing and synthesizing reports from a network of colleagues that has been built up over 20-30 years. many of these reports are from people we are working with, or have worked with for many years as research collaborators, whose capability and integrity we trust. in other cases, we are using sources of information that we have also worked with for some time, although we may not have worked directly on the same research projects. as we have come to know them, we have found these sources to be accurate as providers of information, and their analysis and conclusions are verified by other information and by our colleagues who know that context well. a typical day over the months since early march brings at least five notifications of new reports, blogs and webinars. we have each been checking these sources regularly, scanning them to understand what is going on in towns and cities across the global south, and the responses there to the health and economic crises. these reports have adopted a variety of research methods including ethnographic reporting, analysis of medical data, community monitoring and a host of other techniques. all of these sources were published between 18 february 2020 and 12 august 2020. tables 1 and 2 summarize the set of blogs, grey literature and media sources we have consulted; a complete list is available in the online supplement. we have also checked these findings against peer-reviewed academic papers about pandemics, recent and longstanding, and through discussions with other scholars, particularly those in the medical profession. moreover, we have not been passive listeners. we have ourselves lectured or presented on these topics, written blogs and articles, and provided policy advice over the past months. indeed, our ongoing research activities have also directly or indirectly engaged with covid-19. we are deeply appreciative of the multitude of activities and accounts that have been sent to us, the emerging understandings that have been shared with us and the invitations that we have received. the conclusions here draw on these sources, as understood over the last three months, captured through conversations, blogs, reports, webinars (both presentations and discussions) and news stories. the next section outlines our key concerns with covid-19 responses in lmics and associated discussions. the subsequent section explores the failure to identify and understand what is taking place in towns and cities in the global south, and the potential consequences of this lack of understanding. as we write this in august 2020, the number of confirmed covid-19 cases globally stands at over 26 million, with 824,162 deaths thus far. (8) "by one estimate, the covid-19 literature published since january has reached more than 23,000 papers and is doubling every 20 days". (9) this constitutes one of the largest upsurges in research on any topic. technology-based responses to covid-19 seem to play a particularly dominant role. one commentator groups the digital responses to the pandemic into five categories: (10) solutions for effective and efficient contact tracing, responding to the need to track the pathogen exchange faster than traditional systems of disease reporting; testing and disaster responder capacity to improve, adapt or invest in medical devices, tests and protective gear; early warning and surveillance systems to better understand the pathogen and monitor the outbreak; quarantine and social control as important elements of the human side of a pandemic response; and technical advancements in vaccine, mitigation and treatment research. we find there is a critical gap between the technological solutions being suggested and whether they contribute to inclusive, resilient and sustainable responses from the perspective of economically and socially disadvantaged urban residents. we see that tech-based responses are often based on uncritical and unnuanced techno-utopian understandings of what are deeply unequal relationships. (11) at the same time, technoutopian narratives are an "easy sell", particularly to those who do have access to digital infrastructures and therefore stand to benefit from technological interventions, and they serve as an illusory alternative for meaningful local action. app-based track and trace "solutions" proposed in various countries are an illustration of this. compare for example, the aarogya setu mhealth app (12) promoted by the government of india, (13) and the increasing unease with its use and impact on digital freedoms. (14) these interventions highlight the need for an engagement with issues of inequality and social relations, themes of concern to the social sciences. they mistakenly assume equality of access to digital infrastructures, which in fact are ta b l e 2 22. this finding comes from discussion between medical academics at the university gendered and unequal: across low-and middle-income countries, women are 20 per cent less likely than men to own a smartphone or use mobile internet. (15) the gender gap is exacerbated in low-income areas; a study of informal settlements in nairobi, kampala, lagos, yaoundé, maputo, cairo, bogotá, new delhi, jakarta and manila revealed women are about 50 per cent less likely to be connected to the internet and a third less likely to use a smartphone to connect, compared to men in the same age group with similar levels of education and household income. (16) track and trace approaches assume that the disease is spread through contact resulting from voluntary movement alone and that people do not live in overcrowded dwellings, and can therefore be isolated once identified. this completely disregards the compulsory nature of the economic and sociocultural relationships that force people to continue living and working in precarious locations despite the risk of contracting or spreading the disease. track and trace approaches also severely misunderstand the magnitude of the involuntary movement of people often forced by authorities or landlords who, at least in the initial stages of lockdown, continued evictions unabated. (17) the reflections of alice wanini, a community health volunteer working in nairobi's mukuru village (home to 100,500 households), are captured in a blog series by the muungano alliance, a civil society group in kenya that is affiliated to the transnational network sdi. (18) this is a neighbourhood in which. . . ". . .space is a luxury-and social distancing is nearly impossible, both within the households and on the narrow streets around them. [alice] tells of an incident that recently transpired where a water boozer [bowser or water tanker] supplying free water in the community, brought hundreds of residents scrambling for access to free water. in an area notably known for its erratic water supply, the free supply of water to support regular hand washing and other household usage foresaw residents crowd at the water supply area each aiming to get their water cans full with little care to prioritize social distancing." (19) earlier research details the high densities and lack of services that residents face in this neighbourhood. (20) these challenges run deeper than in relation to specific technologies. covid-19 demands and has secured a wealth of research projects. (21) it appears that many of those with solely medical interests have little understanding of the realities of people living in informal settlements, (22) where low wages and relatively high costs of housing and essential services mean that cash-at-hand and savings are inadequate. (23) measures to control population movements and their consequences for income generation have therefore triggered an economic emergency. here, we recognize the need to look beyond "the immediate health consequences of the pandemic", particularly as these "begin to be superseded by the impact of public health containment measures" (24) -notably through the inability of those subject to these measures to buy essential goods and services. social and economic interdependencies skew health and wellbeing outcomes, but in our opinion, and as we elaborate upon in later sections of this paper, are likely to be underestimated by those without an engagement with the social sciences. of manchester and one of the authors with respect to a research project: specifically on how the sample might need to be adjusted to take account of different social categories, and how the questions need to be framed given local realities. these realities lie behind the formation of the online social science in humanitarian action platform (https://www. socialscienceinaction.org/ about), accessed 26 august 2020. see also wilkinson (2020) . furthermore, the lack of literacy and/or the deep suspicion of formal processes on the part of many low-income residents mean that preferred "modern" approaches to ethics as developed in the global north are not effective in securing the desired ethical response. northern ethics research requires informed consent and documentation to show that this has been secured. typically, this is a form signed by the interviewee. people who are illiterate are asked to listen to a reading of the form and indicate their agreement in some way. however, it is rare that allowance is made for their fear related to officialdom. if their vulnerabilities are recognized, then it may be suggested that this group is left out of the sample. however, excluding those who are illiterate and/or who are unable to take part for these reasons is likely to bias the results, as the same people may have significantly lower incomes. researchers must engage with those who are familiar with local contexts, and those who have been trained in appropriate research methodologies. we believe that societal relations are key to addressing covid-19 -and that these relations have implications for technology and science. solutions have to be locally owned for them to have any chance of success, as shown by matt nohn (25) in his analysis of responses to ebola in monrovia. this level of behavioural change cannot be imposed from above; the required modification of everyday practices has profound implications for all relations including the most intimate. in addition, strong local engagement will enable generalized solutions to be modified so that they are effective within local realities. such modifications to designs are essential to -and as important as -local ownership. the coproduction of responses is essential to secure the required modifications to designs and their effective adoption. too little attention has been given to this. this is the context in which we understand al jazeera's report from 5 june 2020 that there have been 15 killings in kenya to enforce the covid-19 related curfew. (26) in sum, there is an oversimplistic approach to the urban context by "non-urban" professionals and academics. too little attention is given to the multiplicity of ways in which the "urban" nature of settlements and livelihoods influences what is possible in terms of responses to the health and economic emergencies. there needs to be a substantively greater consideration of what it means to seek to intervene in an urban location. we put forward several points in this regard: agglomeration and the nature of societal relationships: it is critical to recognize the nature of social relations, the intensity of -and interaction between -government agencies, and the interconnections between multiple and cascading risks and structural disadvantage. this includes a recognition of the nature of relations between urban residents, the intensity and diversity of state agencies, the creativity of people through interactions and opportunities for capability development, and the dynamic nature of (some) urban contexts. (27) we take note that grassroots organizations are doing much to address local needs. isabel duque franco et al. (28) document and analyse over 200 community initiatives to address local needs related to the covid-19 pandemic across latin america. thirty-seven per cent are related to food security and 34 per cent to public health. a further example is provided by a community leader from mumbai who discusses the ways in which members of mahila milan (a collective of women's savings groups) are helping to distribute food donated by local politicians, focusing on those who do not have ration cards and therefore cannot benefit from state support. (29) another survey of 321 "slum leaders" across 79 informal settlements in two north indian cities (jaipur and bhopal) finds that community leaders in these settlements have persisted in their problem-solving roles during the pandemic and relied upon their informal authority and political networks to request urgently needed government relief. (30) the study also finds however, that community leaders "are not equally positioned to secure information, make claims, and command government responsiveness in the context of the pandemic. . . leaders that are more deeply entrenched in partisan networks also appear to be more likely to contact, and be contacted by political elites, as well as report having received assistance to pandemic-time claims". (31) this raises concerns regarding the inclusiveness and fairness of these efforts. in the philippines, the homeless people's federation did not wait for the government but immediately bought supplies for the neediest households in the neighbourhoods in which they had active organizations. while also working with state agencies providing welfare and relief. (32) these local efforts notwithstanding, in our opinion the nature of urban organizations -and the potential for resistance and collaboration they display -remains understated in present pandemic responses, requiring a recalibration of interventions towards co-producing solutions to covid-19. agglomeration and the commodification of labour: low incomes make it impossible for many living in towns and cities of the global south to secure adequate accommodation. poorly informed government strategies to reduce poverty lay too much emphasis on cash incomes and not enough on the social wage (i.e. access to affordable basic services including water, sanitation, energy, health and education). without access to these public services, households cannot afford safe and secure housing. there is insufficient information on the costs of adequate access to basic services. while community groups have sought to improve access to the services required for health, (33) without state investment this cannot be done effectively and at the scale required. as noted in the following section, there have been multiple reports that low-income households -embedded in economic and spatial informality -have not received social protection. cash transfers are seen as the key source of support (regardless of whether they are actually received). as analysed by wiego, a transnational network working with women employed in the informal economy, government measures have been partial. (34) insufficient attention has been given to the heightened vulnerability profiles due to multiple and cascading risks drawing residents further into destitution -and this may be true even for those who were just about surviving before the pandemic. in peru, for example, informal workers have been denied access to government emergency covid-19 grants because the government does not have lists of those in extreme poverty in urban areas, as it does not consider there to be extreme poverty in these areas. (35) insufficient consideration is given to urban social assistance going beyond cash transfers, "to focus on generating jobs (especially for young people and women) and to link low-income urban residents to basic services such as health care, through subsidies, vouchers, or case management". ( working in precarious conditions. these trade-offs not only underpin their risks and vulnerability to disease in the present situation, but also speak to a much deeper history of marginalization and exclusion. there is a need to draw on the longstanding experiences of these trade-offs to better understand the ongoing health and economic pressures, and to prepare for recovery. wiego also highlights the need for state support for economic recovery for informal sector workers. (37) what is telling is that, despite their comprehensive engagement with government measures, they are only able to identify three countries (burkina faso, jordan and uruguay) that exemplify the measures that might be taken. there is a real fear that lockdown measures will exacerbate inequality. for example, in peru, supermarkets have been allowed to remain open and sell a range of essential and non-essential goods, but the only informal workers allowed to remain trading are those selling essential goods. (38) a key constraint to effective response is identifying and utilizing the appropriate and adequate space for pre-emptive measures (e.g. construction of appropriate wash sites with drainage, strategies to isolate patients who have tested positive), responses (e.g. routes to and from hospitals and parking spots for ambulances; transfer of unwell or indisposed patients from residences), distribution of aid (food, water or other essential distribution), and recovery interventions (e.g. disinfection or sanitization of spaces; opening-up of markets; staggered lifting of other lockdown policies). the lack of adequate consideration of informal vendors who are dependent on street spaces is just one example; wiego reports on the devastating consequences of this lack of understanding for the livelihoods of these low-paid street workers. (39) early experiences from news websites show that the demand for space can change rapidly: the sudden crowds of migrants gathering at the anand vihar bus station in delhi (on 28 march), (40) long queues developing suddenly as food aid was distributed in dharavi, mumbai (on 6 april), (41) and similarly in alexandra township, johannesburg (on 28 april). (42) moreover, space considerations vary by location as well as by gender, age and other socioeconomic markers that influence risks and vulnerability profiles. the visualization of informal settlements in many covid-19 discussions, however, is of homogenous highdensity inner-city shacks, with insufficient attention given to lowerdensity settlements (more likely to have urban agriculture) that may also face health and economic emergencies. furthermore, decisions over the use of space are being carried out in real time and usually from a distance in compliance with lockdown. given the short supply of open space in dense urban areas, intervention sites are being used for multiple actions simultaneously. however, not enough resources are being devoted to rationalize clearance times, to formulate patterns for safe distancing, and to manage perimeters. the onset of rains will change drainage and access patterns, while soil conditions, especially in informal settlements, will increase the risk of other water-related infectious disease, such as malaria, dengue and cholera. (43) proximity to other vulnerable areas or hotspots is also an important consideration, though it has been understated in determining the efficacy of response spaces and strategies, including those involving the eventual easing of lockdown policies. 45. muungano wa wanavijiji (2020a). (2020). 47. iied (2020). (2020). 50. visagie and turok (2020). the potential within urban contexts: the rapid response to the need for masks -in multiple countries -is one example of the potential processes of production, consumption and creativity that exist. the guardian's report on mask making in multiple locations by diverse groups illustrates this, (44) although it may not give sufficient attention to individual entrepreneurship. but this requires an understanding of this context, a sensitivity to the way in which governments intervene, and attention to the unintended and unanticipated consequences of such interventions. in kenya, the muungano alliance, in recognition of the impossibility of informal settlement residents isolating at home, has produced maps of informal settlements indicating places that are appropriate for isolation centres. (45) in lima, street vendors faced a strict curfew introduced on 16 march, as well as state actions against informal workers and a lack of access to government emergency grants. they responded by negotiating with local government for the return of confiscated goods, launching a media campaign to demonstrate their willingness to comply with hygiene measures, and articulating their potential contribution to a safe and secure food supply within a more equitable city. (46) the wealth of grassroots responses to covid-19 is elaborated by the international institute for environment and development (iied), which has drawn on experiences from across its partners in the global south, who provide evidence of local groups stepping in to reduce health risks and provide emergency access to food and hygiene. (47) as a consequence of the failure to adequately contextualize, responses are deficient in three ways. first, there is a tendency to focus concerns on issues of density without adequate attention to lack of services and overcrowding. both the press and the experts have recognized that urban areas are particularly at risk as the disease is spread by close contact, to which social distancing is the solution. the urbanization focus of covid-19 is exemplified by the financial times (in its free-to-read coronavirus updates (48) ), which has been reporting "excess deaths" in 15 urban centres, including five from the global south. the crude aggregation of population density and impact pays insufficient attention to the circumstances under which risk and vulnerability occur. as elaborated by harvard university professor mary bassett in the new york times (49) for the us, the context is everything. this is a context in which poverty leads to residential overcrowding and lack of access to adequate levels of the basic services required for hygiene. density itself is not the problem; it is the overcrowding that is a result of poverty and the lack of infrastructure and services from state neglect. the climate emergency adds to the need for clarity on this point. there has been a recognition that a successful transition to a low-carbon economy is facilitated by more compact cities, and that densification is a solution rather than a problem. however, as noted by justin visagie and ivan turok, (50) densification requires careful planning, especially given the implications of the irregular plots that are frequently associated with informally developed urban neighbourhoods. infrastructure networks and housing need to be planned both to be affordable and to be consistent with overall development of the town or city. (51) in the current 52. ntseku (2020). (2020). 54. moser and peek (2020 63. connolly (2020) . also, see for example klaus (2020). context, de-densification is viewed with trepidation by those who fear that covid-19 will be associated with evictions legitimated through this rationale. see, for example, the response of south african civil society when their government highlighted the potential of "de-densification" as a response to the financial times reports that guayas province in ecuador has had 12,200 excess deaths, which is 248 per cent of what would have been anticipated. (53) the vulnerabilities of the population in the provincial capital, guayaquil, are elaborated by university of manchester emeritus professor caroline moser and architect olga peek in an iied blog post, and relate both to globalization (travel to and from spain, italy and the us in particular) and poverty that puts healthcare out of reach. (54) in response to overcrowding at home, young people have been on the streets, potentially adding to risks. in nairobi, the scale of deprivation in informal settlements is evident. in mukuru, for example, only 1 per cent of residents have access to a private water tap and private sanitation. the lack of provision means that a public tap serves an average of 234 households, and there is one public latrine for every 547 households. (55) this study also documented just how expensive it is to be "poor" and the premium paid to access housing and informal services -not a new story in any respect. more recent research has pointed to the reality that this premium may be related not just to the higher cost of informal services but also to the adverse circumstances under which low-income households access formal services. (56) rigorous community monitoring has shown that despite these adverse conditions, there have been relatively few cases of covid-19 in nairobi, kisumu and nakuru. (57) the impacts of the responses to covid-19, as with historical responses to public health crises such as ebola (in 2014), (58) h1n1 (in 2009) or sars (in 2003) (59) -or even further back historically, the cholera pandemics in cities (for example in london and new york in the mid-19th century) (60) -are filtering through to built environment design, planning and building processes. in the initial weeks of the covid-19 pandemic, much accusatory attention was directed towards highdensity urban areas and mobilities within such areas. (61) subsequently, however, "the contemporary processes of extended urbanisation, which include suburbanisation, post-suburbanisation and peri-urbanisation", have also been linked with "increased vulnerability to infectious disease spread". (62) given this, creighton connolly writes, "governance is a more important factor than density in determining the severity of outbreaks". (63) but there is no consensus as yet on the practical steps required to rethink the material production of the city, nor on how managing density (and overcrowding) and installing new ways of transportation, relate to the vulnerabilities of the lowestincome urban residents living and working in precarious sites. how do we prevent a response driven by environmental health imperatives that is fundamentally hostile to informal dwellers, condemning them because of their poverty? the required response has to prioritize essential investment in basic services and the provision of affordable housing so as to assist lowincome households to secure access to the services and housing that they need for good health and wellbeing. "affordable" in this context cannot be synonymous with "low-cost" unless low-cost is indeed affordable to the lowest-income households. second, the actions and messaging are too frequently top-down, with little attention being given to questions of local ownership. in kenya, the muungano alliance have established a monitoring system (64) in settlements where their membership is strong, to ensure that the government and communities have accurate information. on 20 june 2020, they collected data from 193 community leaders (youth, community, health workers and village elders) from 42 villages in three cities (nairobi, nakuru and kisumu). their data highlight that the areas with the most restrictions are not those with the highest reported rates of infection. specifically, 40 per cent of informants reported cases of covid-19 in mathare, but informants for this area were less likely than those in other areas to report the presence of isolation centres, social distancing and restrictions on movement. pressure from the communities has meant that the alliance is sending the information back to the key informants with summaries of the situation along with updates on both the situation and what is being provided nationwide. going forward, the ability of grassroots organizations to engage with digital information is an opportunity to build new relations between responsible state agencies and organized community groups. the significance of co-productive responses, and the need to ensure strong local ownership, means that this should be explored. however, attention also has to be given to the digital divides, women's relative lack of access to mobile phones, and the risk that some of the older vulnerable groups in the population will not be equally able to represent their needs and interests. third, while recognition is being given to the economic emergency, actions do not acknowledge the depth of the crisis that is facing the urban poor. it is evident that considerable numbers of informal workers and enterprise owners are either unable to sell anything at all because they are forcibly closed, or are selling considerably less than usual due to reduced hours and/or consumers having less to spend. (65) in nairobi, for example, a curfew from 19:00 to 5:00 has considerably reduced the numbers of clients and customers, and a complete lockdown in areas such as eastleigh has meant that domestic workers have lost their incomes -with obvious knock-on effects within, in this case, the adjacent informal area of mathare. (66) the impacts are similar in middleincome countries such as south africa. (67) however, while governments promise income support and emergency cash transfers, many households living in informal settlements have not benefitted from this provision. in nigeria, justice and empowerment initiatives have worked with the nigeria slum/informal settlement federation and the physically challenged empowerment initiative to track the neglect of those living in informal settlements and their inability to either earn a living during lockdown or access government funds. a survey of 383 leaders in 114 communities found that "78 per cent reported people are unable to meet basic needs. meanwhile, the vast majority of urban poor communities (85%) reported government-provided "palliatives" intended for the vulnerable had not reached them." (68) similar findings are evident in brazil where, for example, low-income favela residents in são paulo are not receiving the monthly emergency basic income payment (worth us$ 115), despite the shutdown by the city authorities of informal trading on 15 april 2020. (69) longer-term impacts for low-income residents are likely to be severe, particularly for those engaged in informal livelihoods. the economic 70. rutherford (2020 77. goñi (2020) . 78. see https://www. justempower.org (accessed 4 september 2020) and @ justempower on twitter for consequences of lockdown are already evident in testimonies from those living and working in the informal sector. an early analysis of dhaka, bangladesh is provided by stuart rutherford, a longstanding expert in financial services for low-income households. (70) the lockdown here began on 26 march 2020 and lasted until 30 may, although it was progressively less actively respected and enforced. data from 60 individuals who keep financial diaries (a process ongoing since august 2017) showed a significant collapse in total flows of money. in april 2020, the first full month of the covid-19 lockdown, total money exchanged (inflows and outflows) aggregated across all 60 diarists fell to 1.62 million bangladeshi taka (us$ 19, 000) . for comparison, the average equivalent amount of money (from august 2017, when the diaries began) was 5.49 million taka (about us$ 65,000). average household expenditure of 500 taka a month was financed by income (160 taka), loans (150 taka) and savings withdrawals (100 taka), with the balance being met by gifts and a small payment of 20 taka for the completion of the diary. however, these average figures are deceptive as one-third of all expenditure was made by one family that included two government employees. the remaining families spent four times more than they received in income during april, with 72 per cent of non-construction-related expenditure (71) being spent on food. dramatic falls in income for low-income families in brazil are also reported by rioonwatch, which regularly updates readers on the challenges faced by favela residents. in this case, rioonwatch draws on a national survey to report, "four out of five favela families (80%) across the country are living on less than half the income they received prior to the pandemic, the study found. of those 80%, more than a third reported losing all of their family income, while only 9% of the total experienced no change in income or only a minor drop." (72) one result of this loss of income, combined with a lack of social protection, is that low-income residents are forced to find work despite the risks to themselves and their communities. john taylor, chief technical advisor for the food and agriculture organization (fao) in bangladesh, reports that some low-income workers in dhaka have been working as "rogue rickshaw drivers". (73) he notes that households and communities have turned to urban agriculture as a way to secure access to food. furthermore, national strategies have required a homogenized (and often brutal) enforcement of order under lockdown. this has led to a heightened incidence of violence, fear and anxiety, experienced particularly by those who were already targets of violent evictions or enforcement of cityplanning and state practices, and who suffered sociocultural marginalization and stigmatization as a result prior to the pandemic. as noted by the un high commissioner for human rights, there has been a troubling increase in cases of police brutality and rights violations under the cover of exceptional or emergency measures. (74) an inability to rely on informal arrangements with non-state actors, including illegal and extra-legal groups, has meant the police are hindered in their ability to provide safety and security during the covid-19 pandemic. on the one hand, the police are failing to protect communities from criminal gangs, where they pose an increased risk. (75) at the same time, they have hampered aid efforts when these have come from non-state or criminal groups. (76) city police are tasked with placing physical constraints to stop people from reaching their places of work, (77) while the closure of markets, demolition of informal shops (78) and prohibition of street vending have prevented people from earning a living. (79) there is also a notable increase in domestic violence, violence against children, gender-based updates on this in lagos, such as the demolition of shops in ijora badia on 30 may 2020. 79. see, for example, this report from uganda: hayden (2020 violence (gbv) and antisocial behaviour. (80) we note that in these examples, police and other security services were described as overburdened. trust was noted to be low between communities and enforcement officials, who have been exposed to high levels of violence, service delivery protests and criminal activities that have existed since before covid-19, while at the same time being exposed to covid-19-related risks themselves. (81) maintaining law and order has proven doubly complex given that legal and procedural practices have also needed to adapt extensively and repeatedly to situations of social distancing and lockdown, as exemplified in south africa. (82) in most lmic contexts, police personnel, particularly those holding lower ranks, have limited opportunities to access mental health and other wellbeing support. it is under these difficult circumstances that city police forces have become central to national covid-19 response strategies. they are required to enforce regulations that are often unpopular in public, private and commercial spaces, in lived environments as diverse as informal settlements and gated communities, including their own poorly serviced living quarters, as well as online in response to new and increased digital activities. as authors of this paper, we remain deeply sceptical that the pandemic, and the policy or programmatic interventions in response to it, will trigger the sort of system-wide rethink required to uplift urban futures, particularly for people who live and work in conditions of urban informality and precarity. on the contrary, the most likely outcome is an ossification of pre-existing inequalities, persecutions and structural failures. yet again, we see "the local" placed as the frontline of crisis response. and yet again, the frameworks that guide our collective thinking seem incapable of adequately devolving political authority with adequate resources to this level. without a meaningful and sustained political shift towards the local, crisis response remains debilitated. we despair as we note parallels with the plague epidemic in bombay all the way back in 1896, when colonial policies aimed at supressing the disease showed explicit class bias against the urban poor. (83) those experiences could have triggered a new way of city planning, involving a rethinking of urban service infrastructures, and a re-strategizing of crisis responses, to engage the politics and negotiations of agglomeration. more than a century later, however, mumbai finds itself in the same position. what then is the potential to see the shock of covid-19 as an opportunity? there is -it seems -a new attention to towns and cities in the context of the covid-19 pandemic. for example, we see this in nairobi, where the national government has committed to informal settlement upgrading. in august 2017, the government declared a special planning area with two years to prepare and deliver an integrated plan. that period has now been extended for a further two years. what is exciting in mukuru is that infrastructure improvements in water and sanitation, roads, drainage and electrification have now been finalized, and implementation by nairobi metropolitan services began in may 2020. (84) and the kenyan president announced upgrading plans for both korogocho and mathare on 18 march 2020. meanwhile nairobi metropolitan services announced the suspension of all existing development plans in four further informal settlements in kibera on 26 may 2020, in order to enable a more participatory integrated approach. (85) on 14 february, the city hall (nairobi county) and the ministry of transport and infrastructure announced their intent to scale up the upgrading of nairobi's informal settlements with a special planning area for the neighbourhoods around nairobi central station. covid-19, then, has been associated with an acceleration of plan implementation in mukuru and significant new upgrading initiatives across nairobi. once new external agencies and their interventions are better informed about the urban context and more successfully embedded within urban institutions (both formal and informal), the situation might be recognized as an opportunity. this requires addressing the unequal socioeconomic and political relationships that have come to characterize our cities with a set of reforms that have broad ramifications and that can lead to a realization of the local objectives of key global compacts such as the sustainable development goals. we think that closer attention to such reforms will be helpful as long as it recognizes the insights of the social sciences and the knowledge created and owned by local communities. there is an urgent need to invest in the infrastructure required to make low-income housing safer, especially dwellings in informal settlements. and there is a need to support better-quality housing, through access to more affordable improvements. at the same time, for an effective response to the health emergency, there is a need for residents, community health workers and/or volunteers, and the health authorities to work together. it is critical that those who are knowledgeable about effective urban development approaches are asked to share their expertise. successful interventions are those that recognize the need for targeting financial support, and devolving authority to respond to the municipal (even sub-municipal) level, while at the same time proceeding based on knowledge about economic and spatial informality and building on the efforts, knowledge and capabilities of a range of local agencies, particularly the grassroots organizations that do so much to address local needs. we wish to thank the editorial team at e&u, the two blind peer reviewers for their constructive and timely feedback, and jenifa zahan for research support. https://orcid.org/0000-0003-0076-5954 supplemental material for this article is available online. alfers, l, r moussié and j harvey (2020), "the covid-19 crisis: income support to informal workers is necessary and possible", development matters, 22 april, oecd, accessed 5 july 2020 at https://oecddevelopment-matters.org/2020/04/22/the-covid-19-crisis-income-support-to-informal-workers-isnecessary-and-possible. ali, s harris and r keil (2008) , networked disease: emerging infections in the global city, blackwell, malden. kenyan police 'killed 15' since start of coronavirus curfew ground report: chaos at anand vihar as buses prepare to take migrant workers home how does covid-19 affect urban slums? 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covid-19: exceptional measures should not be cover for human rights abuses and violations -bachelet township lockdown: how south africa's poor bear the cost of coronavirus covid-19 tech will expand surveillance state in china epidemiological alert: dengue in the context of covid-19 -28 impact of covid19 on lagos informal settlements & vulnerable urban poor populations: report on findings 1 physically challenged empowerment initiative, nigerian slum/ informal settlement federation and justice & empowerment initiatives -nigeria viral surveillance: governing social isolation in são paulo, brazil, during the covid-19 pandemic aerial footage shows miles-long queue for food aid in south africa density is new york city's big 'enemy' in the coronavirus fight covid-19 and the hrishipara diarists: was april the cruellest month? germany says it has identified the 1st coronavirus transmission in the country india witnesses upsurge in covid deaths regulations and guidelines -coronavirus covid-19 realising the multiple benefits of climate resilience and inclusive development in informal settlements fighting a cholera outbreak in the middle of a covid-19 pandemic: moroto's story of resilience how dhaka's urban poor are dealing with covid-19 un-habitat covid-19 response plan coronavirus in the daily life of favelas, part 8: in são paulo, guaianases confronts advancing pandemic getting urban density to work in informal settlements in africa impact of covid-19 on businesses within informal settlements government responses to covid-19 crisis, women in informal employment: globalizing and organizing technical considerations in analysing & advocating for cash benefit schemes for informal workers during covid-19, women in informal employment: globalizing and organizing local response in health emergencies: key considerations for addressing the covid-19 pandemic in informal urban settlements briefing: ebolamyths, realities, and structural violence global report: women's rights online translating access into empowerment key: cord-017741-5apdhf2e authors: hussels, stephanie; sherman, claire; ward, damian; zurbruegg, ralf title: south and east asian insurance market growth and development date: 2007 journal: handbook of international insurance doi: 10.1007/978-0-387-34163-7_17 sha: doc_id: 17741 cord_uid: 5apdhf2e recent economic research, notably by king and levine (1993a, 1993b), levine and zervos (1998), levine (1999), levine, et al. (2000), and beck, et al. (2000), indicates that financial services and its various components, including insurance and banking, have substantial potential for spreading positive externalities throughout the commercial sector of an economy. such benefits can stem from improved access to capital by firms, better allocation of capital to investment projects, greater risk management, and enhanced portfolio diversification and liquidity for individual investors. while existing economic research shows the development of financial services is generally important for economic growth, a number of previous studies by outreville (1990) and ward and zurbruegg (2000) provide empirical evidence that insurance market development in its own right can promote economic development. the importance of the insurance industry to the wider economy is seen to stem from the relative size of the insurance industry to gdp in many developed economies, the transfer of risks, and the scale of insurance companies’ financial intermediary functions. recent economic research, notably by king and levine (1993a, 1993b) , levine and zervos (1998) , levine (1999) , levine, et al. (2000) , , indicates that financial services and its various components, including insurance and banking, have substantial potential for spreading positive externalities throughout the commercial sector of an economy. such benefits can stem from improved access to capital by firms, better allocation of capital to investment projects, greater risk management, and enhanced portfolio diversification and liquidity for individual investors. while existing economic research shows the development of financial services is generally important for economic growth, a number of previous studies by outreville (1990) and ward and zurbruegg (2000) provide empirical evidence that insurance market development in its own right can promote economic development. the importance of the insurance industry to the wider economy is seen to stem from the relative size of the insurance industry to gdp in many developed economies, the ^' the authors wish to thank the editors and an anonymous referee for very instructive and helpful comments in developing this chapter. transfer of risks, and the scale of insurance companies' financial intermediary functions. while the link between financial services development and economic growth is well-established, the focus of this chapter is to highlight research that has sought to identify the factors that will promote the demand and supply of the insurance sector. in particular, recent empirical research on insurance markets by beck and webb (2003) , browne, et al. (2000) , esho, et al. (2004) , and ward and zurbruegg (2002) have shown that the level of insurance demand within an economy can be influenced by a number of particular variables, including economic, legal, political, and social factors. despite these results, there has been little information presented on which specific factors should be fostered to aid financial development via the insurance market. to address this problem, the objective of this chapter is to present a synopsis of the existing literature and provide some insight on how the development of the south and east asian insurance market might be achieved. insurance companies who intend to expand their business activities abroad can also utilize this knowledge to select markets in south and east asia. in focusing upon south and east asia, the chapter is organized as follows: first, the relative size, economic importance, and likely developments of the insurance markets within the region are presented. second, empirical evidence relating to how demand and supply within the insurance sector can be developed is discussed. finally, this empirical evidence is then fiirther examined to consider the effects of economic stimulation in the insurance market on insurers operating in south and east asia. before delving into the specific demand and supply features of the regional insurance market in south and east asia, a preliminary statistical review of the countries considered within this chapter is listed in table 17 .1, including 2003 data on population, gross domestic product (gdp), inflation rates, and net written insurance premiums. net written life and non-life insurance premiums for 1998-2003 are included in table 17 .2. this helps to establish a comparative basis to examine insurance market forces within the region, starting below with an analysis of demand. in many of the emerging markets of asia, data by underwriting class is unfortunately difficult to obtain. therefore, in table 17 .3 we only provide a breakdown of non-life underwriting classes for the developed economies of hong kong, japan, and singapore. source: various national annual statistical reports and swiss re (2004a) , pp. 37, 39. note: gdp is gross domestic product. with the recent growth of the south and east asian insurance market, it is no wonder that it is attracting much attention from the global insurance market. life insurance premiums for south and east asia reached a phenomenal growth rate of 18.3 percent in 2002 and non-life insurance premiums grew by 13.8 percent in the same period (swiss re 2003b). as figure 17 .1 indicates, patterns of growth within the region's insurance industry suggest that changes in premiums are correlated with gdp growth, and with gdp predicted to grow at a real rate of 5.7 percent per annum between 2003 and 2006, this growth is likely to continue (swiss re 2003b) . this link between gdp and demand for insurance can be explained through the s-curve relationship (enz 2000) , which indicates that as gdp grows, people begin to have sufficient income and assets to warrant insurance protection. this leads to a steep increase in insurance demand greater than the growth in gdp. however, eventually, as more and more people reach a level where they have already attained insurance, growth in premiums stabilizes. this particular level tends to be different depending on the social security system in place within the particular country. re (1999), p. 25, 27, 29; swiss re (2000), pp. 29, 31, 33; swiss re (2001a), pp. 33, 35, 37; swiss re (2002a), pp. 31, 33, 35; swiss re (2003b), p. 33, 35, 37; swiss re (2004a) , pp. 37, 39, 41 for insurance premiums. note: data for 1999 excludes sri lanka and vietnam. table 17 .4 provides evidence of the increase in premiums in most of the countries in south and east asia. in particular, china has seen outstanding growth in premiums for both life and non-life insurance, at 62.2 percent and 20.1 percent in 2002, respectively (swiss re 2003b). this is not surprising when considering the changing socio-economic structure of the chinese population. a rising middle class with a greater income to protect has opened a new market for insurers. assisted by a decline in restrictive regulations, insurers have been able to offer more insurance products to this developing middle class resulting in a higher growth rate in premiums. the threshold where gdp growth will begin to outpace premium growth has yet to be reached, and hopeful insurers in this market will continue to capitalize on this opportunity until it is attained. note: * not adjusted for inflation. in general, south and east asian countries have relatively high savings rates. the financial volatility experienced within the region's previous decade has meant that people are looking for safer options to invest their savings, and insurance has recently been seen as one way to reduce risk. by capturing a wide customer base, insurance companies have been able to diversify this risk on behalf of the investors within the region. a culture of self-reliance within many of these countries has also fueled the demand for insurance. as faith in the ability of some governments to provide for people in later life fades, people are procuring insurance policies to ensure their well-being. also, as with much of the world, an ageing population in south and east asia is driving demand for pension and investment-linked insurance products, either through direct personal investment or through governments searching for ways to fund their pension schemes. the 1997-98 financial crisis in the region has had numerous effects on the insurance industry, one of which is the increased emphasis on risk awareness and risk minimization. initially, the real estate market experienced a downturn that significantly changed the security holdings of banks. additionally, bad corporate debt insfigated the collapse of many banks within the region (roubini 2004) . as a result, the currencies within asia started to plummet and central banks unsuccessfully tried to support their weakened position. as international funds were being funneled out of the region, and assets were declining in value, companies, governments, and the public within the region became more aware of the risks of investing and relying on established financial bodies to provide good credit assessments. for the insurance industry, this has fueled an increase in demand as a currently limited, but growing public awareness of insurance develops. another factor that has enhanced awareness was the severe acute respiratory syndrome (sars) epidemic, which first appeared in southern china in november 2002 and spread to canada, china, taiwan (china), germany, hong kong, singapore, slovenia, thailand, vietnam, and the united kingdom by march 2003 (world health organization 2003) . in particular, sars has increased the necessity of health-related insurance, and although initially having a marginally negative impact on demand where travel is a major component, it should stimulate further demand for insurance. furthermore, due to other events such as the indonesian riots in 1998, the 1999 earthquake in taiwan, and the tsunami that struck several south and east asian countries in late 2004, a need to insure against the risks of both natural and man-made disasters has become apparent within the region. there are differences in the demand for both commercial and personal non-life insurance that are often dependent on the country's stage of development. more rapidly developing countries such as china, india, and indonesia found a greater proportion of their demand came from commercial insurance in 2001 when compared to their counterparts (swiss re 2003a). this is partly due to the lack of awareness for personal insurance and the low income of members of the general population. however, as stated previously, this is changing. additionally, the rise in total premiums may be due to a relative increase in the price of commercial premiums compared to personal insurance. in summary, the growth of gdp, changes in socio-economic structures within the region, the increased awareness of the need for insurance, and the need for risk minimization highlighted by recent damaging events have lead to an increased demand for both life and non-life insurance within the south and east asian region. nevertheless, coupled with this ongoing increase in demand, is an unlocking of the supply of insurance for this region, which is explored in following section. both singapore and hong kong have well-established insurance markets and, due to the deregulation of financial markets, insurance markets in other countries within this region have also begun to grow over the past five to ten years. changes to the structure of companies and the regulatory environment have been pivotal in opening new avenues for the supply of insurance within the region. the structure of insurance companies can be defined in several ways, namely, whether they are domestic or foreign, government-owned or private, listed or nonlisted, or by their size. data on the market share held by government and foreign owned insurance companies are listed in table 17 .5. also, broadly speaking, within south and east asia's non-life insurance market in 2002, 39 percent of companies were foreign (including joint ventures and branches) versus 61 percent domestic companies (swiss re 2003a). interestingly, this 39 percent of companies represents only 10 percent of the dollar share of net written premiums within the region. these divisions vary widely depending on the country of focus. for example, in singapore 52 percent of the premiums are held with foreign companies, whereas, only 0.6 percent are held by foreign companies in south korea (swiss re 2003a). the opening of insurance markets to foreign companies has allowed investment of much needed capital into the region, where the effects of the asian financial crisis of 1997 and sluggish world investment market continue to linger. note: market share is calculated using the total premium volume of those firms with >50% ownership. > (>) highlight the % held by firms with exactly 50%) foreign ownership or equal ownership (greater than 50% ownership) for some countries. * ownership data is from 2002. ** ownership data is from 2001. n/a is not applicable. between 1997 and 2001, the performance of foreign companies was more impressive than domestic companies, with growth in premiums for foreign firms amounting to 5.3 percent, whilst domestic companies experienced a slight decline (swiss re 2003a). despite this, domestic companies have experienced greater profit margins, albeit, they have not had to incur the start up costs that foreign insurers have. foreign companies have also shown a better ability to assess risk within the region with lower loss ratios in most countries. however, this is only within the short-term as foreign firm admittance is relatively recent and long-term losses may not yet be apparent. in general, there are no discemable differences between the types of businesses that foreign and domestic insurers underwrite, with the exception of motor insurance, which is more prevalent in the domestic realm. within environments characterized by deregulation, consolidation, and a decline in government ownership, the withdrawal of underwriting restrictions and premium controls have provided an increasing opportunity for insurance companies to become progressively more commercially driven and strategically focused. large insurance companies have generally taken the initiative, now representing 8 percent of the insurance companies in the region, but holding 70 percent of the dollar share of premiums.^*^ as with many markets, the large consolidated firms have been able to utilize their economies of scale and breadth of expertise to become more competitive. this push for consolidation has meant that a considerable number of smaller companies have become prime merger and acquisition targets for the large insurance companies. large companies may also be able to diversify to a greater extent when compared to the smaller companies. however, they tend to follow regional market trends, which would not make them as resilient as global companies when considering shocks such as the asian economic crisis. an indication of the degree of market concentration in the non-life sector is provided in table 17 .6. ^ large companies refer to the top 1-5 firms within the country. place within government-owned insurance companies. however, now that the markets are opening to private companies, it is hkely that these matters will receive lesser consideration. interestingly, performance of government-owned insurers is surprisingly consistent with their private counterparts (swiss re 2003b). nonetheless, this may be attributed to their greater ability to secure government business (swiss re 2003a) and use of established distribution networks and databases. it is also worth pointing out that in islamic nations there is a general preference for mutual insurance, which is a form of risk sharing. this would be in contrast to private, profit-seeking insurance companies that profiteer fi-om speculation on life expectancies through the issue of price-related premiums, which does not conform well to sharia islamic law. the world trade organization (wto) has made a significant impact in the south and east asian region by encouraging insurance market liberalization. in particular, market deregulation is breaking down barriers for foreign insurers and creating a more market-based system in countries such as china, india, taiwan, malaysia, and thailand. in china, amendments to the 1995 insurance law, stipulate a market-based insurance system where companies have more control over their policies and premium rates (aliens arthur robinson 2003). the introduction of new regulation on the administration of foreign-invested insurance companies (china insurance regulatory commission 2004) also provides more detail for foreign companies who wish to enter the market. although restrictions still remain, there have been a number of foreign licenses granted and this step is seen as an indication of further liberalization to come. another country that has undergone substantial deregulation is thailand. it has gone from a market where a limited amount of foreign investment has been allowed to a market that encourages foreign capital and involvement. there is considerable foreign involvement in the thai insurance market with much of the foreign investment in complex share agreements and joint venture structures. the reason for this complexity is that foreign insurance companies are limited to a 25 percent holding in any thai insurance company; and there are still restrictions on direct foreign investment, where companies with sole licenses can only operate from one location unless they are in a joint venture with a thai insurance company (aliens 2003). also, until 2004, motor vehicle insurance was not compulsory in thailand. the introduction of compulsory motor insurance will obviously increase the market and, if further commitments to wto agreements are met, this should allow a greater opening of this large sector of the thai insurance industry to foreign investment. de-tariffication of the non-life sector is particularly relevant in china, taiwan, and india. tariffs are placed on most lines of insurance within india, with fire (22 percent) and motor insurance (38 percent) being the most prevalent insurance provided (the tariff advisory committee 2004), currently, information regarding claims is not complete and this means that the tariffs set by the tariff advisory committee are based on assumptions rather than calculated risk esfimates. reforms are in place to change the tariff-based system to a risk-based premium setting, which will assist in a better match of assets coming in to the risk being taken. in general, both the hfe and non-hfe insurance markets in south and east asia are becoming more liberahzed, although some countries are far more regulated than others. given the above discussion of the overall structure and developments in the insurance markets in south and east asia, there is a particular trend in the regional market that deserves particular attention, the recent rise of bancassurance. career agents are agents that are usually licensed to write insurance exclusively for one company and are employed as the most common form of distribution for insurance in south and east asia for both life and non-life insurance (see tables 17.7 and 17.8, respectively) (swiss re 2002b). although their prevalence as the primary means of distribution was a result of their ability to capture a dispersed customer base with a physical presence, there are other burgeoning alternative avenues for distribution such as direct marketing, insurance brokers, financial planners, and the topic in question, bancassurance, which is when a bank distributes insurance products. although only a small percentage of both the life and non-life insurance markets, bancassurance is now a fast-growing distribution channel in south and east asian markets. the bancassurance market may seem to contribute to only a small percentage of the insurance market as a whole. however, as figure 17 .2 indicates, it varies greatly among individual country markets. for example, the life bancassurance market is as high as 26 percent in singapore and the non-life bancassurance market as high as 16.7 percent in hong kong (swiss re 2002b) . life insurance is the most common type of insurance sold through banks, which can be attributed to its similarity with other financial products sold by banks, such as mutual funds and time deposits. the main products offered in the life bancassurance market are whole-life, term-life, health/disability, retirement/pension insurance, endowments, annuifies, and policies linked to loan agreements. the benefit of tying the bank's existing financial products to insurance also influences the types of insurance products offered. the majority of bancassurance products are linked in some manner to deposits, mortgages, or other investment products. in some cases, entirely new insurance products have been created, such as depositor's insurance, which provides a payout in the case of an event (i.e. death) that is a multiple of the depositor's cash balance and over-draft insurance, which provides payment of an existing overdraft in case of a sfipulated event (i.e. death) (munich re group 2001). however, the similarity of some of these products to existing bank products should cause some concern, as there is a risk that substitution may take place. although a smaller secfion of the bancassurance market, non-life insurance offered by banks also includes a wide variety of products. this includes fire insurance, home insurance, and in some cases travel and accident insurance. once again these products are linked to the banks' existing products. for example, home insurance is typically linked with mortgage loans. the motor insurance market is one form of non-life insurance that has not been developed heavily by the south and east asian bancassurance merchants, as it is less related to the banks' existing products. varying degrees of regulation in different countries also dictate the use of this form of insurance distribution. countries such as singapore and hong kong have been using bancassurance for some time and have little or no restrictions as opposed to countries, such as south korea, where bancassurance is gradually being introduced through the staged relaxation of rules (asia insurance review 2005). where restrictions do apply, they are quite varied between countries. for example, in thailand, the restrictions are focused on particular products and licenses. for instance, a bank cannot issue non-life insurance products unless it is under a brokerage license and until recently, an insurance company was not permitted to pay commissions to banks (scor 2003) . alternatively, in china, restrictions focus on the parties of the arrangements, where it is often stipulated that insurers have to deal with each bank branch individually. in south korea, the introduction of bancassurance has been gradual and restrictions have focused on the types of insurance products permitted to be sold by banking institutions (asia insurance review 2005). overall, restrictions governing affiliations between banks and insurance companies as well as restrictions on the distribution of insurance products by non-insurers have been relaxed after the introduction of market liberalization, thus contributing to the rise of bancassurance. despite these current barriers, there has been a push for financial deregulation throughout south and east asia. as a result of this deregulation, boundaries between providers of financial products are blurring and countries that currently disallow bancassurance, such as the philippines, are expected to accommodate this distribution channel through banking subsidiaries within the philippines or through banks that are affiliated with insurance companies. south korea is also hoping to introduce bancassurance; however those with concerns about the polarization of a market that is already dominated by large banks and insurers may inhibit this. some restrictions shape the operations of the bancassurance markets in south and east asia. in particular, restrictions on foreign insurer entry have meant that the majority of bancassurance agreements are between domestic banks and foreign insurers. this form of alliance allows the foreign insurer to tap into the pertinent market without having to form a partnership with direct competitors and to gain access to the market by using existing networks. as a consequence, the level with which these partners are collaborating is mainly through distribution agreements (69 percent) with the remaining operations based on the more integrated joint ventures, subsidiaries, holding companies, and financial conglomerates (swiss re 2002b). these foreign insurers, which are involved in approximately 77 percent of bancassurance operations in south and east asia (swiss re 2002b), also have more experience with this type of distribution elsewhere in the world. the rise of bancassurance in south and east asia is also due to synergies between insurance products and banks' particular channel attributes. for example, this would include a bank's staff already being knowledgeable about such products, an established customer base, and customer information being used to target key segments with great accuracy. along with the increase of experienced foreign insurers in the market, synergies have fueled a major push for bancassurance within the region. the banks' incentive to decrease costs and recoup diminishing interest margins has been heightened due to the asian financial crisis. it has been recognized that the efficiency of using exisfing bank channels and various other distribution channels is greater than using the current career agents system (limra international 2000) . with this acknowledged, bancassurance has been difficult for governments, banks, and insurers to ignore. introducing these new higher-yield products also helps to delay the outflow of a bank's funds, which has been significant recently due to low rates on deposits. another issue highlighted by the financial crisis was the lack of stringency in the credit culture within many of the south and east asian economies. by tying in insurance products to bank loans, for example, fire insurance for a housing loan, the risk of the asset is reduced somewhat. as a rising middle class is fueled by greater economic growth, a new market has emerged. therefore, the traditional distribution systems are no longer targeted towards the entire market. as many of the financial products that are consumed by the new middle class are accessed through existing bank systems, banks provide the perfect avenue to provide their insurance needs as well. this new market is also not necessarily looking for the more traditional insurance products, but is looking for tailored products as the market becomes more financially savvy. consequently, banks and insurers are now collaborating to provide comprehensive coverage and more integrated products. with the lack of pension schemes throughout the region, likely through deficient government and employment pensions, consumers are also becoming increasingly motivated to provide for their own future. in summary, the main issues for bancassurance in this region are the restructuring of the industry with an emphasis on consolidation and integration, a shift in previously restrictive regimes, creating synergies, the need to tap into new markets through more efficient channels, product innovation, and the influx of global competition and partnerships. another fundamental change in the region's insurance industry is the deregulation and liberalization of the market. this also leads on to two final areas that need further discussion as they underlie the movement of the insurance sector in the region that has arisen from deregulation: the type of business that is underwritten in the region as well as the importance of financial intermediation. in general, commercial lines of insurance have seen greater growth than personal, with commercial growth of 3.5 percent versus 1.5 percent for personal lines of nonlife insurance in 2001 (swiss re 2003b). as would be expected, growth in commercial net premiums written increases as the amount of business undertaken within the country increases. this explains the greater proportion of commercial lines within the more developing nations such as india and china compared to the more developed markets such as south korea and taiwan. throughout the region much of the non-life insurance growth can be attributed to motor vehicle insurance, in particular, over half the premiums in both taiwan and thailand relate to this line. other countries within the region also show a large representation with most attributing approximately a third of all premiums to motor vehicle insurance. insurers will come under further pressure to compete within the particular motor vehicle insurance markets in the region as motor vehicle premium rates in india, china, and taiwan are liberalized. the sars epidemic is also thought to have generated a rise in both personal and commercial policies. medical insurance may be affected directly through an increased awareness of health issues such as sars. to add to this, individuals are now conscious of the advantages of having coverage for the use of private medical services because public resources were put under strain during the epidemic. commercial lines of insurance should receive increases in premiums due to sars as disruptions to business and cancellation of events make businesses wary of further health epidemics, even those unrelated to humans, such as the avian flu crisis. although declining, government providers often play a big role within the insurance markets of south and east asia. in particular, governments often provide medical and unemployment insurance as well as pensions. this varies from country to country quite substantially. for instance, in india and hong kong, governments do not usually provide for any of these three lines of insurance. alternatively, singapore, south korea, and taiwan provide all three types of insurance as well as other lines such as crop insurance, workers' compensation, and motor vehicle insurance (swiss re 2003b). some governments have even started to provide insurance against terrorism, particularly for the aviation industry. with greater competition and a more client-oriented focus. south and east asian insurance is becoming more diverse and the scope of contracts available to consumers and businesses are tailored to more specific risks. large insurers, who are now segmenting their considerable customer base to a greater extent, are also developing several innovative products. specialist firms are also continuing to service niche markets. overall, these changes show that the traditional role of insurance companies when providing policies is changing. however, so too is their role as a financial intermediary. despite the world downturn that began in late 2000, optimism within the global financial markets in the beginning of 2005 has strengthened the financial sector. also, growth in bank lending within the region has not been as affected from 2002 to present. however, increases in both consumer and commercial lending have been met with more prudence, to avoid any future investment bubble. the continued confidence of financial intermediaries is an important facet of the recovery from the previous decade's slump. in particular, insurance companies' role in allowing risks to be spread throughout the region (and the world) and their injection of funds back into the region is pivotal. large and foreign insurers are more conservative in their investment activities focusing on more passive investments such as cash and deposits. wide ranging regulation of insurance investment is still prevalent, although changes are expected to increase flexibility and allow for higher yield investments (organization for economic co-operation and development (oecd) 1999). in general, the majority of insurance companies' investments are kept in cash and cash-equivalents (including other relatively risk-free assets, such as government bonds), and more so for non-life insurers than life insurers due to the different liability requirements. over the 1997 asian financial crisis, equity investments declined and bond investments increased (swiss re 2003a). this is not surprising as the volatility of the south and east asian stock markets increased over the last decade. thus, insurers are adjusting portfolios because regulators have consequently maintained a stringent policy on investing in equity markets and because many insurers were negatively affected by their higher weighting of equity holdings during the financial crisis. moreover, despite the fact that the proportion of real estate investments remained relatively stable, there was an overall decrease in the value of insurers' investments. consequently, solvency concerns have come to light as regulators are now looking at insurers' balance sheets with more scrutiny. losses incurred on local investment assets have meant that reshuffling of investments has had to take place to secure appropriate reserves, particularly within thailand, indonesia, and south korea. finally, reinsurance has started to be used to alleviate the mismatch between the assets and liabilities of insurance companies, although restrictions to foreign company entry have hindered the entry of some of the large global reinsurers into the region. due to the long-term nature of life insurance, companies within this sector experienced a greater mismatch between assets and liabilities. in indonesia, problems arose because too few investments were denominated in u.s. dollars to offset the policies that were based in the same currency. this currency risk, which was a by-product of insurers trying to gain fi^om higher returns on domestic investment, proved to be quite detrimental once the financial crisis emerged. there was a mismatch in the maturities of assets and liabilities, where longer-term policies were matched with what proved to be shorter-term investments with diminishing value. perhaps a closer look at what is determining demand and supply within the region will help to alleviate problems such as that experienced in indonesia. this, therefore, leads us into the next section that focuses on academic research of these determinants. the insurance market growth discussed previously has been enormous across asia. but growth in economies such as hong kong, singapore, india, and china has been more pronounced. for key decision makers, such as managers and policy makers, it is essential to understand those factors that promote higher growth rates. the purpose of this section is to provide a basic insight into the drivers of insurance market growth by drawing upon current empirical studies. the discussion highlights the factors that promote the demand and supply of insurance and relate these findings to the insurance market of asia. economies flourish under economic, legal, and political stability. it is therefore of little surprise that economic sectors, such as insurance, should also do well under similar conditions. economic growth and economic stability, coupled with effective political and legal institutions, have been found to promote the development of insurance. however, for a better understanding of the differing rates in insurance market growth experienced in the markets across asia, it is necessary to explore these factors more fully. there is broad agreement that growth in gdp and/or gdp per capita leads to higher demand for insurance (beenstock, et al. 1986; truett and truett 1990; browne and kim 1993; outreville 1996; ward and zurbruegg 2002; beck and webb 2003) . as economic prosperity increases, the need and ability to purchase insurance also increases, although not at a constant rate. as consumers become increasingly wealthy, they can afford to retain risks within their current financial portfolios. therefore, the strongest link between income and insurance consumption occurs in those countries with moderate levels of gdp per capita, which ward and zurbruegg (2002) found to be the asian 'tiger' economies.^'^ however, as these economies continue to grow, the demand for insurance will wane, which must be an important consideration for insurance companies seeking to exploit growth in asia on a longterm basis. economic stability is equally important for insurance consumption. high rates of inflation devalue the net present value of insurance; and therefore reduce its attractiveness to consumers. moreover, excessive inflation can be linked to macroeconomic instability, with consequences for consumption, investment, and exports. ward and zurbruegg (2002) provide evidence that inflation is around 2.5 times more important for insurance demand in asian economies than it is for developed oecd countries. this emphasizes the role that broad macroeconomic ^' in this discussion, the 'asian tiger economies' are categorized as consisting of hong kong, south korea, malaysia, singapore, taiwan, and thailand. stability plays in the long-term development of the demand for insurance, a role that is mirrored by the accelerated growth of insurance within the relatively stable economies of singapore, hong kong, india, and china. recent debate on economic development and economic stability has been dominated by discussions of the function played by legal and political institutions. prominence, however, has usually been given to the effectiveness of legal systems in promoting commercial transactions within an economy. as a contractual exchange of risks, insurance market development is arguably very sensitive to legal and political effectiveness. ward and zurbruegg (2002) and esho, et al. (2004) find clear support for this hypothesis in both the life and non-life sectors. importantly, a direct positive correlation seems to exist between an improvement in the legal systems within a country and life insurance demand. it is, therefore, highly evident that the effectiveness of the legal environment within an economy is very important for the development of the insurance sector. the significance of legal and political variables is usually measured from constructed indices. a good example is from bcnack and keefer (1995, 2000) , who use an index of governance constructed from five international country risk guide (icrg) variables that reflect the security of private property and the enforceability of contracts: 'corruption in government,' the 'rule of law,' 'expropriation risk,' 'repudiation of contracts by government,' and 'quality of the bureaucracy.' the higher the index the more effective the legal and political system is. in the case of indonesia where the index was low, weak functioning legal systems are associated with low gdp growth and low insurance market growth. the message for international insurance companies is, therefore, very clear. along side considerations of economic stability, legal effectiveness is also a necessary condition for economic and insurance market development, especially within the asian economies. social factors can also play a role in the development of insurance market demand. hofstede (1995) argues that the level of insurance within an economy depends on the national culture and the willingness of individuals to use insurance as a means of dealing with risk. while an appealing argument, esho, et al. (2004) and park, et al. (2002) fail to identify national culture as a significant driver of insurance demand. however, of particular interest to asia is the role of muslim dominated countries, where religious beliefs inhibit those forms of insurance that facilitate speculation of future events, thereby discouraging growth of the insurance sector. since asia has a number of important muslim based societies, including indonesia and malaysia, these maybe expected to have a lower rate of insurance market development. the supply of insurance, more so within many asian economies is composed of domestic and international supply. the amount of supply, the number of firms, and the openness of competition, are all important for an understanding of market development, pricing, and ultimately profitability. unfortunately, little is empirically known about the determinants of domestic supply in the insurance industry. however, there has been an enormous research agenda in measuring the efficiency of various insurance industries around the world, see cummins and weiss (2000) for a review. however, little has been done to develop this work into an understanding of growth rates in domestic supply. admittedly, the use of malmquist indices to measure productivity developments over time is useful, but these indices have not been linked to the dynamics of the insurance market, including such topics as growth rates in premiums, number of insurance companies, or the types of risks being traded. all of which are important supply related topics. a tradeoff is often seen to exist between increased competition and financial stability. however, this view, arguably, places too great an emphasis on regulation being supply constraining, rather than supply enhancing. regulation can restrict flawed products and facilitate the development of competition, innovation, and new beneficial products. regulation can also be an ally of the sector, rather than simply being an enforcer of rules. swiss re (2003a) provides a brief review of regulatory characteristics and expected changes in the south and east asian region. it is notable that the fastest growing insurance markets. hong kong, singapore, and south korea have the most liberal regulatory environments. admittedly, prudent regulation is still important and the need to regulate foreign insurance companies in asia will only grow as globalization continues, but even globalization brings risk reduction. for example, globalization enables international insurance companies to diversify a broad range of risks, from the obvious examples of underwriting to the investment opportunities presented by different capital markets. in addition to these operational risk reductions, globalization also offers world players in the insurance market the opportunity to strategically reduce risk by broadening activities across many different international markets. as a result, financial stability can be strengthened by accessing a broad array of strategic positions in a variety of developing, emerging, and developed economies. a key development in the leading insurance markets of the world has been the emergence of alternative risk financing, characterized by cat bonds, insurance derivatives, and the securitization of insurance lines (swiss re 2001b and cowley and cummins 2005) . the benefits of such developments are the ability to draw on additional capital and to diversify risk beyond the insurance companies' balance sheet, or that of its reinsurer. these capital market developments highlight to the emerging economies of the world that the development of insurance supply is intrinsically linked to the development of the entire financial system and ultimately the depth and diversity of the accessible financial markets. economies, such as singapore and hong kong with well-developed capital markets and access to the capital markets of north america and europe, should be able to bolster underwriting capacity and supply by broadening capital market access and financial innovation. the international supply of insurance services can take two broad forms, the export and import of insurance services and the provision of insurance services through foreign direct investment. in assessing the attractiveness of international markets to insurance companies ma and pope (2003) reveal that the number of domestic competitors and high levels of existing demand are most important. in essence, international insurance companies appear to seek out high growth markets, with an abundance of existing suppliers; and therefore, no dominant incumbent. this may ease entry into the market by facilitating accommodation and switching between suppliers. in asian countries, where state provision of insurance has led to the creation of a dominant incumbent, international entry into these markets maybe limited. this may then constrain future price competition and long-term growth of the market. in addition to examining the factors that attract the import of insurance services, it is necessary to understand why insurance may be supplied internationally across national borders. a key argument is that the continued and growing supply of financial services across international boundaries is suggestive of competitive advantages gained from access to superior and cheaper factors of production, particularly labor and capital. recent research conducted at the world bank also sheds light on recent liberalization commitments in financial services trade, and how there are domestic and international forces that drive this liberalization process (schuknecht, et al. 2003) . international insurance companies can use this analysis to benchmark their own domestic resource base and level of competitive advantage against the international markets into which they are contemplating entrance. promoting economic development stimulates both life and non-life consumption. in particular, national income seems to have a stronger impact on life insurance consumption in asia, than on the oecd markets. decision makers should, however, not overvalue these results. recent research indicates that the effect of national income on insurance demand decreases enormously after controlling for legal and political factors. the empirical resuhs generally suggest that economic stability, conditioned on legal and political stability, appears to be more crucial for long-run success than economic development alone. these findings are also reflected in the impact of income per capita on the demand for life insurance in the asian 'tiger' economies. after controlling for legal and political factors, income elasticities tend to be smaller. while economic development may occur at faster rates in asia, the link to insurance market development does not appear to be as strong. insurance companies intending to expand their business activities abroad should consider these factors when choosing which markets to enter. in the non-life sector, empirical findings highlight the fact that the link between insurance demand and the legal environment is focused on the single issue of property rights enforcement. this indicates that the effectiveness of the legal system in enforcing contracts is paramount to the development of the insurance market. however, in contrast to the life insurance industry, existing research highlights that the non-life insurance business is largely unaffected by cultural and institutional factors. in fact, esho, et al. (2004) state that the development of non-life insurance is 'technically rather than culturally located' indicating the importance of the legal and regulatory environment. on the supply side, decision makers need to be aware of how a number of key findings fi-om the literature, in particular, the factors that promote a comparative advantage in insurance, drive international insurance supply. an important determinant is the capital to labor ratio. applying this finding to the insurance sector is likely best achieved by arguing that the level and quality of technical infi-astructure is important for supply side development in the insurance sector. to price risks and manage losses, decision makers should include the quality of office space, the clustering of insurance companies, services for shared experience and technical advice, and the reliability and breadth of telecommunication and computer systems. the quality of capital and labor is also important since a comparative advantage is found to be related to the amount of schooling and the level of research and development (r&d) expenditures. again, relating these directly to the insurance sector, r&d becomes important in the development and implementation of risk management and control systems. fire systems, construction methods, motor vehicle security, and safety are further examples, along with the development of underwriting models and the ability to model financial and capital market risks. when coupled with an educated workforce and the development of professional training, the insurance sector can exploit and leverage knowledge available within its broader environment. in terms of attracting an international supply of insurance. ma and pope (2003) show that international involvement in domestic markets is promoted by increased domestic competition and increased liberalization. therefore, in order to promote supply, the emerging economies of asia need to enable greater competition among existing and potential entrants and present flexibility and growth through increased liberalization. deregulation, increased licensing of insurance companies, reduction in rate setting, and the broadening of underwriting lines and potential investment options are all suitable policies to promote. the south and east asian economies offer a variety of risks and opportunities for global and domestic insurance companies. in the relatively developed and economically stable economies of singapore, india, south korea, hong kong, and japan growing economic prosperity is strongly associated with insurance market growth. with increasing deregulation, fi*eedom of market access to foreign companies, and a willingness to integrate financial services through bancassurance, these markets are competitive growth spots for the world's leading insurers. in the more emergent economies of the region, where economic, legal, and political effectiveness are less-assured, commercial confidence and insurance market development is more open to macroeconomic shocks and potential financial crises. governments need to foster a commercial environment, which creates greater confidence for economic exchange and insurance risk transfers. legal stability and the enforcement of property rights are essential for an economy to grow and to make insurance sectors attractive and profitable for both domestic and international players. in the future, it will be interesting to see how domestic competitors rise to the challenge of international rivals; and the fight may not be one sided. singapore, in the areas of telecommunications, aviation, and shipping, has shown itself to be a dominant regional competitor; and the same is possible in financial services, and in particular insurance. international rivals should not assume that the markets of south and east asia offer effortless opportunities. perhaps most interestingly, the insurance sector stands in stark contrast to many other industries reflecting the trends of globalization. while many manufacturing industries view south and east asia as a source of low-cost inputs, global insurance companies view south and east asia as a potential source of premium growth. the empirical evidence suggests that intra-industry trade in insurance is promoted by a convergence in economic activity across economies. therefore, an increasing international supply of insurance in south and east asia will benefit from increased economic growth, and more importantly, salaried employment and rising personal disposable income. all factors which are likely, however, to impede further development of low cost manufacturing and subsequent export growth. it is without a doubt that the south and east asian economies are now arriving at an important economic crossroad, with pressures to expand into the financial services industry while also trying not to lose their cost-advantages in their already established manufacturing sector. how successfully these economies migrate from manufacturing to service-based economies may have important implications for the medium term economic development of their respective markets, and the consequential desire to purchase insurance. annuity. an annuity is a life insurance policy in reverse, whereby the purchaser gives the life insurance company a lump sum of money and the life insurance company pays the purchaser a regular income, usually monthly. bancassurance. bancassurance is the amalgamation of assurance and banking business within a financial environment, whereby banks are used as distribution channels to sell insurance products. a broker is an individual who arranges and services insurance policies on behalf of the insurance buyer. the broker is the representative of the insured, although the broker receives compensation in the form of a commission from the company. career agents. career agents work on behalf of the insurance company, selling products to potential policyholders. they are also referred to as a tied agent. cat bonds. cat bonds are risk-based securities that allow (re)insurance companies to transfer natural catastrophe insurance risk to institutional investors in the form of bonds. cat bonds help to spread peak exposures. they are also called catastrophe bonds. a claim is a demand by an insured for indemnity for loss incurred from an uninsured peril. commercial insurance. commercial insurance is sold by privately formed insurance companies with the objective of making a profit. depositor's insurance. depositor's insurance provides a payout that is a multiple of the depositor's cash balance in the occurrence of a certain event (i.e. death). endowment insurance. endowment insurance provides the insured with the face value of a policy if the insured or the beneficiary is alive on the maturity date stated in the policy. foreign direct investment reflects the objective of obtaining a lasting interest by a resident entity in one economy ('direct investor') in an entity resident in an economy other than that of the investor ('direct investment enterprise'). the lasting interest implies the existence of a long-term relationship between the direct investor and the enterprise and a significant degree of influence on the management of the enterprise. direct investment involves both the initial transaction between the two entities and all subsequent capital transactions between them and among affiliated enterprises, both incorporated and unincorporated. gdp. gross domestic product represents the total value of final goods and services produced within a country's borders during a specific time period, usually a year. gnp. gross national product is the total value of final goods and services produced by domestically owned factors of production. income elasticity. income elasticity of demand measures the responsiveness of the quantity demanded of a good to the income of the people demanding the good. it is measured as the percentage change in demand that occurs in response to a percentage change in income. insurance derivatives. insurance derivatives are investment instruments which are determined directly and solely by the loss pattems of natural catastrophes. liability insurance. liability insurance is insurance for damages that a policyholder is obliged to pay because of bodily injury or property damage caused to another person or entity based on negligence, strict liability, or contractual liability life insurance. life insurance provides for a payment of a sum of money upon the death of the insured. more specifically, in exchange for a series of premium payments or a single premium payment, upon the death of the insured, the face value minus outstanding policy loans and interest is paid to the beneficiary. malmquist index. the malmquist index is a measure of the degree of concentration in a market. it is the sum of the squares of the percentage market shares of all companies in the market. a mutual insurance company is an insurance carrier, without capital stock, that is owned by the policyholders. it may be incorporated or unincorporated. organisation for economic co-operation and development is an intemational organization of those developed countries that accept the principles of representative democracy and a free market economy. it originated as the organisation for european economy co-operation (oeec) to help administer the marshall plan for the re-construction of europe after world war ii. later, its membership was extended to non-european states, and in 1961 it was reformed into the oecd. over-draft insurance. over-draft insurance covers the repayments of an overdraft facility in the case of certain events (i.e. death). premium density. premium density is premiums per capita. a premium is the payment, or one of the periodical payments, a policyholder agrees to make for an insurance policy reflecting his/her expectation of loss or risk. premiums earned. premiums eamed are premiums an insurance company has recorded as revenues during a specific accounting period. premiums written. premiums written are premiums for all policies sold during a specific accounting period. product liability insurance. product liability insurance is insurance for the manufacturer or supplier for of goods for damage caused by their products. research and development can be defined as any project to resolve scientific or technological uncertainty aimed at achieving an advance in science or technology. advances include new or improved products, processes, and services. sars. severe acute respiratory syndrome is a viral respiratory illness caused by a coronavirus, called sars-associated coronavirus (sars-cov). sars was first reported in asia in february 2003. over the next few months, the illness spread to more than two dozen countries in north america, south america, europe, and asia before the sars global outbreak of 2003 was contained. term life insurance. term life insurance is a life insurance policy that has a set duration limit on the coverage period. once the policy is expired, it is up to the policy owner to decide whether to renew the term life insurance policy or to let the coverage terminate. permanent life insurance. permanent life insurance, also referred to as ordinary life insurance or whole life insurance, is a life insurance policy that covers an insured for their entire lifetime, assuming premiums are paid as specified in the policy. whole life insurance provides a guaranteed fixed sum (sum assured) upon death of the life or lives assured. time deposits. time deposits are savings accounts which require notice of withdrawal. wto. world trade organization. focus: insurance and reinsurance asia interview with the regulator-bancassurance in korea: future supervisory directions finance and the sources of growth economic, demographic, and institutional determinants of life insurance consumption across countries the determination of life premiums: an international cross section analysis international property-liability insurance consumption an international analysis of life insurance demand regulations of the people's republic of china on administration of foreign-invested insurance companies securitization of life insurance assets and liabilitiqs analyzing firm performance in the insurance industry using frontier efficiency and productivity methods the changing focus in the supervision of insurance company investment the s-curve relation between per-capita income and insurance penetration law and the determinants of property-casualty insurance general insurance in japan fact book insurance as a product of national values office of the commissioner of insurance finance and growth: schumpeter might be right institutions and economic performance: crosscountry tests using altemative institutional measures law, finance, and economic growth financial intermediation and growth: causality and causes stock markets, banks, and economic growth survey of alternate distribution channels: asia determinants of intemational insurers' participation in foreign non-life markets bancassurance in practice the economic significance of insurance markets in developing countries life insurance markets in developing countries determinants of insurance pervasiveness: a cross-national analysis basic readings and references on the causes of crisis explaining liberalization commitments in financial services trade bancassurance across the globe: meets with a very mixed response world insurance in 2000: another boom year for life insurance: retum to normal growth for non-life insurance india: transition from uniform insurance tariff system to risk-based approach the demand for life insurance in mexico and the united states: a comparative study does insurance promote economic growth? evidence from oecd countries update 3-severe acute respiratory syndrome (sars), www.who key: cord-295622-znmpheia authors: simione, luca; gnagnarella, camilla title: differences between health workers and general population in risk perception, behaviors, and psychological distress related to covid-19 spread in italy date: 2020-09-04 journal: front psychol doi: 10.3389/fpsyg.2020.02166 sha: doc_id: 295622 cord_uid: znmpheia in this study, we investigated the perception of risk and the worries about covid-19 infection in both healthcare workers and the general population in italy. we studied the difference in risk perception in these two groups and how this related to demographic variables and psychological factors such as stress, anxiety, and death anxiety. to this aim, we administered an online questionnaire about covid-19 together with other questionnaires assessing the psychological condition of participants. first, we found that the exposition to infection risk, due to living area or job, increased the perceived stress and anxiety (i.e., medical staff in north italy was more stressed and anxious with respect to both medicaland non-medical participants from center and south italy). then, we conducted hierarchical logistic regression models on our data to assess the response odds ratio relatively to each regressor on each dependent variable. we found that health workers reported higher risk perception, level of worry, and knowledge as related to covid-19 infection compared to the general population. psychological state, sex, and living area were less related to these factors. instead, judgments about behaviors and containment rules were more linked to demographics, such as sex. we discussed these results in the light of risk factors for psychological distress and possible interventions to meet the psychological needs of healthcare workers. on december 31, 2019, some cases of pneumonia of unknown etiology have emerged in the hubei region of china. then, on january 07, 2020, the causative agent has been identified by means of oropharyngeal swabs, i.e., a virus belonging to the coronaviridae family called sars-cov-2 (severe acute respiratory syndrome coronavirus 2). this new coronavirus was responsible of the respiratory syndrome called , 2020). most patients with positive swab test developed only minor symptoms, such as fever, dry cough, and pharyngitis, with a benign evolution and spontaneous resolution of the clinical picture. however, some patients developed severe complications, such as interstitial pneumoniae with acute respiratory distress syndrome, pulmonary edema, multiorgan failure, septic shock, and even death (sohrabi et al., 2020) . patients at risk were especially males, aged older than 60 years, suffering from cardiovascular comorbidities (e.g., arterial hypertension, diabetes, and chronic coronary artery disease), and affected by chronic pneumopathies or cancer (world health organization [who] , 2020; zhou et al., 2020) . in the following month, the disease spread to other countries outside china, including italy, where the first positive cases were found on february 21, 2020 (spina et al., 2020) . italy experienced a significant increase in new cases, mostly in the month of march, in particular in the north regions, and this caused in turn a growing alarm throughout the italian medical-hospital sector due to the imbalance between the resources of the national health system (indicated as ssn, i.e., "sistema sanitario nazionale") and the expected need for treatment required by forecasts on the virus spread. this concern was publicly expressed in the guidelines published by the italian society of anesthesia, analgesia, and intensive care (named siaarti, i.e., "società italiana anestesia, analgesia, rianimazione e terapia intensiva") on march 06, 2020, which reported that in case of huge imbalance between the population clinical needs and the effective availability of intensive resources, medical doctors should have selected patients for intensive therapies based on their actual hopes of survival (siaarti, 2020) . in fact, in italy, there were about 5,200 beds in total for intensive care units, and on march 11, 2020, 1,028 of these beds had already been destined to patients suffering from covid-19. according to the predicted number of new cases, the peak of contagions would have been reached by mid of april, when at least 4,000 beds in the intensive care units would have been needed in order to treat patients with covid-19 (remuzzi and remuzzi, 2020) , with significant consequences also for patients not affected by covid-19, who would have given less assistance in the aforementioned units. however, on the one hand, doctors and other health workers multiplied their alarms relatively to this critical situation and to the related recommendations regarding behaviors to be followed and the hygienic conduct to be implemented; on the other hand, there were daily episodes of violation of such medical recommendations by the population, apparently only scarcely aware of the problem. for this reason, i.e., the failure of the unanimous spontaneous compliance of the population to the proposed hygienic rules and health practices, since february 23 the italian government implemented increasingly restrictive dispositions to limit the spread of the disease throughout the country with various prime minister decrees (named dpcm, i.e., decreto del presidente del consiglio dei ministri; see dpcm on february 23, march 01, march 04, march 08, march 09, and march 11, 2020) . in fact, a significant portion of population continued to engage in risky behaviors, prompting increasingly stricter rules emanated by the authorities. therefore, a gap appeared to emerge between the indications and requests from the national health system staff and the reception of these same indications by the population, as well as a general difference in the perception and evaluation of the risks associated with the covid-19 infection between the two groups. such a difference seemed more evident especially in the areas of central and southern italy, where the covid-19 spread was lower than those of northern italy, as reported by the daily data provided by the national civil protection (see cereda et al., 2020) . the spread of the sars-cov virus in 2002 has shown how this type of epidemic disease has important psychopathological consequences, in the short and long term, in particular on health workers (sim and chua, 2004; lung et al., 2009; maunder, 2009) . thus, in the actual spread of the new sars-cov-2 virus attention to psychological health of doctors and others healthcare workers had already been expressed regarding the chinese situation relating to covid-19 (see for example xiang et al., 2020) , with proposals for intervention and support from the hospital structures . in fact, chinese health workers in wuhan faced a situation characterized by poor safety and protection, with excessive workloads, high infectious risk, absence of adequate personal protective equipment, and shortage of staff. this risky situation for one's own and loved ones' health could have clinical consequences, but also psychic ones. in fact, these health workers showed a symptomatology characterized by tiredness, worry, fear, frustration, isolation, depression, anxiety, stress, insomnia, anger, and negation (kang et al., 2020) . in particular, in this group of workers, women, workers with more than 10 years of service, and operators who had a history of psychological suffering showed higher risk of stress, anxiety, and depression (zhu et al., 2020) . a further risk factor for psychological distress has been also a reduced social network support, a protective factor in the stress resilience (ozbay et al., 2007) . in the emergency situation caused by sars-cov-2, healthcare workers are indeed at high risk of acute stress, and this risk could be even higher if they feel such a disjunction from the social community formed by the other citizens, as the situation in italy seemed to lead. in addition to the personal consequences on the psychophysical health of the health professionals, this could easily lead to a progressive decline in their health services, with a worsening of the quality of care provided. the experience with the disease caused by h1n1 in japan showed how policies that take care of healthcare and give physicians confidence positively affected the overall care they provide to the population (maunder, 2009; imai, 2020) . for all these reasons, it is very important to study the trait and state psychological variables of healthcare workers as risk or protective factors with respect to the actual stressful situation. in this manner, it would be possible to evaluate the analogies and the differences with the chinese model at both intracultural and intercultural levels (mccrae, 2001) , for considering which intervention strategies could be suited for italian healthcare workers and thus importing the most adequate recently developed for the chinese healthcare system in response to the spread of covid-19. in such an emergency situation, characterized by contrasts between the opinions and the worries of medical doctors on one side and the behaviors and the attitudes of the general population on the other, we designed and conducted this study. according to the evidences reported above, our objectives were (i) to probe the opinions and the worries relative to covid-19 spread in both the general population and healthcare workers; (ii) to study which demographic, geographic, and psychological variables were related to a higher perception of the health risks; and lastly (iii) to assess any difference in risk perception relatively to covid-19 between the general population and healthcare workers. thus, our aim was to understand the influence of psychological and training/working experience in shaping opinions, worries, and risk perception relatively to covid-19. to this aim, we administered an online battery including a questionnaire about the direct experience, the opinions and the worries relative to the covid-19, and some questionnaires evaluating the psychological distress state. to evaluate the participants distress level, we administered questionnaires measuring perceived stress, anxiety, and death anxiety as they usually increased in the general population (brooks et al., 2020) and in healthcare workers (brady, 2015; kang et al., 2020) during emergency situation. as the social-health situation in italy was evolving continuously in the beginning of march, we limited the data collection in the days 10-12 march 2020. based on the evidence reviewed so far, we hypothesized that healthcare workers would show higher levels of distress in terms of stress, anxiety, and death anxiety, particularly in north italy, where the contagion was higher. in fact, as reported by lai et al. (2020) , direct exposition to virus outbreak affected the psychological health of healthcare workers, with those living in the region of wuhan reporting higher distress than colleagues living elsewhere. then, we hypothesized that healthcare workers would perceive higher levels of risk for themselves and for their relatives and that this effect would be true even when controlling for such psychological distress. in fact, we expected that this higher risk perception was not linked only to a worse psychological state, but also to a greater knowledge of the covid-19 disease and of its possible consequences. thus, we also expected that healthcare workers would report higher levels of knowledge of the new coronavirus. about containment and prevention measures, we expected that healthcare workers would report a higher engagement in preventing measures with respect to other people and request for more stringent containment measures, in order to prevent ssn collapse due to an increased number of accesses in hospital. following all the previous hypotheses, we expected that participants not in the healthcare workers group would provide more optimistic forecast about the progress of the spread of covid-19. three hundred fifty-three italian adults participated in this study (mean age = 38.26 years, sd = 12.24 years; females = 265, males = 88). we divided our sample by means of their job or training: in the first group, we included medical doctors, nurses, paramedics, and students in medicine/nursing/other medical disciplines ("med" group; n = 167; mean age = 35.56 years, sd = 9.90 years; female = 133, males = 34), whereas in the second group, we included all the other participants (no-med or "nom" group; n = 186; mean age = 40.69 years, sd = 13.58 years; females = 132, males = 54). we recruited our participants with a convenience sample method via email and social media. participants received a brief description of the study together with an informed consent module. after providing the informed consent, they completed an online battery of questionnaires, as described afterward. data were collected in anonymous format, and participants were invited at the end of the battery to leave their email in order to be contacted for possible follow-up measures. in this study, we collected data not reported here, as fully specified in the "materials and methods" section. in this study, we administered questionnaires to evaluate the psychological condition and personality traits of each participant. where possible, we opted for short or brief version of each questionnaire, in order to contain the total number of items (45 total items). we included in our battery the following questionnaires: • the four-item perceived stress scale (pss; cohen et al., 2006) , a questionnaire evaluating the stress perceived by the participant in the last month, that is, the participant's perceived feeling to be in control over external events, relationships, and emotional life. we used the short fouritem version. each item was evaluated on a five-point likert scale ranging from 0 (never) to 4 (very often). in our sample, the four-item pss showed a good reliability score, cronbach's α = 0.73, similar to what was reported in the original version, α = 0.72. • the six-item version of state-trait anxiety inventory (stai; marteau and bekker, 1992) , which assessed the anxiety of the participants on six items including emotions or feelings. each item was evaluated on a four-point likert scale ranging from 1 (almost never) to 4 (almost always). in our sample, the six-item stai showed a similar reliability score, cronbach's α = 0.85, to that reported in the original version, α = 0.82. • the death anxiety scale of the existential concerns questionnaire (ecq; van bruggen et al., 2017) , which evaluated the anxiety of the participant relatively to his/her sense of finitude, to the fear of diseases and death. the total score was computed overall five items. each item was evaluated on a five-point likert scale ranging from 0 (never) to 4 (always). in our sample, the ecq death anxiety scale showed a good reliability score, cronbach's α = 0.89 (in the original version, only the internal consistency for the global score was reported, α = 0.92). • the marlowe and crowne social desirability scale (m&c; manganelli rattazzi et al., 2000) , which assessed the tendency of answering in a socially desirable manner. this version of the scale implied nine items evaluated over a six-point likert scale ranging from 1 (absolutely false) to 6 (absolutely true). in our sample, the m&c scale showed an acceptable reliability score, cronbach's α = 0.62, slightly lower than that reported in the cited italian validation, α = 0.69. we also included in the battery other questionnaires, which results were not reported in the present work: the 10-item big five questionnaire (guido et al., 2015) , the acceptance and action questionnaire ii (pennato et al., 2013) , and the emotion regulation questionnaire (balzarotti et al., 2010) . we further developed a questionnaire about sars-cov-2 and covid-19-related experience and personal opinion. both authors (l.s. and c.g.) compiled a first list of items, and then this list was revised by five experts (medical doctors and psychotherapists) in order to remove, change, or add relevant items. we obtained a final list including 68 items. a complete list of the items was reported in appendix a. to keep the questionnaire simple and easy to understand, we preferred to include mostly yes/no questions. the questionnaire we administered included the following: data analysis was conducted with statistical software r, version 3.6.3 (r core team, 2014). as first step, we assessed differences in our sample between the med and nom groups for the demographic variables in order to control for unbalanced factors in our sample. we conducted these comparisons by means of t-tests for numerical data and of χ 2 tests for frequencies. then, we described the experiences about covid-19 infection in our sample and compared med and nom groups again and areas (north vs. center vs. south italy). we also compared the psychological state of our participants by group and area to assess difference in levels of anxiety, stress, and death anxiety. for these comparisons, we implied mixed-effects analyses of variance (anovas) with one between factor (group, two levels: med vs. nom) and one within factor (area, three levels: north, center, south). we further decomposed significant main or interaction effects by means of least significant difference-corrected post hoc pairwise comparisons. as main analysis, we computed hierarchical logistic regression on the dichotomic responses and reported overall our participants about preoccupations, opinions, and behaviors relatively to their experience with the new coronavirus. this analysis allowed us to estimate the odds to obtain a positive response to a particular question given a set of parameters. for non-dichotomous variables (e.g., contagious spread in the next days could either increase, decrease, or stay stable), we created n dichotomous dummy variables, where n was the number of possible alternative responses to "equal" response (e.g., for contagious spread in the next days, we created a dummy variable for increased forecast and a dummy variable for decreased forecast). we used as reference the middle-point response, i.e., "equal" response, and evaluated the propension to respond "more" or "less" with respect to this point. moreover, we did not analyze the questions for which we obtained identical or almost identical responses by all our participants, i.e., question with >98% of equal responses. in fact, for such questions, it was easy to find one of the outcome categories so underrepresented that it could lead to rare event outcome or be linearly separated by only one of the independent variables (ivs). we introduced the regressors in the model at different steps of computation. at the first step, we introduced the demographic variables such as sex, age, and living area (with the north italy as reference). at the second step, we added to these variables the psychological state factors of perceived stress (pss score), anxiety (stai score), and death anxiety (ecq score), in order to investigate the contribution of these regressors. as last step, we investigated the difference between med and nom groups in responding to the questionnaire. for this aim, at the third step, we introduced the group variable as regressor. when conducting logistic regression analysis, we should check for assumption violations. first, we considered the sample size issue. in the full model, i.e., model at step 3, we had a total of eight ivs including all the regressors and the covariates. considering our sample size of 353 participants, this resulted in an event per variable (epv) of approximately 50, computed as the ratio between number of participants and number of ivs. this epv could be considered as fairly sufficient to make the interpretation of our global model meaningful (harrell, 2015; ogundimu et al., 2016) , even if the more stringent bujang et al.'s rule of thumb bujang et al. (2018) would suggest to include at least 450 participants for such a number of variables. moreover, for each tested model, we checked for influential outliers and for multicollinearity. to test for influential outliers, we computed cook's distance for each data point and check for values larger than 3 sd from the mean, as a large value of cook's distance indicates an influential observation (martín and pardo, 2009; zhang, 2016) . to test multicollinearity, we computed the variance inflation factor (vif) for each regressor and check for any value greater than 2.5, considered as more strict threshold with respect to the usual value of 5 or 10 (midi et al., 2010) . for all our logistic regression models, we found no influential outliers or any vifs greater than the threshold value. the results of these tests, together with the reported epv greater than 50, testified that our logistic regression analyses could be considered sufficiently reliable. to further support our logistic regression model results, we conducted semipartial correlation analysis by means of the ppcor package for r (kim, 2015) . we assessed the degree of relationship between group (coded as nom = 0 and med = 1) and each dependent variable of the covid-19 questionnaire while controlling for sex, age, living area, anxiety, death anxiety, and stress. semipartial correlations were reported as pearson r for each computed correlation, with values ranging from −1, very strong negative relationship, to 1, very strong positive relationship. even if we conducted a great number of statistical analyses on the same sample, we decided not to apply a general correction to significance level for multiple tests. because of the exploratory nature of this study, we preferred not to strictly control over false-positive rate (type i error) while avoiding to inflate falsenegative rate (type ii error); i.e., we decided to collect all the significant results emerging from our analysis so to guide further, confirmatory experiments and studies (see fiedler et al., 2012 , for an overview of the problem on multiple testing correction). table 1 reports the descriptive statistics for the two groups and the relative tests for samples' comparison. as shown, participants in the med group were younger (mean = 35.56 vs. 40.69), studied more years (mean = 23.02 vs. 21.34), had less children (mean = 0.40 vs. 0.58), reported to sleep in average less time per night (mean = 6.84 vs. 7.06), and were more frequently vaccinated for annual flu in 2019 (40% vs. 13%). in this first results section, we reported the analysis of the data relatively to the experience with the covid-19. we thus referred to the data in the first part of the questionnaire, in which we asked if participants had personal experiences or contacts with covid-19 infection. we reported data overall participants and divided by groups in table 2 . frequencies were compared by means of χ 2 test. for the overall sample, we found an effect of the living area on question 3, about the presence of symptoms related to covid-19, χ 2 (2) = 44.48, p < 0.01; question 4, about thinking that the symptoms relate to a covid-19 infection, χ 2 (2) = 11.64, p < 0.01; question 6, about the quarantine status, χ 2 (2) = 30.67, p < 0.01; question 7, about contact with people at risk of infection, χ 2 (2) = 21.87, p < 0.01; and question 9, about the presence of positive case in the living area or city, χ 2 (2) = 132.71, p < 0.01. in answering to all these questions, participants from north italy reported a greater direct experience with covid-19 than participants from center or south italy, whereas participants from center italy reported more personal experiences than participants from the south. then, we compared the frequencies between the two groups, med versus nom. we found significant differences in question 7, about contact with people at risk of infection, χ 2 (1) = 14.41, p < 0.01, and in question 8, about contact with people positive for covid-19 test, χ 2 (1) = 20.01, p < 0.01, with participants in the med group reporting more frequent contacts with people at high risk of infection or already positive. we measured various indexes of psychological distress state, i.e., anxiety, death anxiety, and stress. here, we tested if any difference existed between groups in the psychological state and if this difference was modulated by the living area. to this aim, we conducted mixed-effects (anovas) with a between-variable of group (med vs. nom) and a within-variable of living area (north vs. center vs. south italy). we controlled for the effect of age and sex as covariates. we probed significant effects by means of post hoc corrected tests. for the death anxiety score (ecq; see figure 1 , left panel), we found no significant main effects or significant interaction, all p's > 0.19. for the perceived stress score (pss; see figure 1 , middle panel), we found a significant main effect of the living area, f(2,348) = 6.52, p < 0.01, with participants from north italy reporting higher stress levels than participants from both center, p < 0.01, and south italy, p < 0.01. the analysis also revealed a significant group × living area interaction, f(5,345) = 3.16, p < 0.05, with med participants from north reporting higher stress score than other med participants from both center, p < 0.01, and south italy, p < 0.01, as well as higher stress score than the nom group participants from all living areas, all p's < 0.05. for the anxiety score (stai; figure 1 , right panel), we found a significant main effect of living area, f(2,348) = 3.31, p < 0.05, with participants from north italy reporting higher anxiety levels than participants from center, and a significant group × living area interaction, f(5,345) = 2.96, p < 0.05. the interaction was due to a significant difference in anxiety between med participants from north with respect to the med participants from center and south italy, p's < 0.01, and with respect to nom participants from center italy, p < 0.01. this analysis thus revealed that the med group participants from north italy reported higher levels of anxiety and stress than the general population and the medical and paramedical staff from other living areas. before conducting the regression analysis on the questionnaire data, we reported some descriptive information and statistics about the response frequency of participants. response frequencies for each item overall sample as well as divided by group are reported in table 3 , left group of columns. here we reported also a χ 2 test comparing the frequency of "yes" responses for the two groups. of note, 57% of participants were thought to be at risk of contagion, but only 18% were thought to be at risk when the first cases appeared in italy. they also thought that their loved ones would be at risk (65%). the med group reported higher frequency of thinking to be at risk (71%). many participants in this group (57%) were scared about health consequences or death if infected, but almost all (93%) were more worried for family or loved ones' consequences of infection. similarly, the 73% of them reported worries about the global sociopolitical implication of virus spread, and the 83% about the possible collapsing of the national health system. moreover, 83% of them thought that people's behavior could be ever scaring of the infection and 73% were worried by the increased aggression risk for health workers in the near future. most of our sample (97%) reported to adhere to hygiene measures and to avoid public events or places (94%), and only a few participants reported to have risky behaviors for themselves (18%) or their family (17%). however, only 16% of nom and 6% of med believed that people's behavior was adequate to the situation. about violation of the public health dispositions, most of participants thought that violation should be punished more severely (90%) or that the national army should be implied (91%), as they reported to be preoccupied or angry toward such violations (89%). few reported to have bought more canned food (23%), and very few participants reported that they would try to escape if the infection would spread in their living area (2%), even if a great part of them (71%) believed that the infection fear could be considered a valid reason to break the containment rules. about the possible problem of accessing healthcare services, most of participants (71%) believed in the national health system, whereas few thought that it was right to give priority to people with greater hope of survival in case of shortage of hospital beds (25%) and even less (5%) that they would accept an exclusion for them or their loved ones at all kindly. about their opinions on the containment measures disposed, 98% of the participants thought that these measures were necessary, but only 56% thought that these same measures were adequate (the med group was more skeptical than the nom group), and 80% proposed to strengthen them. in line with this, most participants thought that it was right to limit people's freedom for controlling the virus (93%), as well as one's own freedom (99%), as they already limited their behaviors (99%). about the information, they reported to be properly informed about the virus (84%) and the social situation related to it (70%), but also requested more information from experts (68%). about perception of risk in public opinion, 64% of participants reported to think that it was lesser than it should be and 30% that it was greater. interestingly, 40% reported to think that there was some hidden information about the virus, and 68% of these that such hidden information was related to a greater danger related to the infection. the med group, instead, reported to be less convinced of the existence of hidden information (34% vs. 46% of the nom group). lastly, about the spread of the virus, the med group was more pessimistic than the nom group. in fact, they reported less likely that the spread would slow down in some days (19% vs. 45%) or in some weeks (71% vs. 78%). in this subsection, we present logistic regression results on the covid-19 questionnaire. we used each question as a dependent variable in a three-step hierarchical logistic regression. at step 1, we used as regressors the demographic variables (see "data analysis" section) and the living area, considering north italy as the reference (the coefficients reported should be interpreted as the odds that a participant from center or south italy would answer "yes" to a question compared to a participant from north italy). at step 2, we added as regressors the psychological factors of perceived stress, anxiety, and death anxiety. finally, at step 3, we included the group effect. along with step 3 results, we also provided semipartial correlation score for the relationship between each dependent variable and the group (coded as 0 = nom and 1 = med). for the sake of brevity, we reported only the questions for which we obtained significant regressors. at step 1 (see table 3 , step 1 block of columns), we included in the model only demographic variables. of these, the most influential were sex and age. with respect to male sex, female sex was linked to higher odds to be concerned by the following risks: being infected (1.68), loved ones being infected (1.71), developing serious complication or dying (2.99), global crisis (1.88), people's behavior in response of virus outbreak (1.89), infecting family members or love ones (2.38), and people's violating the containment provisions (2.65). in fact, females had higher odds to report that the public opinion had less riskrelated perception about covid-19 than it should be (1.80), that risky behavior should be punished more severely (3.37), that containment provisions should be improved (1.90), and that it would be right to limit people's freedom in this situation (4.71). in line with these results, they reported more likely to have not continued to attend public places and events (0.32). about age factor, older age was related to lower odds of reporting worries about the risk of infection for the loved ones (0.98), or about people's behavior as more dangerous that virus infection (0.95), or about the perception of risk in public opinion as lower that is should be (0.95). older age people also reported table 3 | hierarchical logistic regression odds for demographics (step 1), psychological (step 2), and group (step 3) factors for the covid-19 questionnaire. frequency of "yes" responses step 1 step 2 step 3 questions in italics showed imbalanced responses (almost all "yes" or "no"). sex was coded as 0 = male, 1 = female. group was coded as 0 = nom and 1 = med. ecq = existential concerns questionnaire (death anxiety scale); pss = perceived stress scale; stai = state-trait anxiety inventory. rightmost column (sp. cor.) reports pearson r for semipartial correlations between group and questionnaire responses (coded as 0 = "no" and 1 = "yes") controlling for all the other variables, i.e., sex, age, living area, anxiety, death anxiety, and stress. significance level marked as follows: + p < 0.10, *p < 0.05, **p < 0.01. frontiers in psychology | www.frontiersin.org lower odds to be concerned about their behavior as risky for themselves (0.97) or loved ones (0.96), but higher odds to be concerned about their health status in case of covid-19 infection (1.03) and by people reaction to virus spreading (1.03). lastly, they reported lower odds to request for more information by experts on media (0.96). also, the living area had a relative impact on the outcome variables at this step. with respect to participants from north italy, those from both center and south italy showed greater odds to judge the actual containment measures as adequate (center = 2.41, south = 2.74) and to think that some information about covid-19 was hidden from them (center = 1.69, south = 2.23), whereas they reported less likely to be at infectious risk (center = 0.46, south = 0.64 not significant) or to consider themselves at risk when the first cases were discovered in italy (center = 0.38, south = 0.41). of note, participants in south area reported lower odds with respect to participants in north area to consider fear of infection as a valid reason to violate the containment measures (0.47). at step 2 (see table 3 , step 2 block of columns) of hierarchical model, we added psychological factors of perceived stress (pss), anxiety (stai), and death anxiety (ecq). we found that these factors were related to few, but interesting outcomes. in particular, the pss score was related to a higher worry to be currently at infection risk (1.11) and a major need of information by experts (1.14), while their opinion on the virus spread was that it would show equal speed in the weeks following the compilation (0.84 for both accelerated or slowed-down spread). instead, the stai score was related to higher concerns of accelerated spread of virus in the weeks following the compilation of the questionnaire (1.14). lastly, the ecq score was related to a higher level of worrying about the covid-19 situation, in particular about possible severe outcome of the disease for themselves (1.16) or loved ones (1.11) and marginally related to higher level of worrying about possible catastrophic social global outcomes (1.05) or violation of containment measures (1.07). at step 3, we added to the logistic regression model the group factor to check for the predictive effect of being in the med or nom group while controlling for both demographic and psychological variables. results are reported in table 3, step 3 column (see the rightmost column). participants in the med group reported higher odds of thinking to be at actual risk of infection (2.71) and also to be at risk from the beginning of the covid-19 spread in italy (1.94). they also reported more likely to think that their family or loved ones were at risk of infection (1.70). the med group showed higher odds to report that the fear of contagion would be a valid reason to violate the containment measures (1.65) and that the ssn would adequately cure them in case of infection (3.78) and to report a sufficient level of information about the characteristics of the disease (4.53) and about the social situation relative to . they also reported less likely that some information about the virus was hidden (0.60), but the ones who answered affirmatively to this question had more than two times the odds with respect to the nom group thinking that such hidden information was related to a greater virus-related danger (2.70). about the spreading of the virus, participants in the med group were less probably convinced that the virus spread would slow down in the following days after the compilation of the questionnaire (0.28). lastly, the med group participants more likely reported that perception of risk in public opinion was lower than it should be (1.83). semipartial correlations mostly confirmed this pattern of results. however, differently from the logistic regression, this analysis revealed that the med group was related to the opinion that people's behavior was not adequate to the situation, r = −0.12, and to agree to give care priority to people with greater hope of survival, r = 0.27. also, semipartial correlations did not confirm the regression results for the questions about the fear of contagion as a valid reason to violate the containment measures, r = −0.05, and the adequacy of the ssn to take care of people in case of infection, r = 0.09. in this article, we investigated the worries and the perception of risk toward the health and social situation in italy related to the outbreak of covid-19. to this aim, we conducted a crosssectional study by means of online questionnaires administered to a convenience sample of volunteer participants including both health workers and the general population. we asked participants to report their worries and opinions about covid-19 in about 50 different questions combined with psychological variables measuring stress, anxiety, and death anxiety. we obtained and analyzed data from 353 italian adult, divided in 167 participants in the med group (medical doctors, paramedics, health workers, and students) and 186 participants in the nom group. we mainly compared the answers given to the questionnaires by these two groups. we also investigated the effect of the living area in italy, as the northern regions were more involved than the central and southern ones (cereda et al., 2020) . first, we assessed risky situations in which people were involved relatively to covid-19. as expected, people from north italy reported more direct experiences with covid-19, including more symptoms related to the infection, more prolonged quarantine status, more contacts with people at risk, and higher numbers of positive cases in their zone. the med group, instead, reported a higher number of contacts with people currently infected or at risk. thus, both living area and group predicted a major or minor probability to be involved in risky situations or contacts. following this, we found that participants from north italy reported higher levels of stress and anxiety and in particular that health workers in north area showed a higher level of both health workers from other areas and the general population from the same area. thus, both living area and job combined with the higher exposition to infection risk in order to increase the level of stress and anxiety in health workers from north italy. we would caution about the relatively small number of participants in each area divided by group: our results about living area should be considered strictly as preliminary. further studies are welcome in order to confirm or refute the results that we presented on this topic. however, we should note that our result was in line with the psychological response of health workers in china, where lai et al. (2020) found that psychological distress increased for workers closer to the outbreak of epidemic (i.e., who lived and worked in wuhan region) or assigned to patients affected by covid-19. thus, the same rule applies here: the closer to the risk of infection, the higher the risk of acute psychological distress. similar results were found in previous researches on new disease outbreaks. for example, wong et al. (2007) reported higher levels of anxiety in university students during the sars epidemic, in particular among medicine students and students living in the area in which the infection spread more. also wheaton et al. (2012) reported higher levels of anxiety in students in response to pandemic spread of h1n1. more generally, anxiety emerged in response to various viral diseases, from the annual influenza virus to the h1n1 pandemic (coughlin, 2012) . in the period of viruses spread, anxiety seems to increase in population along with mood disorders, and this increase was related to exposition and infection risk. in line with these results, participants of our study reported higher levels of perceived stress and of anxiety proportional to their risk of infection, i.e., health workers from north were more stressed and anxious than both their colleagues in center and south italy and the general population. while our result supports an acute increase of stress and anxiety, we should carefully monitor the psychological state evolution in order to assess also the effect of covid-19 over time. in fact, we expected that the virus spread and the quarantine state endurance in italy could have also mid-and long-term consequences. survivors from sars reported posttraumatic stress, anxiety, and depression symptoms 1 month after discharge, suggesting that lifethreating condition could have important psychic sequelae (wu et al., 2005) . such sequelae could be even more significant in health workers, showing higher levels of psychological distress both during and after a quarantine period (brooks et al., 2020) . for this reason, supporting psychological intervention for healthcare workers could be crucial in the first phase of an outbreak (xiang et al., 2020) , in particular considering that a timely and effective intervention could greatly reduce the later onset of posttraumatic stress disorder symptoms following a catastrophic event (watson et al., 2002) . we analyzed the answers to our questionnaire on covid-19 by means of logistic regression. for each item, we computed the response odds related to each regressor in three successive steps, by adding sequentially demographic factors, psychological factors, and the group factor. here we discussed the implication of all these computational steps by dividing the questionnaire items by content. in this section, we discuss the variable that we found for the items relatively to risk perception and worries related to the covid-19 outbreak in italy. group was strongly related to risk perception: healthcare workers showed about 2.5 times the odds of other participants to perceive themselves at risk of infection, as well as about two times the odds to think they were at risk even at the very start of virus outbreak in italy. moreover, they worried about their family situation and about virus spread as they reported that it would not slow down. this supported the idea that medical doctors, nurses, and paramedics had greater risk perception about the covid-19 infection, probably due to also a greater exposition to danger and to suspect positive cases. also, living area predicted the perception of risk, as both participants from center and south italy reported 0.5 times less preoccupation about risk of infection with respect to participants from north italy. again, combination of work, i.e., health workers, and area, i.e., north italy, combined for the greater perception risk. about the demographics, the stronger regressor of such worries was female sex, which was related to higher perception of risk, both at personal and family levels, and of a number of worries about social situation and people's behaviors. in particular, female healthcare workers were reported to be at higher risks of stress, anxiety, and depression during the covid-19 outbreak in china (lai et al., 2020; zhu et al., 2020) . this increased distress level in female health workers could be related to an increased perception of risk for themselves and for their relatives as we found in our study, as also reported usually in researches about risk perception in female participants (gustafsod, 1998) . our results suggested carefully supporting female healthcare workers implied in covid-19 treatments, as they could be more exposed to risk-related stress compared to their male colleagues. another important demographic variable was age, as we found that aged people were more worried than younger people about severe consequences of covid-19, as they already knew that the disease was more dangerous for older people, in particular when older than 60 years (novel coronavirus pneumonia emergency response epidemiology team, 2020). lastly, also psychological factors influenced the odds of perceived risk of infection. in fact, stress was related to increase in perceived risk, while death anxiety was related to the concern about fatal or severe consequences of covid-19. while the effect of both stress (traczyk et al., 2015; sobkow et al., 2016) and death anxiety (langford, 2002) on risk perception and risk taking was already reported in literature, it should be noted that higher levels of stress could also be due to actual exposure to contagion risk in the case of covid-19, as shown by our results about comparisons on levels of perceived stress between healthcare workers from north, center, and south italy. taken together, all these results suggested a higher risk perception relative to covid-19 in healthcare workers living in outbreak areas, especially if females and with high levels of stress. for covid-19, knowledge on medicine and on virus could thus increase risk perception, whereas in other fields such as nuclear radiation usually knowledge was associated to lower risk perception (e.g., sjöberg and drottz-sjöberg, 1991) . it should be noted that, in case of nuclear radiation, knowledge could be associated to an increase capacity of avoiding risky behavior or situations, whereas in case of covid-19 spread knowing, the health risks related to disease, but feeling powerless against its containment could exacerbate the danger perception. a reducing stress intervention by means of psychological support to medical workers could reduce the worries due to the perceived risk, so that they could avoid both risky behaviors and overwhelming, stressful concerns. we proceed here by discussing the variables related to risky behaviors, judgments about behaviors, and confinement actions. in this respect, female participants reported higher levels of worries about their own behavior, as well as other people's behaviors as risky. related to this, they also were four times more likely than men to report the thought that it would be right to limit people's freedom in order to block the virus spread and three times more likely than men to request more severe punishment for risky behaviors. capraro and sippel (2017) showed that females adopted stricter moral judgments than men in personal dilemmas, such as behaving appropriately in the actual covid-19 outbreak scenario. females seemed more prone to strict adherence to rules and even to imply stricter rules, probably also in relationship to their increased perception of risk (see section "risk perception and worries about covid-19"). also, the living area showed a strong relationship with these dependent variables. participants from center and south italy were more likely to judge the containment measures as adequate compared to participants from north italy. on note, participants from south also reported less likely than north ones that concerns about covid-19 were a valid reason to violate the containment measures. this result could be related to the recent great "escape" of people from the north italy (when virus spread initially) toward the south, increasing worries in south population, politicians, and medical staff. again, please consider results on living area no more than preliminary because of the limited number of participants per area in our sample. lastly, we should mention that both the group variable and the psychological factors had none or little impact on these variables thus, our data suggest that opinions and judgments about behaviors and containment actions rely more on demographic variables than on psychological or work-related ones. conflict of interests or searching media visibility. the same criticisms, however, are often not applied, for the antiscientific community, to the studies supporting their theories (kata, 2010) . all these factors could have an effect also on the underestimation of medical advices and warning on covid-19 infection by the general population, resulting in the unappropriated behaviors expressed. thus, providing more information to population could be ineffective, if not supported by psychological evaluation of social dynamics underlying the antiscientific phenomenon, for example, the questioning of the legitimacy of traditional authorities (see kata, 2010) . understanding how to contrast such a phenomenon could be even more important in case a vaccine for covid-19 is provided, as already happened for the h1n1 flu in 2009, when many people refused to vaccinate despite the availability of a vaccine (see offit, 2009 ). further studies are needed in order to investigate these contrasting hypotheses for planning effective interventions relative to public health problems. this study is not free from limitations. first, it implied a crosssectional design; thus, a relationship between variables could be interpreted only with cautions. second, we implied a convenience sample method to recruit our volunteer participants, with a possibility for introducing biases that could undermine the possibility to generalize our results to the entire population. we also collected a small sample with respect to the optimal one, i.e., about 450 participants (as suggested by bujang et al., 2018) , thus calling for caution while interpreting our results. for all these reasons, we should underline that our results could not be considered as conclusive and they should be confirmed with further experiments or studies. however, we should note that we conducted this study with two major difficulties. the first was a time-related issue: we had a very short time to collect data as the containment rules and the virus spread vary at a day-by-day rate. thus, we should collect our data in a concise and brief timeframe. the second issue was a logistic one: most people in italy, including the authors of this article, were quarantined at the time we collected and analyzed the data, so we were forced to opt for an online methodology of data collection. while methodologically limited, our results could open a number of possible future studies. first, this study could be considered as a time-zero data collection for a longitudinal study. in this regard, we would contact our previous participants in order to ask if they will participate to further data collection. thus, we could follow the change in risk perception and psychological situation in the general population and healthcare workers during the evolution of covid-19 infection spread. more experimental and cross-sectional studies are requested in order to better understand the relationship between healthcare workers' and the general population's information gap and risk perception in a pandemic disease scenario. this could help scientific community to find new strategies for conveying lifesaving information to population. reducing such information gap could also help in reducing the sense of separation between the healthcare workers and the rest of population and thus the sense of isolation with its negative psychological consequences on both groups. our study supports that a difference in risk perception between health workers and the general population exists and suggests a number of explanations for its causes as well as possible solutions to reduce it, with benefits in the psychological conditions of both groups of participants. more efforts need to be done in this direction, also because reducing psychological distress could advantage physical health state (prince et al., 2007) , in particular for medical staff facing such a difficult time, improving the quality of care they could provide (maunder, 2009; imai, 2020) . the raw data supporting the conclusions of this article will be made available by the authors, without undue reservation, to any qualified researcher. ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. the patients/participants provided their written informed consent to participate in this study. ls and cg designed the study and administered the questionnaire. ls conducted the data analysis. ls and cg wrote and revised the manuscript. both authors contributed to the article and approved the submitted version. an italian adaptation of the emotion regulation questionnaire death anxiety among emergency care workers the psychological impact of quarantine and how to reduce it: rapid review of the evidence sample size guidelines for logistic regression 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clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study covid-19 in wuhan: immediate psychological impact on 5062 health workers we would like to thank all participants to our study, who voluntarily donated their time. in particular, we thank healthcare workers, whose time is even more precious in this difficult situation for all the country, who participated and distributed the questionnaire to their peers and colleagues. finally, we would like to thank our colleagues and friends martina formisano, alessio montemagno, antonello catinari, francesco romano, elisabeth prevete, carola de berardinis, and salvatore chiarella for their valuable help and sustain. the supplementary material for this article can be found online at:https://www.frontiersin.org/articles/10.3389/fpsyg.2020. 02166/full#supplementary-material in this section, we discuss how demographic, psychological, and group variables impacted on the perceived level of knowledge relative to covid-19 and to its related sociopolitical situation. in this regard, the group was the strongest factor. in fact, healthcare workers reported higher odds than nonmedical participants of being properly informed about both covid-19 and its related social situation. they also were less likely convinced that some information about coronavirus was hidden from public opinion, but those who credited such secret information more likely believed that this information was about a greater virus threat. also, they reported the opinion that perceived risk in the population was not adequate. this result pattern suggests a large gap between the two groups about the perception of being properly informed.this information gap could explain the risk perception difference, because a greater knowledge could actually influence the personal risk awareness. it should be noted that, in general public opinion, the risk related to the new coronavirus was mistakenly considered as similar to that related to the common cold or annual influenza viruses, an error that could have been induced by the similarity in the spreading strategy and of some of the symptoms. this underrepresentation of fatal or serious outcomes of covid-19 led to a poor adherence to health recommendations in the very first phase of the coronavirus outbreak in italy, with important consequences afterward. these considerations seem to suggest that the reduction of such an information gap could eventually mitigate the disproportion in risk perception between groups and consequently increase the adherence to public health rules. also, our results seem to support this possibility because of the lack of information from experts lamented by more stressed participants, who also perceived a higher level of personal risk. to this aim, an information campaign about the novel coronavirus characteristics, its related disease symptoms and consequences, and public health problems linked to that could greatly support population in this moment, reducing the stress and also the risky behaviors.however, increasing the communication and the information could not be the most appropriated solution to the problem. in the last decades, especially because almost everyone has a large access to internet resources, we have witnessed not only a significant spreading of online information, but also misinformation; this is causing the diffusion of baseless rumors, difficult to erase from common people system of beliefs (kata, 2010; del vicario et al., 2016) . misinformation spreading combines with people's distrust in experts' authority, a more and more rising phenomenon despite the increase in the general education level. as a result, as proposed by gawande (gawande, 2016, p. 3): "to defend those beliefs, few dismiss the authority of science. they dismiss the authority of the scientific community. people do not argue back by claiming divine authority anymore. they argue back by claiming to have the truer scientific authority." this kind of problem is well known in the field of the unfounded, yet persisting, vaccine fear. in anti-vaccination movement, this mistrust phenomenon has been also exasperated by conspiracy theorists and other actors moving criticisms toward physicians and other experts, accused of having conflict of interest: the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.copyright © 2020 simione and gnagnarella. this is an open-access article distributed under the terms of the creative commons attribution license (cc by). the use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. no use, distribution or reproduction is permitted which does not comply with these terms. key: cord-263650-jxkjn8ld authors: andruske, cynthia lee; o'connor, deborah title: family care across diverse cultures: re-envisioning using a transnational lens date: 2020-10-20 journal: j aging stud doi: 10.1016/j.jaging.2020.100892 sha: doc_id: 263650 cord_uid: jxkjn8ld in an increasingly globalized world, the importance of developing a more culturally complex understanding of family care has been clearly identified. this study explored family care across three different cultural groups chinese, south asian, and latin american living in a metropolitan, pacific-west, canadian city. in-depth qualitative interviews were conducted with 29 family members from one of the three family groups exploring how they practiced ‘care’ for their aging, often frail, relatives. the importance of conceptualizing family care as a transnational, collective undertaking emerged from the outset as critical for understanding care practices in all three cultural communities. three themes identified contributed to this conceptualization: the need to broaden the understanding of family care; the centrality of geographic mobility, and the need to rethink the location of aging and consider its relationship to mobility; and the use of technology by extended family networks to facilitate continuity and connection. an over-riding notion of ‘flow’ or fluid movement, rather than a fixed, static arrangement, emerged as critical for understanding family care. this perspective challenges the dominant approach to studying family care in gerontology that generally conceptualizes family care practice as one local primary caregiver, often female, with some support from other family members. understanding family care from a transnational lens builds support for the importance of a feminist ethics of care lens and has important implications for policy and service delivery practices. canada, like many other western countries, reflects an increasingly globalized world with almost a quarter of adults living in canada selfidentifying as an immigrant (stats canada, 2019) . of these, 15% are over age 65 (stats canada, 2019) , and if they came after 1990, they likely belong to a culturally diverse community, including 48% from asia and the pacific region and 10% from south and central america (citizenship and immigration, canada, 2009) . a majority of older immigrants have come to the country under canada's reunification policy and are more likely to be living with and/or supported by family for at least 10 years after their arrival (mcdonald, 2011) . the need to understand the implications of this culturally diverse world on the aging experience (phillipson, 2015; torres, 2015) and the provision of family care (bryceson, 2019; chappell & hollander, 2011; keating & de jong gierveld, 2015; kirkland et al., 2015; roberto & anderson et al., 2002; guo, kim, & dong, 2019; pinquart & sorensen, 2003) and the differential uptake of support, both formal and informal (greenwood, habibi, smith, & manthorpe, 2015) . however, many questions remain. in particular, two gaps in this body of knowledge limit its usefulness. first, at a general level, the strong focus of the stress/burden model has tended to assume one fixed primary caregiver and resulted in an incomplete understanding of the role of the rest of the family in providing care and support (sims-gould & martin-mathews, 2007) . second, in considering ethnicity and/or culture in family care, this body of knowledge has rarely focused on finding a meaningful way to examine the significant role that immigration and acculturation may have in implicating family care practices (guo et al., 2019) . a second body of research, found largely outside of the gerontological literature, has focused more explicitly on the role of transnationalism and migration in family care. this body of work has explored intergenerational care across the life-span including a small but growing body of research examining care of aging parents. 'care' in this body of research has generally been extended to capture a diversity of caring arrangements and activities as proposed by finch (1989) and fisher and tronto (1990) . seminal work by a western australian research group (baldassar, baldock, & wilding, 2007 ; see also baldassar & merla, 2014) has been particularly influential as a foundation for considering transnationalism as it relates to family care in the field of aging. their work has explored how care for an aging parent is accomplished and negotiated between family members living far apart and in different countries. during one of their first ethnographic studies, they interviewed 100 australian immigrant families -about two thirds were of european descent with the remainder from new zealand (8), singapore (14), iraq (9), and afghanistan living in iran (21). to capture the experiences of both the immigrant adult children and older parents in their home countries, the researchers interviewed the immigrants in australia and the parents and other family members still remaining in the home countries. interviews included family and immigration histories, types of communication used, travel, and reciprocal care for care receivers and care givers based on finch's (1989) typology of family care exchange (financial, emotional, personal, practical, and accommodation) . additionally, the researchers observed and recorded how families organized space, tools, and other artifacts used for communication exchanges . the work of this research group has made important contributions for understanding transnational care. in particular, they highlighted the diversity and complexity of how care arrangements were negotiated and managed, drawing attention to issues such as how obligation may be culturally mediated, the impact of the migration process on establishing care capacity, and the importance of technology in these care arrangements. a small literature base has built on this body of knowledge as it relates to aging family care especially in europe (see for example, kordasiewicz, radziwinowiczówna, & kloc-nowak, 2018; miette sagbakken, spilker, & ingebretsen, 2018; zechner, 2008) . findings continue to demonstrate the complexity of understanding these family processes, and miette sagbakken et al. (2018) concluded by recognizing the importance of considering both the availability of kin members but also their understanding of obligation and reciprocity and how that might reflect their embeddedness in more than one society. despite its promise, however, this body of literature is only rarely addressed in the broader gerontological work on family care and a 'substantial void' in the caregiving literature remains in relation to understanding cultural values and processes (lee, chaudhuri, & yoo, 2015) , especially in relation to examining the experiences of non-western immigrants (dhar, 2011b; wilding & baldassar, 2018; zhou, 2012 zhou, , 2015 . this current study bridges these two, somewhat disparate, bodies of research. specifically, drawing on a broad understanding of care that is consistent with fisher and tronto (1990) ; also tronto, 2013) , the purpose of our study was to explore and compare the relationships between culture and informal family care practices across three diverse ethno-cultural groups: chinese, south asians, and latin americans living in vancouver, british columbia, canada. although transnationalism was not considered at the outset of the study, all three of these groups have unique immigration trajectories, with the latin americans representing a relatively recent group immigrating for political and economic reasons from south and central america while the south asians and chinese have much longer histories in canada. we explored the following questions: 1) what are the cultural interpretations and meanings of caring for an older family member within select ethnic minority communities? 2) how do cultural meanings of relationships influence the care process? this qualitative study drew on constructivist grounded theory (charmaz, 2014 (charmaz, , 2017b charmaz, 2017a) to explore the process and meanings of family care across non-western cultural groups. the constructivist approach is designed to facilitate development of a framework to better understand the processes individuals create around their experiences and ways of being in the world. in keeping with this, the interview was designed iteratively; the researchers began with a few broad questions in order to develop a deeper and richer exploration and understanding of concepts through reflection and theoretical interviewing. throughout the research process, it is important to acknowledge the reciprocity that exists between the participants and researchers as well as the expertise of the participants (charmaz, 2014 (charmaz, , 2017b charmaz, 2017a) . this also helps diffuse power imbalances between participants and researchers. adults self-identifying as chinese, south asian, and latin american, and providing unpaid, informal care or support to someone over the age of 65 needing some level of assistance with activities of daily living, were invited to participate. drawing on the work of finch (1989) and fisher and tronto (1990; tronto, 2013) , we conceptualized care as a "multifaceted complex social phenomenon, entailing both emotional and material (instrumental) aspects" (kordasiewicz et al., 2018, p. 77 )this encapsulated notions of caring for, caring about, providing care, and caring with (fisher & tronto, 1990 ) -and left it up to participants to describe what they meant by providing informal care or support. participant recruitment initially took place through researchers' personal networks, ads, and organizations in each of the chinese, south asian, and latin american communities. as the study progressed, snowball sampling was utilized, and participants were purposefully selected to ensure cultural, gender, and relational diversity. the final number of adults included 29 participants: nine (9) chinese (2 males and 7 females) from china, hong kong, and burma. ten (10) south asians (3 males and 7 females) originated from india, east africa, and england. the ten (10) latin american participants (2 males and 8 females) immigrated from chile, colombia, argentina, el salvador, and venezuela. table 1 provides an overview of the family members consenting to participate. with signed informed consent, up to three personal, semi-structured, audio taped interviews were conducted with each of the 29 individuals in the language of their choice. to capture cultural meanings and connotations and ensure carers' comfort and ease of expression, all but four individuals chose to be interviewed in their native language (cantonese, hindi, punjab, or spanish). the interviews were designed as an iterative process where three experienced researchers (each fluent in the respective group's native language/s) began with broad questions focused on family members' experiences and perceptions of providing informal care or support to an older adult, and then developed a deeper and richer exploration of concepts through reflection and theoretical interviewing. topics included exploring how each defined giving care in terms of their own cultural beliefs and backgrounds, and how -from their perspectives -these influenced the assistance or support they provided. consistent with a constructivist grounded theory approach, interview questions were honed and refined throughout the data generation process to explore emerging concepts and understandings. follow up interviews, ranging between a couple of weeks to a month after the first interview per the accessibility and schedule of participants, were conducted, and for some a third meeting, focused on expanding and verifying insights. at the end of the final interview, a demographic questionnaire was completed orally with each participant to collect information about both the carer and care receiver (for example, age, education, health status, financial resources, time in canada, citizenship, and others). ethical approval was obtained through the ethical review board from the university of british columbia. table 2 below provides a picture of care receivers as described by their relatives. each family was caring for or assisting at least one parent, spouse, or relative ranging in age from 65 to 100. some care receivers were healthy and independent while others had severe health problems such as alzheimer's, heart problems, or other diseases. in keeping with canada's family reunification program (mcdonald, 2011) , 27 of the 29 older adults had immigrated to canada to reunite with their families. although only two latin americans still resided in south america, visiting their adult children only when economically possible and based on immigration policies, they planned on immigrating at a later date. furthermore, the 27 care receivers had lived in canada for 10 years or more and in some cases, even for 30 to 39 years (10). also, most care receivers (22) either lived with the carer or a family member. data analysis was a collaborative (team), iterative process using a strategy consistent with the constant comparative method. first, all taped interviews were translated verbatim, (to capture cultural meanings), into english by the respective research associate who conducted it. next, a three-stage process began with the research associate affiliated with each of the three groups analyzing several interviews and coding them. then, associates with the principal researcher in vancouver met to discuss the interviews to analyze meanings, initial codes, and compare these among the three cultural groups. using these team decisions and codes, a code book was developed. it was then used to conduct a line-by-line coding of each transcript. atlas-ti facilitated this coding process. once data was coded, the research team began looking for links among codes to develop categories, for creating broader themes as they began to emerge. these were then refined and developed through subsequent interviews with the participants and by returning to the data. data revealed a process of family care that was complex and dynamic across all three cultural groups. specifically, a sense of flow and fluidity created a picture of care as a shared phenomenon -across family members and geography -that was highly dependent upon communication technology. hence, a significant theme that emerged across all three groups was the importance of conceptualizing family care as a transnational, collective undertaking underpinned by three themes: broadening the conception of 'family care'; locating family care as transnational; and increasing reliance on technology. in this study, consistent with existing research dhwan, 1998; flores, hinton, barker, franz, & velasquez, 2009; guo, li, liu, & sum, 2015; hsueh, hu, & clarke-ekong, 2008; pharr, francis, terry, & clark, 2014) , family care emerged as a normative cultural expectation in all three groups. however, each labelled and described the concept differently. for example, for the chinese (ch) participants, this revolved around the language of filial piety and/or 'ganqing' based on a relational sense of moral duty and responsibility, resulting from confucianism. these values were generally volunteered spontaneously and explicitly: it is our "culture" to "look after" the elder. it's more emphasized in our education from when we were kids....although my parents never said: 'you have to take care of me,'… but from a young age when we were "brought up," you know "ganqing" [you feel you] have to take care of him/her… especially those with alzheimer's (an 1 -ch daughter caring for mother, age 80, with alzheimer's). supporting this perception as a culturally expected norm, sing mei, caring for her chinese parents, noted: 'i see my other friends, they also doing the same thing to their parents, to take carce of their parents' (sing mei -ch daughter caring for parents, ages 75+). south asian (sa) participants also positioned family care as a normative cultural expectation, but they were more likely to draw upon a religious understanding: describing caring for seniors and others as part of their religion where caring for others is an ingrained culturally expected religious responsibility to serve god and, thus, others. for instance, depicting this link between 'seva' or religious service and 'farz' note: ⁎ the two chinese caregivers worked outside of canada longer than they resided inside of canada. ⁎⁎ originally, 10 chinese agreed to participate. however, one male dropped out. ⁎⁎⁎ two of the south asians indicated that another person was also the "primary" caregiver with them. ⁎⁎⁎⁎ nr -= no response to request for age ⁎⁎⁎⁎⁎ one wife was also a daughter-in-law to one of the male la participants. of la americans, 2 were only children. or cultural responsibility, kavya, a south asian wife, caring for her husband and living with their daughter stated: 'culture, we are so religious from inside that we are taught from the beginning culture and religions, they are the same, and they run parallel.' kavya explained further: our foundation is such right from the start; serving others is like our religion. it is like serving god when we look after someone who is sick. we are told from childhood to look after sick people. what our children are doing…is part of our culture. in our culture, we teach to share. we shared with them; they are returning it to us. (kavya -sa wife caring for husband, age 70+) although religion is an important underlying value for the latin american (la) participants in this study, they described and explained caring for elders, family, and friends as 'deber' or duty. here, "family obligation" was based on the notion of collective loving family relationships and loyalty to family cultural values that extended beyond duty to immediate family into the community of friends. sandra, a previously paid health care provider, recently retired to care for her aging chilean mother, captured latin american cultural caring as collective and communal: as a family member, there is the affective aspect. never would i leave a parent, a very good friend, godmother, or whatever, if they don't have a family member or a person close to them. i feel that it is my "deber" (duty and obligation) for feelings for sentiments. i feel it is my "deber" to take care of/be concerned with that person, pay attention to them. (sandra -la daughter caring for mother, age 94) caring for elders as a social expectation of being a 'good' son, daughter, or family member in the kin relationship network, then, was consistent across all three cultural groups. these cultural expectations also extended to friend networks described by many participants from all three groups. moreover, participants explained this care was a reciprocal act embedded within the social fabric of the culture. subtle differences in the foundations for understanding these expectations emerged, however. caring obligations appeared to be linked explicitly to religion for south asian participants, but it seemed more related to the teachings of political philosopher, confucius, for the chinese whereas latin americans tended to describe caring as a more collective sense of family extending beyond blood relationships. importantly, across all three cultural groups, this notion of family care was communal, embedded in a loose definition of the extended family network that included friends, blood relatives, and relational family. to illustrate, in our study, carers did not define a primary caregiver, but they discussed caring in terms of networks and relationships. even only adult children like argentinian rossana pointed out that she had created networks from her family (husband, daughter, and grandchildren, among others) and paid companions as well as her 92-year-old mother's long-time friends to provide support and care. another argentinian, 50-year-old casimiro, an only adult son, drew on his partner and extended family, like his female cousin living in seattle to provide support and companionship for his aging mother living independently. casimiro commented: my cousin, andrea, who is like my sister, comes from seattle every two months, and sometimes she stays for a week with my mother to keep her company. when i am here at my breaking point, she comes. she takes over. she releases me. for example, she came last week, and she cooked for two weeks. she leaves things prepared. she cares for my mother all the weeks. she takes her; she brings her back. she gives me license… (casimiro -la son, only child, assisting mother, age 81) thinking further about his support network, casimiro explained: when i have problems with her [my mother], andera, my cousin, and daniel, my partner, are the two people who assist me…ahhh. i have a very good friend of hers in the [spanish community] group also…. that woman is very, very good also, and she helps me too… yes…she knows her [my mother] very well. she is from ecuador, and she knows the latin culture very well, so she cheers me up. (casimiro -la son, only child, assisting mother, age 81) care was often described in terms of friend networks that provided support. for example, yoyi, a colombian business woman and daughter-in-law noted: 'in my country, (laughs) if someone is sick, 20 people arrive to care for them' (yoyi -la daughter-in-law coordinating care for mother-in-law, age 89) while a sa daughter, aaliyah, commented, 'my white friends get very surprised that my friends come right away when i need them.' furthermore, aaliyah (sa) explained that friendship was much more: 10-19 = 7 2 = 85-89 1 = diabetes2 = prostate 4 = mothers 1 = independently 20-29 = 1 2 = glaucoma2 = hard of hearing ⁎⁎⁎ 1 = father 30-39 = 2 40 = 0 south asians (13 ⁎ ) ⁎⁎ 2 = 70-74 2 = 65-69 2 = alzheimer's 8 = mothers 7 = with caregiver ⁎⁎⁎ 1-9 = 0 1 = 70-74 1 = bedridden 3 = fathers 4 = independently 10-19 = 7 2 = 75-79 2 = 75-79 1 = brain hemorrhage 1 = wife 1 = care home 20-29 = 2 2 = 80-84 9 = no health issues reported 2 = husbands 1 = with cg's brother 30-39 = 4 1 = 85-89 1 = mother-in-law 40 += 0 1 = 100+ latin americans (11 ⁎ ) 2 = 75-79 2 = 65-69 3 = alzheimer's 7 = mothers 5 = with caregiver ⁎⁎⁎⁎⁎⁎⁎ 1-9 = 0 1 = 75-79 1 = pace maker ⁎⁎⁎ 1 = father 3 = independently 10-19 = 2 2 = 80-84 2 = diabetes 1 = husband 3-nursing homes 20-29 = 1 1 = 85-89 1 = prostate cancer 1 = daughter-in-law 30-39 = 4 3 = 90-94 1 = stroke 1 = aunt 40 = 2 ⁎⁎⁎⁎⁎ 3 = old age 2 = visit c& live in south america 2 = healthy note: ⁎ number of care receivers is greater because some caregivers are caring for more than one person. ⁎⁎ one south asian caregivers was also a care receiver. ⁎⁎⁎ 2 chinese indicated 2 health issues; 2 chinese indicated 3 health problems; 2 latin americans reported 2 illnesses ⁎⁎⁎⁎ although some of the south asians indicated that the cr lived with them, in actuality, a number would live part-time with others in the family assisting with care. ⁎⁎⁎⁎⁎ one cr was a canadian by birth but had lived outside of canada for a number of years. ⁎⁎⁎⁎⁎ one latin american cr was born in south american but resided in the us ⁎⁎⁎⁎⁎⁎⁎ some started out living independently and then lived with cg or returned to independent lving, or started out living with cg and then moved o a nursing home. i went to india after 16 years, believe it or not, my friend kept my mother with her for a full month. who would do that? i can't imagine. my mother was very happy. if she [friend] hadn't, we couldn't have gone to india. we both had to go, me and my daughter, we couldn't have thought of it. we didn't worry at all. it is our culture. if there is anything, i know that my friends are here, i don't have family, but my friends will be there. (aaliyah -sa daughter caring for mother, age 80+) in essence, two types of friend networks emerged during conversations with participants: friends of carers (as pointed out above) and friends of care receivers. although care receiver friend networks may not have provided direct care for their aging friends, they offered different types of support. this 'care' was more supportive and reinforcing companionship. five of the la participants spoke directly to the importance of this support: for example, rossana, an only child, maintained: [my 92-year-old mother] has two friends, well, she had. she has another friend who telephones her every so often…..sometimes she goes to visit her, but only once a month, but my mother counts on that. my mother has a little book where she has everyone's telephone number written down, and she calls… she asks people to call for her because she can no longer dial because she has lost her dexterity, so someone dials for her, and so she can talk. (rossana -la daughter, only child, caring for mother, age 92) the deeply embedded cultural values, perceptions, and actions held by these three ethnic groups regarding family care created tensions within the canadian context for some, especially for those individuals dealing with relatives suffering from alzheimer's or severe illness. for instance, a recently retired chinese daughter, an, whose mother with alzheimer's lived with her and her retired chinese husband recognized the stress of this tension as she talked about how she had visualized her retirement quite differently: …after i retired, i was hoping to live the life of a retiree, hoping to do some traveling and enjoying life in retirement, doing more activities. but because i have to take care of an elderly [80-year-old] person with "alzheimer," i can't do what i want to do personally. (an -ch daughter caring for mother, age 80, with alzheimer's) for an, even though caring for her aging mother was causing stress in her marriage, as a chinese wife and daughter, pointed out: this situation is -…because she's my mother, and she's very afraid of going into a seniors' home, and i can't -my heart myself -basically i'm chinese, so "until" she really cannot "manage" one day, i mean when i cannot "handle" her "at home," i cannot bear to send her away to a seniors' home. (an -ch daughter caring for mother, age 80, with alzheimer's) other participants from the three cultural groups articulated views about cultural tensions between the canadian context and embedded cultural values of their elders. according to abhijeet, a retired south asian son, caring for his 100-year-old mother, 'there is culture in us,…a 30-year culture…we brought with us [when we immigrated to canada], …still alive in us. we know, it is not for us, we know…elders from india, after 60, when their life is almost over, they cannot change' (abhijeet -sa son caring for mother, age 100). sandra, the la retired health care worker, addressed the necessity of balancing canadian beliefs and way of life with her cultural values since she has a canadian born son and her 94-year-old chilean mother living with her. sandra was clear, however, that she would ensure that her chilean mother's cultural family caring beliefs would be respected and honored despite what others might say. the doctor told me, "…well… there are institutions where you can put your mother." i said, "forget it! forget it! my mother is never going to be in an institution either." because the doctor is also chilean, and he would say, "forget what i said. forget it." because i would just look at him, "do you really think my mother would accept going there?". (sandra -la daughter caring for her mother, age 94) nevertheless, as a 17-year immigrant to canada, sandra's changing values were reflected in her views of her own future old age in canada. i say to my son, "forget it. i am canadian now. the day that i begin to fail, in front of my house, there is a nursing home, you don't have to do any more than cross the street, and you put me there" (laughs). because my son is canadian, and he's going to marry a canadian girl, so then i must accept that the canadian family is different so his wife might think, ya the woman [mother-in-law sandra] is very slow, and there [nursing home] she will be very calm. (sandra -la daughter caring for mother, age 94) other participants expressed similar change s in their values the longer time they spent in canada. participants despite some accepting the changes in cultural values, abhijeet, retired south asian son and husband, a long-time resident (17 years) of canada, expressed the tensions that emerged in all three groups in this way: my parents, my father, her [wife] parents, my grandfathers, these are their pictures. when they were aged, they were looked after. at that time, the culture was different. now, it has changed. people over here are westernized, who bothers? go and leave your mother there [nursing home]. we'll pay money there. your attachment?. (abhijeet -sa husband and son caring for wife, age 68, and mother, in summary, family, kin, and friend care networks often were bounded, at least loosely, along cultural lines in their beliefs, intentions, perspectives, and actions. participants across all three cultural groups in this study drew firmly upon cultural beliefs about family care to make sense of their actions and responsibilities. for many, cultural perspectives about family care helped them explain their own sense of responsibility. importantly, however, cultural values also set the foundation for caring arrangements that were much more communal and relational. the sense of responsibility, however, could create tensions as participants experienced perceived cultural clashes regarding the understanding and meaning of familial care. a surprising theme to emerge early in this study was related to the relevance of geography and mobility to the flow of care. care processes were fluid, often transcending national, international, and geographical boundaries. mobility involved all members of the care network, including the person being cared for. geographical flow of care often consisted of the care receiver being cared for or supported across multiple households and geographical borders -both within the immediate locality as well as across different countries. furthermore, individuals providing some type of support or 'care' varied in terms of the type of relationship (immediate family; extended family; or friend networks) and location. one description of the mobility of the flow and fluidity of care between households by the immediate family was explained by chaaya, a south asian daughter, sharing care of their mother with her sister: mummy, from the time she came from india, first she lived with me, and later my sister moved out, and now she lives with my sister. half the week she lives here, and the other half she lives with my sister, and she has a very flexible schedule, and we are happy to keep her with us. there is joy in the house, that there is an elder in the house. (chaaya -sa-daughter caring for mother, age 67) while the movement of this flow of care often occurred with immediate families at the local level, particularly for frail care receivers, surprisingly, mobility of care receivers took place fluidly across transnational borders. it was not uncommon for older adults, particularly if health allowed, to spend time (often months) with family members either between different households locally or dispersed throughout north america and/or transnationally in a former country of origin. often, it was difficult to determine what country or geographic location was 'home' to the older adult care receiver given the frequency and regularity of these mobile relocations. although some chinese and south asian individuals were mobile locally and nationally, this transnational movement phenomenon tended to be more frequent among latin americans. what was clear in the data was the complexity of facilitating this geographical movement. to illustrate the intricate and complicated support arrangements created by extended families, margarita, chilean only daughter, caring for her 90-year-old mother later diagnosed with alzheimer's, described: i have a cousin who lives in los angeles. she is my mother's niece, and she called me one day and said, "i'm going to chile. do you want me to take my aunt?" i said, "yes," so that we bought her a ticket so that she could go to chile, and so that afterwards she would be able to go to brazil. i have a son in brazil. we bought her the ticket. i, my boyfriend, and my mother travelled to los angeles where my cousin lives, and from there my cousin took her to chile, and, initially, she was going to stay with her brother there, but it didn't work out, and before she left, we looked for another arrangement, and a distant relative, said that she could have her in the house, and for a reasonable amount of money so much so that she went there for a month, and after a month, she went to my son's house in brazil. (margarita -la only daughter caring for mother, age 90, with alzheimer's) as explained above, planning trips was extremely cumbersome. participants not only had to take into account the complicated nature of planning travel for their aging parents, but they needed to account for other factors influencing movement across international and national borders. for example, ignacio, the youngest son of three colombian brothers, explained that although his 68-year-old mother was independent and able-bodied, she is afraid of airplanes, so she cannot come alone. she is very frightened of airplanes, [and] she speaks absolutely nothing of english, or rather, for her to come alone is not an option either…" to counteract these issues, "we need to go there and bring her here, …" and then accompany her back when she returns to colombia. (ignacio -la son assisting mother, age 68) ignacio pointed out the importance of revising immigration, airline, and health policies, and programs to facilitate travel for aging immigrant parents: 'if they [policymakers, healthcare professionals, airline owners, or others] would simplify the way to bring parents, that way they would not have to become permanent residents or citizens.' he described ways travel could be facilitated and more accessible for older as well as frail adults. ….a program,…, where someone could bring them [older adults], and one wouldn't need to go and bring them here, rather that there would be a system where someone could bring various at a time, accompanying them in the airplane and helping them with running around for immigration. that would exist a way in that they could have tickets, a discount on the air fares….in the future an easier and faster way would exist that if the children are here, and the parents are alone there to make the immigration process faster because the time that they are there alone, well, it could become a risk that they experience other inconveniences because they are alone. (ignacio -la youngest son assisting mother, age 68) finally, not only was the older adult mobile, carers also travelled within or between cities nationally or internationally to help provide care for aging relatives. jasmine, a chinese canadian daughter, stated: [when i was] away in toronto for a brief period, about a bit more than a year, my sister came to live with her' [their mother]. …, my sister, my brother-in-law, and my father were with my mother. in the end, they left, went back to hong kong. in 2002, i came back from toronto to be with my mother. (jasmine -ch daughter caring for mother, age 80+, with alzheimer's) a prevalent theme underpinning the data from all three ethnic family networks indicated the importance of technology for facilitating an approach to family care that promoted a geographically fluid caring experience. in its least sophisticated form, technology included regular telephone contact -both locally and transnationally -with other family members and the care receiver. however, it also involved taking advantage of 'newer' technologies such as email and skype. the importance of telephone connection was highlighted by many: 'comfort was just a phone call away,' noted chaaya, a counselor and sa daughter. it enabled sibling and kin caring for older adults to be in 'communication all the time, absolutely, all the time, so that, well, or rather directly with her and through my sisters…' (chaaya -sa daughter sharing care with her sister of their mother, age 67). low cost international calling was relied upon extensively. regular phone contact -sometimes daily -was maintained between family networks. this ensured all members were involved in daily life and decision making for the senior and family. it also helped reduce stress for those currently providing hands-on care and ensured all family members had an understanding of the older adult's care needs. this allowed each family member to contribute to care decisions as they emerged daily based on each person's abilities and time to assist with and participate in the care and support process. meiling, 73-year-old chinese wife, caring for her 77-year-old husband with dementia e pointed out: our daughter came two years ago to see her daddy, but she has work and children and family, so they can't come every year….they have to wait for the right time, the children's summer holidays, to come over. so we rely on telephoning. they call 1, 2, or 3 times a week to talk with us. it's good. at least with the phone call, you get to know the situation. you can talk…now, they ask how's life with daddy, how he's deteriorating, get to know his conditions, that can help me reduce my stress [laughs heartily]. (meiling -ch wife caring for husband, age 77, with dementia) illustrating the many ways phone calls were used strategically, one son, ignacio, − a physician working in canada as a researcher -telephoned not just to keep his mother in colombia close to him but also to assist in monitoring her health: in actuality, we do it [call] once a week, and i ask her how her health is, if she has had medical appointments. i always find out what happened during the medical appointment, what medicines, what exams they ask for, what prescriptions she is taking, how she is feeling. perhaps, her health is the most important thing that i am aware of in addition to that, her emotional state. (ignacio -la son assisting mother, age 68) while not a replacement for actual physical contact and recognizing the complexity and financial cost associated with travel, phone calls were helpful. much of the calling was, not unexpectedly, between members of the family kin network, but the potential value of using telephone contact with health professionals strategically to keep family aware and involved, was also raised. thinking about his mother, ignacio suggested: -to find a way that the doctors there [in colombia] can communicate with the children here [in canada]…one could send them an email or tell them…a communication bridge to tell them how he found my mother, what needs to be done, because my mother goes to the doctor, and the doctor explains a mountain of things in medical terms that she is not going to understand. she goes home, and i ask her how it went, and she tells me fine. (ignacio -la son assisting mother, age 68) frequently, telephone calls were used to share news, keep in touch, and communicate -often daily. usually, these calls dealt with the mundaneness of daily living and celebrations. some extreme examples demonstrated the importance of contact as a lifeline. for instance, one venezuelan niece, leila, described how a visa problem limited her ability to travel, so she had to rely on an international call to talk with her dying aunt. previously, leila had cared for her aunt for more than 15 years in the us. devastated that she could not be by her aunt's side in her last moments, leila remembered saying as she listened over the phone to her aunt's labored breathing: little aunt, you are with god. never be afraid because god is with you. you will see that you are going to be super well. god loves you. i don't know how much. i love you so much, you know. (leila -la niece caring for aunt, age 75, with alzheimer's) leila recognized the importance of emotional caring by an extended family member as a fundamental aspect of care. the warmth of family caring could not be replaced by professional caregiving -and her simple use of telephone contact allowed leila to continue providing loving, heartfelt, emotional support, connection, and comfort. not being able to be there…, it was like disappearing from her life. before that…, we talked, and all, but……it was that i was there at every moment for her [when she had been caring for her aunt with alzheimer's on a daily basis in the us]. the woman [professional caregiver] she had was excellent, but it was not the same quality, or rather the love, or rather the quality of care could have been very special, very professional, and all, and…very affectionate, latina, …, quality, but nothing like the love of the family. (leila -la niece caring for aunt, age 75, with alzheimer's) despite its utility and importance for emotional support, comfort, and communication, technology had some downsides. even with reduced costs of international calling cards, daily international calls still remained expensive. moreover, telephone calls could be intrusive to one's personal life as explained by casimiro, argentinian son, an only child: if she [my mother] needed something, she would call me a number of times. i tell you that because if not, she becomes another of the things; this …is very interesting. with her, one must have balance because i visit her every day. she becomes very possessive, and afterwards, she thinks i have the obligation! at the same time, when i answer the telephone every time, but i do not answer one time, she says to me, "why didn't you answer the telephone!" …i say, "mami, i am working. i am doing business. sometimes, i cannot attend to you. leave me a message, and i will answer you." it is something very interesting. it is like an education…if i answer her immediately every time, sometimes when i do not answer, it is "oh, lala!" (laughs). (casimiro -la son, only child, assisting mother, age 81) beyond the telephone, other types of technology -for example, skype -emerged as an important facet for facilitating more traditional views of collective caring and played a key role in uniting local, national, international, and transnational 'carers.' it brought family members at a distance closer together in terms of proximity, particularly for some latin american participants. a vivid illustration of how technology facilitated day-to-day involvement was offered by antonia. despite residing a continent away, this 37-year-old female doctoral candidate described the continued closeness between her two sisters living in venezuela, her mother, and herself in canada. antonia pointed out that through technology, she, as the youngest daughter, was in constant communication with her mother in order to be part of and share experiences with her mother's daily life: by…using skype, we also see each other. then, if she goes saturday to have lunch at my sister's, my nieces turn on the computer. i say, mami, get on so that i can show you the little flower that bloomed on the plant. then, i show her through the house with the computer showing her the little flower, and it is so wonderful…it feels wonderful because she knows… as if she had come to actually see how it is doing, what the house is like here, and if the plant, and if it grew or if it didn't grow. i show her how…i hung a few new pictures. then, through skype, i can see the paintings. this makes it easier. (antonia -la youngest daughter supporting mother, age 66) technology played an important role in facilitating and fostering the fluidity and flow of care for cultivating a sense of closeness, proximity, and presence of family, kin, and friend networks caring for and involved in the life of the older person and family. as described by all three family cultural groups, technology spanned local, national, and geographical distance and transnational borders to bring comfort, support, presence, closeness, and involvement in decision making while allowing family, extended kin, and friends to participate in seniors' daily lives and experiences at a distance. recognizing the importance of culture within a context of informal family care, the research team for this study sought to better understand the process of family care within three ethnic communities in vancouver, bc, canada. a broad understanding of giving care was adopted, allowing participants to self-identify their role in the care process from their cultural perspectives. this, perhaps, set the stage for the importance of fundamentally challenging conventional ideas associated with the study of family care in north america that has often focused on one 'primary' caregiver. specifically, across all three cultural groups, our findings support an understanding of family care as truly occurring within broader family kin (and friendship) networks that tended to be culturally bounded, often loosely, but not geographically constrained. this meant that in all three cultural groups, but especially with the latin american participants, it was often difficult to name a 'primary' caregiver since even only children, like rossana and casimiro, created extended kin and friend support networks that aided in the provision of support and care. consistent with this approach, none of the family carers identified themselves as the 'primary' caregiver. the notion of a primary carer was further disrupted by the mobility and use of extended travel by both the older adult to live with other family members and/or by family members spending time with the older adult making it difficult to even determine the location where primary care was being provided. our participants described complex negotiated decisions made by kin networks as a collective family undertaking about how, when, where, why, and by whom care and support would be provided to aging seniors. care was fluid and flowing throughout individuals, networks, time, space, distances, and ages. this suggests to us the need to extend ideas about aging in place -a term that commonly directs policies and practice -to consider more specifically the notion of 'aging-across-place' (r. beard, personal communication, august 17, 2020) as a relevant concept for understanding care within culturally diverse, immigrant groups. these findings position family care using a lens that is far broader and relational than the narrow focus on the provision of instrumental care that has typically dominated understanding of family care within conventional gerontological literature. hence, our findings support the much more inclusive and complex approach to care offered by scholars, such as finch (1989) and tronto (2013) . tronto has developed the concept into an ethics of care framework. grounded in feminist relational theory, an ethics of care lens captures the reciprocity of care in that we are all interdependent, both receiving and giving care throughout our lives. in this framework, tronto identifies five principles to guide the provision of care: attentiveness, responsibility, competence, responsiveness, and solidarity. these correspond to five phases of care: 'caring about,' 'caring for,' 'care giving,' 'care receiving,' and 'care with.' these phases are fluid and can operate simultaneously and sometimes contradictorily, across different relationships. pragmatically, the phases and corresponding principles capture the complexity of the caring process and provide a useful lens for exploring relationships: purpose, needs, emotions, and power. this framework lens may be especially important for understanding the interface between the experiences of family and formal care, particularly within ethnically diverse communities where underutilization of formal supports has, in many cases, been identified as a problem. second, our findings raise questions about how place of residence may be re-interpreted and understood as a more fluid concept than is typically assumed with movement occurring at the local, national, and international levels. in raising these insights, the study contributes to the understanding of family care as a transnational global phenomenon and bridges two important bodies of research. as identified in the introduction, migration scholars introduced the importance of a transnational perspective to describe and conceptualize relationships individuals and communities develop and sustain across geographical distances and national borders (baldassar, 2007; horne & schweppe, 2017) . with few exceptions (baldassar, 2016; baldassar et al., 2007; merla, 2014) , this lens has rarely been applied to the study of aging and/or understanding family care of older adults (amin & ingman, 2014; horne & schweppe, 2017; näre, walsh, & baldassar, 2017; zechner, 2008) , especially related to non-western cultural groups (dhar, 2011b; torres, 2015; wilding & baldassar, 2018; zhou, 2012 zhou, , 2015 . this lens did not initially inform our research. however, the importance of it emerged early on in the data generation phase, and, consistent with a grounded theory approach, was used to help question, refine, and develop understanding. for example, we began to explore the fluidity and flow of care, role of technology, and describe how some ethnic older adults experience this notion of aging across different geographical places. our research suggests that this lens has much to offer to the study of family care in gerontology and supports findings by baldassar et al. (2007, baldassar, and merla, 2014 ) that family care does not need to be proximate in order to be effective. a transnational lens draws attention to a number of areas that require further exploration and development. first, consistent with the work of baldassar, nedflcu, merla, and wilding (2016) ; wilding, 2006; wilding & baldassar, 2018) , and others (see for example, ahlin, 2020; lee, lee et al., 2015) , the promises and challenges of information communication technology (ict) for facilitating a more holistic understanding and enactment of 'family care' emerged as a critical aspect of family care that requires further examination. our findings lend texture to wilding's (2006) suggestion that technologies blur lines of imagined proximity and physical separation as families creatively incorporate diverse types of technologies into their provision of care to meet cultural, social expectations, and health needs in these contexts that tend to be particular to specific points in time. it supports the value of ict for 'enacting everydayness' (ahlin, 2020) , p. 76 as a key theme related to 'good care at a distance.' one powerful example of the blurring of distance and time in this study was the graduate student, antonia, having lunch with her mother daily via skype. an understanding of the importance of ict also highlights ways of re-visioning the provision of formal support. for example, family conferences using supportive technology may help ensure that the entire family -irrespective of geographic location -has the necessary information to provide quality care and support, particularly for ethnic collective cultures. ensuring both the availability and uptake of effective communication technology infrastructures and digital literacy for older adults and their families will be an important area for research and service development. this is especially urgent in these times of covid 19. our study also supports the works of bryceson (2019), wilding and baldassar (2018) , and zhou (2012 zhou ( , 2015 that focused on the need to better understand how structural issues may impede the process of family care. transnational care or 'distant care' has received little recognition in the area of policy development (baldassar & merla, 2014) , and yet, as identified by at least one participant, ignacio, in our study, policies and practices, for instance around travel, may deter families from being able to care and provide culturally appropriate support in the way that they want while residency requirements may act as barriers for use of health and social care support services. future research is needed to understand how diverse health and social policies in both the home country as well as the country of immigration impact family care ( lee et al., 2015) . finally, attention to the notion of care as fluid and flowing for both able-bodied as well as those who are frail or ill emerged from our study as an important finding. 'flow of care' related to the presentation of negotiated, reciprocal, and shared family collective informal care was based on ability, availability, and capacity to care, occurring in motion, fluidly, through time and space as the care receivers transitioned and moved geographically to be with family as they aged and/or family moved to be with them. in addition to being consistent with an ethics of care framework, this notion develops further the work related to the circulation of care being developed by baldassar and merla (2014) ; . the concept of care circulation offers a broad view on transnational care through its focus on 'the reciprocal, multidirectional, and asymmetrical exchange of care that fluctuates over the life course and within transnational family networks subject to the political, economic, cultural, and social contexts of both sending and receiving societies' (baldassar & merla, 2014, p. 25) . in some of their work, they have examined how the older adult contributes in this circulation of care: an important limitation of our study is that we did not explicitly explore the role of the older person in the family care process except in relation to receipt of care. further research is needed to broaden and deepen the picture of family care, addressing more explicitly the role of reciprocity within the process. through this study, we explored the process of providing informal care to a family member within three diverse, non-western cultural immigrant communities. findings highlight the importance of recognizing family care as more communal and geographically fluid, supported by the innovative use of technology. the study suggests the need for a reframing of our understandings of family care -for example broadening moving from a notion of 'aging in place' to one of aging across geographical locations -and the need for policies and practices that can accommodate a different way of providing family care. we need to reinterpret care as flowing freely and fluidly throughout family, kin, and friend networks of informal, collective, and communal care through space, time, and distances locally, nationally, transnationally, and globally. no conflict of interest existed by the authors. good care" with icts in indian transnational families eldercare in the transnational setting: insights from bangladeshi transnational families in the united states transnational families and aged care: the mobility of care and the migrancy of ageing de-demonizing distance in mobile family lives: co-presence, care circulation and polymedia as vibrant matter families caring across borders: migration, aging and transnational caregiving transnational families, migration and the circulation of care: understanding mobility and absence in family life ict-based co-presence in transnational families and communities: challenging the premise of face-to-face proximity in sustaining relationships comments about a concept in the text of a manuscript from the editor of the 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concluding reflections: 'care circulation' in an increasingly mobile world: further thoughts dementia and migration: family care patterns merging with public care services ageing in transnational contexts: transforming everyday practices and identities in later life culture, caregiving, and health: exploring the influence of culture on family caregiver experiences placing ethnicity at the centre of studies of later life: theoretical perspectives and empirical challenges differences between caregivers and non-caregivers in psychological health and physical health: a meta-analysisanalysis at the intersection of culture: ethnically diverse dementia caregivers' service use diverse family structures and the care of older persons theorizing in family gerontology: new opportunities for research and practice family caregiving or caregiving alone: who helps the helper? immigration and ethno-cultural diversity highlight tables. immigrant status and period of immigration, 2016 counts, both sexes, age (65 years and over), canada, provinces and territories, 2016 census -25% sample data expanding the gerontological imagination on ethnicity: conceptual and theoretical perspectives caring democracy: markets, equity and justice virtual' intimacies? families communicating across transnational contxts ageing, migration and new media: the significance of transnational care care of older persons in transnational settings space, time, and self: rethinking aging in the context of immigration and transnatonalism time, space and care: rethinking transnational care from a temporal perspective we would like to thank dr. daniel lai (formerly of the university of calgary and now the hong kong polytechnic university) and acknowledge his leadership for this project.we would like to thank research assistants sonia andhi, msw for her work with the south asian interviewees and dr. sing mei chan for her assistance with the chinese participants as well as their help during the research process. a special thank you goes to, vancouver public librarian marilyn macpherson for her help in locating some of the statistics canada data.we are especially grateful to the chinese, south asian, and latin american participants and their families for sharing their experiences of caring and supporting their elderly relatives. this research was made possible by a canadian institutes health research grant (cihr #178845 -npi: dr. daniel lai) canada. this research was approved by the ethics committees from the university of calgary (calgary, ab) and the university of british columbia (vancouver, bc). key: cord-354972-nc496v6s authors: margolin, emmanuel; burgers, wendy a.; sturrock, edward d.; mendelson, marc; chapman, rosamund; douglass, nicola; williamson, anna-lise; rybicki, edward p. title: prospects for sars-cov-2 diagnostics, therapeutics and vaccines in africa date: 2020-09-10 journal: nat rev microbiol doi: 10.1038/s41579-020-00441-3 sha: doc_id: 354972 cord_uid: nc496v6s the emergence of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) has resulted in a global pandemic, prompting unprecedented efforts to contain the virus. many developed countries have implemented widespread testing and have rapidly mobilized research programmes to develop vaccines and therapeutics. however, these approaches may be impractical in africa, where the infrastructure for testing is poorly developed and owing to the limited manufacturing capacity to produce pharmaceuticals. furthermore, a large burden of hiv-1 and tuberculosis in africa could exacerbate the severity of infection and may affect vaccine immunogenicity. this review discusses global efforts to develop diagnostics, therapeutics and vaccines, with these considerations in mind. we also highlight vaccine and diagnostic production platforms that are being developed in africa and that could be translated into clinical development through appropriate partnerships for manufacture. coronaviruses are ubiquitous rna viruses that are responsible for endemic infections in humans and other animals, and sporadic outbreaks of potentially fatal respiratory disease in humans. four human coronaviruses, namely hcov-229e, hcov-oc43, hcov-nl63 and hcov-hku1, circulate in the human population, causing the common cold, with some causing potentially life-threatening disease in infants, young children, older individuals and individuals who are immunocompromised 1 . in the recent past, two additional coronaviruses have crossed the species barrier from other animals to infect humans. these are severe acute respiratory syndrome coronavirus (sars-cov) and middle east respiratory syndrome coronavirus (mers-cov), which emerged in 2002 and 2012, respectively 2,3 . in december 2019, a novel betacoronavirus, subsequently named sars-cov-2, was implicated in an outbreak of respiratory disease in wuhan, china 4 . the first cases to be reported presented as atypical pneumonia and were traced to the huanan seafood wholesale market, although cases without any association with the market, and predating the putative index cases, were subsequently recognized. following these first reports, community transmission rapidly ensued, culminating in a global pandemic 5, 6 . the virus is speculated to have originated in bats and possibly to have passed through another host before infecting humans, but an intermediate host or intermediate hosts have yet to be defined. this remains the subject of considerable debate, and recent work suggests that the host receptor-binding motif of sars-cov-2 was acquired through recombination with a pangolin coronavirus [7] [8] [9] , but further work is needed to establish the origin of the virus. infection with sars-cov-2 in humans manifests as coronavirus disease-2019 (covid19) , a spectrum of disease that ranges from asymptomatic infection to acute respiratory distress syndrome with multisystem involvement. older individuals and individuals with co-morbidities are at greatest risk 10 . in individuals who are symptomatic, fever and cough are most commonly reported, although sore throat, shortness of breath, fatigue, anosmia, dysgeusia and gastrointestinal involvement are also frequently observed 5, 11 . extrapulmonary manifestations of covid-19 are being increasingly recognized. among adults with preexisting diabetes mellitus, diabetic ketoacidosis may be a common complication and is associated with a poor prognosis 12, 13 . according to the international diabetes federation, africa has an estimated 19.4 million adults aged between 20 and 79 years living with diabetes and is the region with the highest proportion of undiagnosed diabetes 14 . neurological and neuropsychiatric complications have also been recognized as presenting or complicating factors 15 . children generally have a milder course of disease and are more likely to be asymptomatic, although recent reports have described hyperinflammatory shock in children who were previously asymptomatic that seems similar to kawasaki disease [16] [17] [18] . further studies are required to determine the prevalence of this phenomenon and to define the immunological the first documented cases in a disease outbreak. a rare condition associated with inflammation in blood vessels that most commonly presents in children under 5 years of age. drivers of the illness. however, the contrasting presentation of covid-19 in children and adults suggests that the immune responses of children and adults to sars-cov-2 may be different. the virus continued to spread globally, prompting the implementation of radical travel restrictions and social distancing measures 19 . at the time of writing this article, the virus has resulted in over 25 million confirmed infections and has claimed the lives of over 850,000 people 6 . as of 8 august 2020, there have been over 1.2 million confirmed cases of covid-19 in africa, with 29,833 deaths reported (africa cdc) there is concern that the pandemic may pose an even greater risk to countries in africa owing to their weak health-care infrastructure, large burden of co-infections, including hiv-1 and tuberculosis, and ongoing outbreaks of emerging and re-emerging infections such as ebola virus (democratic republic of congo) and lassa haemorrhagic fever (nigeria) that will divert much-needed resources away from the fight against covid-19 (ref. 20 ) ( fig. 1 ). differences in global population demographics and health status are also likely to affect the severity of the pandemic in different regions and are a major concern in africa ( fig. 2 ). in addition to the health-care infrastructure, the general infrastructure throughout africa is also highly variable, and thus access to appropriate medical care is an important determinant of covid-19 disease outcome. the number of hospital beds in a population of 10,000 individuals varies from as low as 1 in mali to 32 in libya. however, libya is an exception for the region, and many central and west african countries are at the lower end of this range and generally report fewer than 10 beds per 10,000 individuals. this is in stark contrast to other developed countries such as germany and the usa, where 80 and 28.7 beds per 10,000 individuals are available, respectively. a similar trend is also seen for the number of doctors per 10,000 individuals. in more than 10 african countries, less than 1 doctor is available (per 10,000 individuals), whereas germany and the usa report 42 and 26 doctors (per 10,000 individuals), respectively 21 . concerns have been raised regarding the impact of the pandemic on other diseases and access to essential medicines 22 . for example, according to a newspaper article, the ministry of health in zimbabwe reported a 45% increase in malaria infections compared with 2019 (ref. 23 ). many african countries lack the capacity to implement widespread testing, including the identification of asymptomatic and mild infections that are major drivers of the pandemic 24 . although it is difficult to determine the number of tests conducted in many africa countries, the publicly available data clearly highlight the limited testing capacity on the continent. south africa is currently conducting the largest number of tests per 10,000 individuals (0.5/10,000 individuals), whereas many other countries, including ethiopia, nigeria, zimbabwe, tunisia, senegal and rwanda, perform fewer than 0.1 tests/10,000 individuals. this is markedly less than in the usa (1.54/10,000 individuals), the uk (0.9/10,000 individuals), italy (0.91/10,000 individuals) or germany (0.55/10,000 individuals) 25 . similar infrastructure limitations constrain the development of prophylactic vaccines and therapeutic interventions, which results in a concerning reliance on developed countries. another important consideration in the response to the pandemic in africa will be to limit the impact of the virus on vulnerable economies where prolonged lockdowns may not be feasible. the first case of covid-19 in africa was reported in egypt on 14 february 2020; subsequently, infections -19) pandemic. this is worsened by the high burden of infectious diseases, which may worsen disease outcome and compete for the available resources. a further challenge is the dire economic consequences of prolonged lockdowns in countries with weak economies. www.nature.com/nrmicro have been documented in 44 other african countries, with south africa reporting the highest number of cases 6 . interestingly, in spite of the obvious challenges in combatting the growing pandemic, african countries have observed a delay in the exponential growth trajectory that has been described by countries in the developed world 26 . this may be partly attributable to lower testing capacity in the region and the impact of implementing lockdowns in the early phase of the pandemic. the warmer climate has also been proposed to influence the spread of covid-19, which could explain the delayed pandemic in africa compared with the rest of the world, although this is largely speculative (box 1). the transition into winter in southern africa has been accompanied by an increase in sars-cov-2 infections, further complicated by seasonal influenza and limited influenza vaccine availability. in this review, we discuss the global efforts to develop diagnostic tests and therapeutic options to treat covid-19, as well as the vaccine platforms for immunization, with a focus on the opportunities and challenges for africa. the diagnosis of sars-cov-2 poses a major challenge owing to the prevalence of asymptomatic infections, pre-symptomatic infections with high viral loads in the upper airways (probably at peak infectivity) and the range of non-specific symptoms that manifest in individuals who are symptomatic 5, 24 . widespread testing is therefore critical to identify infected individuals who are asymptomatic, pre-symptomatic and symptomatic, and to enable contact tracing and isolation 27 . whereas this has been highly successful in countries such as germany and south korea, it is not generally possible in most african countries where the infrastructure is weak. indeed, in countries such as south africa, where widespread community testing was attempted, this has resulted in a very large backlog of tests and delays of weeks for returning test results, which are then rendered meaningless for quarantining of cases and containment 28 . in many african countries, testing is only available for severe cases of presumed covid-19, and self-isolation is recommended for less severe cases. therefore, reported cases and true prevalence do not equate. accordingly, the capacity provided by academic laboratories and pharmaceutical companies is being leveraged to increase testing capacity further, as has been necessary even in developed countries 29 . diagnosis of acute infection is by pcr with reverse transcription of respiratory tract specimens, which is generally performed in central laboratories with specialized equipment 30 . scale-up of testing is a major challenge for countries in africa, owing to laboratory infrastructure, costs and availability of test reagents that are largely imported and currently stretched global supply chains. a recently launched, continent-wide initiative, population demographics and prevalence of known co-morbidities for each of the six world health organization regions. although africa reports a lower average age compared with other regions, the burden of infectious disease is disproportionately high. both hiv and tuberculosis are associated with an increase in coronavirus disease-2019 (covid-19) disease severity, and their prevalence in africa will increase the risk of fatal infection for a large number of people. there is also a large proportion of individuals in africa with raised blood pressure, which is a known risk factor for severe disease. other known co-morbidities, including raised cholesterol, raised glucose and obesity, are less prevalent in africa compared with the other reported regions. raised blood pressure (systolic blood pressure ≥140 mm/hg or diastolic blood pressure ≥90 mmhg), raised fasting blood glucose levels (≥7 mmol/l or taking medication), raised total cholesterol levels (≥5 mmol/l) and body mass index (bmi) >25 are reflected as age-standardized estimates. all data shown reflect the latest available data from the world health data platform (global health observatory). the number of people living with hiv-1/aids (in millions) reflects the population of individuals who were infected in 2018, tuberculosis cases shown reflect the number of incident cases in 2018 and malaria cases reflect the estimated number of cases in 2017. nature reviews | microbiology the africa medical supplies platform, seeks to leverage collective purchasing for procurement of testing supplies, personal protective equipment, medical equipment and even, potentially, future vaccines 31 . in addition, repurposing of rapid, automated molecular diagnostics platforms such as genexpert® (cepheid), which is widely used for the diagnosis of tuberculosis in south africa, has the potential to decentralize and accelerate testing in certain countries, including using mobile testing centres, although test kits are also in limited supply. however, this has to be understood in the light of the potential for unintended consequences on the management of tuberculosis, with fewer diagnostic platforms being available as a result of increased sars-cov-2 testing. testing for tuberculosis in south africa has reportedly decreased by 50% during the lockdown period and, concurrently, the weekly average of microbiologically confirmed tuberculosis cases decreased by 33% (ref. 32 ). recently, a rapid method of heating samples prior to quantitative pcr with reverse transcription has shown promise to improve the turnaround time for testing and bypasses the need to order rna extraction reagents or kits 33 . furthermore, a rapid crispr-cas12-based test has also been developed to diagnose infection from respiratory sample-derived rna 34 . the test yields a result within 1 h and is less reliant on sophisticated laboratory infrastructure and test reagents that are in limited supply. implementing this test in africa could be a useful way of expanding the current testing capacity and could offer a faster turnaround time for high-priority cases. serology-based testing approaches have been proposed, but the delay between infection and the development of detectable antibodies (within 19 days) renders this approach impractical for the diagnosis of acute infection 35, 36 . nonetheless, these tests are critical for seroprevalence studies and to identify appropriate donors for convalescent sera, and potentially for the isolation of monoclonal antibodies that can be developed as therapeutics. serology studies are also crucial for understanding the longevity of the antibody response after infection, with the key caveat that it is not known whether humoral responses are a correlate of immunity against the virus. in addition, preliminary data suggest that not all individuals who are infected may seroconvert 37 , and early evidence is emerging that antibody levels may wane rapidly during the convalescent phase 38 . several serological assays have already been developed, and binding antibodies against the spike and nucleocapsid proteins are both indicative of past sars-cov-2 infection 39, 40 . many of these assays are also commercially available, but their specificity and sensitivities seem to be variable 41 . a major outstanding question is which antigen, or region of the antigen, is most appropriate for serology testing. most assays have favoured the spike glycoprotein for the detection of an immune response against the virus, although it is worth noting that the nucleocapsid is the most abundant viral antigen 42 . recent work has suggested that the receptor-binding domain alone may be sufficient to detect antibody responses to sars-cov-2, and given that it is not conserved between coronaviruses, its use may limit cross-reactivity arising from other coronavirus infections 43 . nonetheless, a nucleocapsid-based elisa (enzyme-linked immunosorbent assay) may be the easiest to implement in an african context as the antigen could easily be produced locally at low cost. nucleocapsid could be produced in escherichia coli, pichia pastoris or even in plants, as has been reported for the nucleocapsid proteins of three bunyaviruses, two of which were used successfully in validated assays [44] [45] [46] . moreover, the biovac institute in south africa has the capacity for bacterial fermentation and the required infrastructure for downstream processing, and a new plant-based production facility (cape bio pharms) is currently generating s1 protein derivatives as reagents. although the spike glycoprotein is heavily glycosylated and needs to be expressed in a more complex expression host to ensure appropriate post-translational modifications, both mammalian cells and plants would be suitable to produce both spike and nucleocapsid, and novel approaches to enhance recombinant glycoprotein production in plants have also been developed in south africa 47 . given the optimistic development timeline of 12-18 months before any vaccines could be available for widespread use, it is clear that these efforts will not box 1 | potential impact of climate on sars-cov-2 dissemination the comparatively low incidence of coronavirus disease-2019 (covid19) in africa has raised the possibility that climate could influence the spread of severe acute respiratory syndrome coronavirus 2 (sars-cov-2). there is some circumstantial evidence describing a possible association between higher temperatures and lower severity of covid-19 to support this hypothesis; however, outbreaks in malaysia, hong kong, australia and south africa seem to be inconsistent with this theory as large numbers of infections have been reported despite higher temperatures [130] [131] [132] . the influence of climate could potentially account for the severity of the pandemic in central china and northern italy, where winter may have been particularly conducive to the spread of the virus 131 . these cold conditions are reminiscent of the environment in which sars-cov first emerged in china in november 2002 (ref. 133 ). although these observations are compelling, it is noteworthy that many of these studies have yet to undergo formal peer review, and the accuracy of species distribution models is constrained by variability in global testing capacity 134 . for example, infections in many african countries are expected to be an underestimate that reflects the lower number of tests conducted. it is also acknowledged that numerous other variables could influence the spread of the virus and may confound interpretations of the impact of climate. these variables may include variation in population density and age distribution, timely lockdown measures, adherence to social distancing protocols or even childhood vaccination with mycobacterium bovis bacille calmette-guérin as examples 135 . the impact of differing behaviour, with increased social mixing, in the winter months also cannot be discounted 136 . as with many respiratory pathogens, both middle east respiratory syndrome (mers-cov) and sars-cov exhibit decreased viability in the laboratory following exposure to increasing temperature and humidity 137, 138 . similar observations have also been reported for influenza virus and respiratory syncytial virus, for which the incidence of infection is highest under cold and dry conditions, which results in seasonal cycles of infection 139, 140 . a similar seasonality has also been observed for other endemic human coronaviruses, which led to the speculation that sars-cov-2 may also conform to a seasonal cycle of infection 136 . however, although all four endemic human coronaviruses (hcov-229e, hcov-oc43, hcov-nl63 and hcov-hku1) exhibit a marked winter seasonality 141 , the pathogenic human coronaviruses (mers-cov and sars-cov) do not conform to such a defined infection cycle. for example, mers-cov generally occurs mostly during summer months in the middle east despite temperatures often exceeding 50 °c 142 . by contrast, the highest incidence of sars-cov was reported during the winter months, although the outbreak continued to spread throughout spring in hong kong 143, 144 . therefore, more research is needed to define the impact of climate on the spread of sars-cov-2. a diagnostic test that measures the presence of antibodies in blood to determine exposure to pathogens or to diagnosis autoimmune diseases. sera obtained from individuals who have recovered from an infectious disease and contain antibodies against the pathogen. www.nature.com/nrmicro affect the first wave of the pandemic 48 . more importantly, the lack of manufacturing capacity in africa and the global demand for immunization against the virus will further delay the availability of vaccines in the region. repurposing existing drugs presents a feasible short-term strategy to manage the pandemic, especially given that some of the drug candidates are already available and have an established safety profile in humans 49 . these drugs would face lower regulatory barriers for approval and, in addition to being used for treating active infections, may have potential to be used as prophylactics for individuals at high risk, such as health-care workers or those who have been in contact with documented cases of infection. currently, two treatments have been shown to have an effect on the outcome of covid-19. the broad-spectrum antiviral drug remdesivir has been shown to shorten the recovery time in adults admitted to hospital with severe covid-19 in a publication of preliminary results from a double-blind, randomized, placebo-controlled trial in the usa 50 . however, remdesivir did not reduce mortality. by contrast, initial data from the recent recovery trial in the uk suggest that daily oral or intravenous doses of dexamethasone (10 mg for 10 days) reduced mortality by one-fifth in hospitalized patients with proven covid-19 requiring oxygen therapy, and that mortality was reduced by one-third in patients who needed mechanical ventilation 51 . it had no effect on patients hospitalized with covid-19 who were not requiring oxygen. the reductions in mortality were seen in patients whose symptoms started >7 days before receipt of the drug. the fact that a commonly used corticosteroid could reduce mortality in this trial is promising, as numerous other corticosteroids such as prednisolone and hydrocortisone (which were options in the recovery trial in pregnant women) are equally available, and some of them are manufactured in africa, which means that access may be less of an issue than for other more novel medicines. more commonly available medicines have been, and some continue to be, used in investigational treatments for covid-19. the commonly available antimalarials chloroquine and hydroxychloroquine were among the first to be investigated. initial studies were small and underpowered, and some combined hydroxychloroquine with azithromycin 52 and some proved highly controversial in relation to their conduct, leading to retraction 53 . one of the arms of the recovery trial included hydroxychloroquine, and on 4 june 2020 the independent data monitoring committee review of the data concluded that there was no beneficial effect of hydroxychloroquine in patients hospitalized with covid-19 (ref. 54 ). shortly after, the world health organization (who) announced that recruitment for the hydroxychloroquine arm of the solidarity trial was being stopped 55, 56 . all experimental treatments should either be introduced into properly conducted clinical trials or, if a country decides to use such a medicine outside a trial, then it should be controlled according to the who's monitored emergency use of unregistered interventions (meuri) framework, whereby it can be ethically appropriate to offer individuals investigational interventions on an emergency basis, in the context of an outbreak characterized by high mortality 57 . large-scale adaptive studies such as the recovery and solidarity trials continue, and such trials will reduce the time taken for randomized clinical trials 58 . several african countries, including south africa, burkina faso and senegal, are in the process of joining the solidarity study. similarly, small studies are ongoing in several countries, looking at the utility of convalescent plasma from patients who recently recovered from covid-19 as potential prophylaxis or treatment 59 . the need for randomized control trials using this treatment modality has been stressed 60 . unlike other investigational medicines, convalescent plasma can be readily produced, even in low and middle-income countries, through the national blood transfusion service, making it an attractive option for study. however, scaling production for use is the rate-limiting step for this intervention. preliminary studies identified monoclonal antibodies with the ability to neutralize sars-cov-2, which may also be important candidates for both treatment and prophylaxis, although similar issues with manufacture are a challenge 61, 62 . there is increasing recognition that pathophysiology of severe covid-19 includes an appreciable component of hyperactivation of inflammatory responses, manifesting as a cytokine storm and secondary haemophagocytic lymphocytic histiocytosis. in addition to the findings relating to dexamethasone detailed above, various immune-modulating drugs have been proposed as treatment options for covid-19. the il-6 inhibitors tocilizumab (actemra; roche) and sarilumab (kevzara; sanofi and regeneron), which are used to treat arthritis, are already being used in patients with covid-19 (nct04327388) 63 . their mechanism of action involves the prevention and the inhibition of the overactive inflammatory responses in the lungs. both drugs have entered phase iii clinical trials for sars-cov-2. a late-stage clinical trial with another il-6 inhibitor, siltuximab (sylvant; eusa), started in italy in mid-march (nct04322188). anti-inflammatory drugs used in combination with an antiviral drug such as remdesivir may increase the potential of the drug to improve disease outcome 64 . genentech has recently initiated a phase iii trial (remdecta) to study the efficacy and safety of tocilizumab and remdesivir in patients hospitalized with severe covid-19 pneumonia (nct04409262). additionally, the covacta study (nct04320615) will evaluate tocilizumab and standard of care versus standard of care alone in a similar cohort 65 . patients who have chronic medical conditions may be at higher risk for serious illness from covid-19, including those with pulmonary fibrosis 66 . the antifibrotic drug pirfenidone (genentech) has already entered a study to evaluate its efficacy and safety (nct04282902). recombinant angiotensin-converting enzyme 2 (ace2; apn01) that lacks the transmembrane region of the protein was developed by apeiron biologics for the treatment of acute lung injury and pulmonary artery hypertension. the soluble ace2 has the potential to reduce lung injury by activating the anti-fibrotic and a disproportionately large cytokine response that promotes inflammation and is harmful to the host. nature reviews | microbiology anti-inflammatory angiotensin (1-7)-mas receptor axis of the renin-angiotensin-aldosterone system, and by acting as a decoy and preventing infection by binding to the sars-cov-2 virus and inactivating it. apn01 is being tested in a phase i trial in china, and approval has been secured to carry out phase ii trials in austria, germany and denmark (nct04335136). currently, there are no targeted therapies for covid-19. however, numerous drug discovery programmes are in progress, and a recent study reported a structure-based drug design strategy, as well as virtual and high-throughput screening to identify lead compounds that bind to the main protease of the virus (m pro ; also known as 3cl pro ) 67 . the active site of the protease is highly conserved among coronaviruses, making a strong case for pursuing an m pro -targeting drug. the organoselenium drug ebselen, which is an anti-inflammatory and antioxidant, showed high affinity for m pro and showed promising antiviral activity (concentration that gives half-maximal response ec 50 = 4.67 μm). thus, the presented approach may greatly accelerate the discovery of drug leads with potential in the clinic. the drug discovery and development centre (h3d) based at the university of cape town is the only fully integrated drug discovery centre in africa that has taken a drug into a phase ii clinical trial. the centre has very strong collaborations with the pharmaceutical industry and mmv, a leading product development partnership, as well as the infrastructure and expertise to find potential therapies against covid-19. h3d has assembled chemical libraries for its malaria and tuberculosis projects that could be screened to identify possible drug leads against sars-cov-2; however, this will require additional resources and funding because the centre is contractually focused on antimalarial and anti-tuberculosis drug development. the infrastructure for large-scale, high-volume vaccine manufacturing is largely absent in africa, and the rapidly escalating covid-19 pandemic highlights the urgent need for capital investment in the region to lessen reliance on developed countries. the few facilities that are available are specialized, and are not well-suited to produce vaccines for sars-cov-2 (table 1) . it is also anticipated that it would take a minimum of 18 months to build a suitable manufacturing plant under ideal conditions, and therefore to contribute to the global covid-19 vaccine initiative, african developers will need to outsource large-scale manufacturing in the short term. the african vaccine manufacturing initiative, which aims to develop local manufacturing capacity in africa, has established a working group and is actively engaged with key stakeholders to meet the local need for a vaccine. innovative biotech (nigeria) has already partnered with medigen (usa) and merck (germany) to apply their insect cell production platform to producing virus-like particles with the intention of initiating a clinical trial in nigeria. similarly, the ethiopian public health institute (ephi) is planning to partner with techinvention (india) to produce the sars-cov-2 spike protein in a yeast-based fermentation system, although limited details are available (personal communication, s. agwale, ceo of innovative biotech). last, biovac (south africa) has modern facilities at a modest scale and has initiated a feasibility study for a large-scale facility with an annual minimum production capacity of 100 million vaccine doses for covid-19 and future pandemic vaccines, as well as vaccines for routine immunization use (personal communication, p. tippoo, head of science and innovation, biovac). given the global demand for a covid-19 vaccine, it is likely that even when a suitable candidate is approved for human use, there will be a considerable delay before it is available in africa. this is not unprecedentedduring the 2009 h1n1 influenza pandemic, a global shortage of influenza vaccines resulted in limited supplies being provided for countries in the region, and, in fact, the vaccines only became generally available after 2010 (ref. 68 ). this unfortunate, but entirely plausible, scenario may necessitate prioritizing high-risk groups, such as health-care workers and older individuals, to receive the first sars-cov-2 vaccines to reach africa. more than 100 vaccine candidates are currently in preclinical development around the world, and 15 vaccines are already being tested in clinical trials 69, 70 (table 2) . these vaccines are mostly focused on eliciting immunity against the spike glycoprotein, although other viral antigens may also have a role in vaccine-mediated protection (box 2). the speed of clinical deployment of these vaccines is unprecedented, but there are concerns regarding the longevity of immune responses and the potential although the rapid progress to clinical testing is encouraging, it is still too early to determine whether they will confer immunity against sars-cov-2 infection or whether they will ameliorate the disease course following infection. the only peer-reviewed report of a sars-cov-2 vaccine in clinical trial to date is for cansino biologics' ad5-ncov vaccine, which recently completed phase i testing. encouragingly, the vaccine elicited both binding antibodies and antigen-specific t cells, although, disappointingly, only 50% of volunteers developed neutralizing antibodies in the low (5 × 10 10 viral particles) and medium (1 × 10 11 viral particles) dose regimens. however, 75% of the high-dose group (1.5 × 10 11 viral particles) developed neutralizing antibodies. perhaps unsurprisingly, the high-dose group also reported a higher incidence of adverse effects following vaccination and only the low and intermediate doses will be pursued in phase ii trials 71 . despite the absence of suitable facilities for current good manufacturing practice (cgmp)-compliant vaccine or therapeutics manufacturing in most of africa, considerable expertise in preclinical vaccine development is also available in academic institutes, and vaccines could be manufactured on contract for clinical trials as was the case for the south african aids vaccine initiative 72 . accordingly, groups at the university of cape town (south africa), the national research centre (egypt) and the kenya aids vaccine initiative (kavi) have all confirmed that early-stage research on sars-cov-2 vaccine development is underway -although further details have not been disclosed 73 . important considerations for these vaccines will be the cost, their safety in individuals who box 2 | sars-cov-2 virus structure and targets for vaccine development severe acute respiratory syndrome coronavirus 2 (sars-cov-2) comprises pleomorphic virions, ranging from 60 to 140 nm in diameter, with prominent glycoprotein spike proteins projecting from the virus surface 4 . the virion also contains the membrane, envelope and nucleocapsid proteins, which encapsulate the viral genome and accessory proteins (see the figure, left). the spike protein is a glycosylated type 1 fusion protein that mediates infection by binding the host membrane-anchored angiotensin-converting enzyme 2 (ace2) 145 . the glycoprotein is organized into extracellular (s1) and membrane-spanning (s2) subunits, which mediate receptor binding and membrane fusion, respectively (not shown). binding of the spike protein to ace2 results in a conformational change that enables the dissociation of the s1 subunit and the insertion of the fusion peptide into the host membrane 146 . the spike glycoprotein is the primary target of vaccine development, based on the premise that neutralizing antibodies against spike will prevent viral entry into susceptible cells (see the figure, right). this is supported by preclinical immunogenicity studies, for the related middle east respiratory syndrome coronavirus (mers-cov) and sars-cov, for which immunization with spike-based vaccines elicited protective antibody responses 147, 148 . more recently, neutralizing antibodies against the sars-cov-2 spike have been reported in natural infection; these are readily elicited and frequently target the receptor-binding domain in s1 (ref. 35 ). the potential role of cell-mediated immunity in coronavirus vaccines generally has not been as well explored. it is reasonable to expect that cellular immune responses would contribute to viral clearance and ameliorate the severity of the disease, as well as support the development of antibody responses. accordingly, robust and durable cellular responses have been observed against the spike, membrane, envelope and nucleocapsid proteins in patients who recovered from sars coronavirus infection [149] [150] [151] . ultimately, both cell-mediated and humoral responses are desirable in a vaccine, especially given the observation that cellular responses are longer lived than antibodies following infection with sars coronaviruses 152, 153 . mhc, major histocompatibility complex. humoral immunity: • neutralizing antibodies prevent interaction of spike with ace2 • antibody effector functions can contribute to viral clearance • b cell memory for durable immunity genetic immunization with plasmid dna is perhaps the easiest vaccine modality to develop for clinical trials as the manufacturing process is well established, the incumbent costs are low compared with other platforms and multiple clinical trials have shown their safety. technological advances have also substantially reduced the time from identifying the viral sequence to initiating immunizations in humans 74 . accordingly, dna vaccines have been advanced into the clinic in response to several emerging pathogens, including mers-cov, and inovio pharmaceuticals (usa) have already completed recruiting participants to initiate a phase i trial with a candidate dna vaccine against sars-cov-2 (nct04336410) 75 . recent preclinical data demonstrated that the vaccine elicited neutralizing antibodies in both mice and guinea pigs, and an unrelated study reported that immunization with a dna vaccine protected against viral challenge in macaques 76, 77 . genetic immunization is well-suited to clinical development for africa, and candidate vaccines could be manufactured to cgmp standards using one of the contract manufacturers offering this service. however, there are no licensed human vaccines based on this platform, and the current delivery methods are not suitable for large-scale immunization. host-restricted viral vectors are another promising vector platform for immunization in africa 78 . replication-deficient chimpanzee adenovirus-based vaccines have shown promise for several emerging viruses, and given their simian origin, they circumvent concerns for vector-specific immunity as was observed when using human adenoviral vectors for immunization 79 . a single dose of a mers-cov-2 vaccine using this platform was reported to elicit protective immunity in non-human primates 80 . more recently, a single immunization with chadox1 encoding the sars-cov-2 spike protected against pneumonia and lowered viral loads in both bronchoalveolar lavage and respiratory tract samples in macaques following challenge 81 . this effect was observed in the absence of high titres of neutralizing antibodies and the impact of the vaccine was to ameliorate severe disease rather than to prevent infection. although it is disappointing that the vaccine did not confer sterilizing immunity in monkeys, it is noteworthy that the monkeys only received a single immunization and that the inoculum used for challenge was high. it should be noted that the high-challenge inoculum was conceived to determine whether immunization resulted in vaccine-mediated enhancement of infection, and that there was no evidence to suggest that this would be a concern 81 . this is the vaccine being pursued by the university of oxford in collaboration with astrazeneca that is now in phase ii testing. a clinical trial for this vaccine has recently been initiated in johannesburg (south africa), and this is the first vaccine for sars-cov-2 to be tested in africa. the manufacturing cost of chadox1 would be far less than for a subunit vaccine and, moreover, no adjuvant is needed for immunization. poxvirus-based vectors are similarly attractive: they elicit strong humoral and cellular immune responses, can be manufactured at low cost and are stable in the absence of a sustained cold chain 78, 82 . in addition, they can accommodate larger genetic insertions, which could be exploited to encode multiple sars-cov-2 genes (such as the spike, nucleocapsid, membrane and envelope antigens) and could potentially produce virus-like particles. suitable examples of candidate poxvirus vectors include the attenuated orthopoxviruses modified vaccinia ankara (mva) 83 and nyvac 84 , the avipoxviruses canarypox virus (alvac) 85 and fowlpox virus (fwpv) 86 , and the capripoxvirus lumpy skin disease virus (lsdv) 87 . mva is the most widely explored of these vectors. having been attenuated by more than 570 passages in chick embryo fibroblast cells, mva has a well established safety record, including in individuals who are immunocompromised, and has recently been approved as a vaccine against smallpox 88, 89 . nyvac was engineered by the purposeful deletion of 18 genes involved in host range and pathogenicity; it causes no disseminated disease in immunodeficient mice, like mva, and is unable to replicate in humans 90 . several mva-vectored vaccines of particular relevance to africa have shown promise in clinical trials, usually in prime-boost regimens together with other vectors such as dna or adenovirus. these include vaccines against hiv-1 (ref. 91 ), mycobacterium tuberculosis 92 and box 3 | immunological challenges for sars-cov-2 vaccine development two concerns have been raised that could undermine the vaccines against severe acute respiratory syndrome coronavirus 2 (sars-cov-2) in clinical testing: the longevity of immunity, and the potential for adverse effects following sars-cov-2 infection in immunized volunteers. the durability of antibody responses has implications for vaccine development, as immunization may need to induce stronger immunity than natural infection. this concern is partly due to observations of waning neutralizing antibody titres after sars coronavirus infection, and a lack of knowledge regarding the potential for sars-cov-2 re-infection [154] [155] [156] . encouragingly, preliminary data suggest that rhesus macaques may be resistant to challenge with sars-cov-2 after clearing the primary infection 157 . the duration of this protection remains unclear, as do the correlates of immunity. low neutralizing antibody titres were recently reported in 30% of patients who recovered from mild infection with sars-cov-2, which suggests that cellular responses may have an important role in viral clearance. however, it is plausible that neutralizing antibody titres correlate with disease severity and merely reflect the extent of antigenic stimulation 61 . another concern is vaccine-induced enhancement of infection. this can manifest as either antibody-dependent enhancement or cell-mediated inflammatory responses that result in pathology following exposure to the virus. accordingly, type 2 t helper cell-mediated lung pathology with eosinophilic infiltrates has been observed in vaccinated and challenged animals for both middle east respiratory syndrome coronavirus (mers-cov) and sars-cov [158] [159] [160] . the potential impact of antibodydependent enhancement in the context of coronavirus vaccines has not been as well defined, although the phenomenon has been described for a monoclonal antibody targeting the mers coronavirus spike glycoprotein 161 . preliminary data suggest that antibody-dependent enhancement may account for the severity of covid-19 in some cases, where previous exposure to other coronaviruses may have elicited responses that enhanced infection, although this remains to be determined 162 . www.nature.com/nrmicro ebola virus 93 . lsd, a notifiable disease of cattle worldwide, is prevalent in most african countries, and the live-attenuated neethling vaccine strain is widely used to control the disease on the continent 94 . lsdv is being developed both as a multivalent cattle vaccine vector 87, 95 and as a host-restricted hiv-1 vaccine vector 96 . it has been shown to have no adverse effects in immunodeficient mice, and although this vector could not be used in countries free of lsdv, it has potential as a human vaccine in sub-saharan africa 96 . together with mva and nyvac, the avipoxvirus vectors alvac (attenuated canarypox virus) and fwpv are probably more realistic targets for rapid clinical development, as they have also undergone testing in humans, and alvac is already licensed for several veterinary applications 97 plant-based vaccine protein production is an emerging technology that is well-suited to resource-limited areas given the capacity of the system for rapidly scalable production, the low manufacturing costs and the less sophisticated infrastructure requirements than mammalian expression systems 98 . the platform is well established to produce diverse classes of recombinant proteins, and recent advances in expression technologies and molecular engineering have also enabled improvements in glycoprotein production in plants 47, 99 . encouragingly, a preliminary pilot study suggests that these appro aches can be applied to produce the sars-cov-2 spike in nicotiana benthamiana plants, warranting further testing of the recombinant antigen in preclinical vaccine immunogenicity models 100 . three leading plant biotechnology companies, medicago inc. (canada), ibio inc. (usa) and kentucky bioprocessing inc. (usa), have already announced the successful production of candidate virus-like particle vaccines against sars-cov-2. although plant-based manufacturing of recombinant protein antigens may be the most suitable solution for africa, it may also pose a challenge for manufacturing. the major advantages of plant-based vaccine production for sars-cov-2 in africa are the lower costs and the potential for rapid production scale-up to accommodate the large demand for a vaccine. this is best demonstrated in the context of influenza vaccine development, as a fully formulated virus-like particle vaccine was produced within 3 weeks following release of the viral sequence 101 . this rapid development timeline supported the production of 10 million doses of the vaccine within 1 month 102 . however, despite the costs to establish a gmp-compliant plant-based manufacturing facility being considerably less than those for the equivalent mammalian platform (for example, us$80-100 million versus us$250-350 million, respectively), they are not insignificant, and the capital investment required has been prohibitive for africa 98 . furthermore, there are few suitable contract manufacturing organizations worldwide, and these are already invested in their own sars-cov-2 vaccine development programmes. several recent preliminary data have suggested a possible correlation between bacille calmette-guérin (bcg) vaccination and lower prevalence and mortality due to covid-19 (refs [103] [104] [105] [106] ). the bcg vaccine is one of the most widely used vaccines worldwide and has been used to vaccinate against tuberculosis for nearly 100 years. the vaccine comprises a live, attenuated form of mycobacterium bovis, which provides protection against disseminated forms of tuberculosis in infants but gives variable protection against pulmonary tuberculosis in adults 107, 108 . non-specific cross-protection against other pathogens, including those causing respiratory tract infections, has also been documented 109 . this effect may be attributable to altered expression of host cytokines and pattern-recognition receptors, as well as the reprogramming of different cellular metabolic pathways that, in turn, increases the innate immune response to other pathogens 109, 110 . however, potential correlation between bcg vaccination and covid-19 severity should be interpreted with caution. first, it is unlikely that bcg vaccination at birth will still provide non-specific cross-protection against viral pathogens in older individuals. second, the correlation could be influenced by numerous unknown confounding factors, including variation in testing between countries, which leads to differences in the recorded case numbers; differences in average population age, ethnic and genetic backgrounds; the stage of the pandemic in each country; and different approaches to mitigating the spread of the disease in different countries. numerous clinical trials are presently underway to determine whether bcg vaccination reduces the incidence and severity of covid-19 in health-care workers and older individuals (supplementary table) . a trial has also started in egypt (nct04347876), where disease severity and mortality in patients with covid-19 will be compared between those with positive and negative tuberculin tests. in brazil, the bcg vaccine will be given to patients with covid-19 as a therapeutic vaccine to evaluate the impact on the rate of elimination of sars-cov-2, the clinical evolution of covid-19 and the seroconversion rate and titres of anti-sars-cov-2 antibodies. as the bcg vaccine has been administered to most neonates in south africa and france until recently, these trials will also investigate the effect of revaccination with the bcg vaccine. in addition, a new modified version of bcg, namely vpm1002, which expresses listeriolysin instead of urease c, will be tested in health-care workers and older individuals in germany 111 . securing a reliable supply of bcg vaccine doses could be a challenge in africa if re-immunization shows promise, as there is limited manufacturing capacity for the vaccine on the continent. historically, shortages of the vaccines were documented in 41% of countries on the continent between 2005 and 2015 (ref. 112 ). this was largely due tuberculosis diagnostic tests that involve the intradermal injection of bacterial antigens to determine whether the recipient mounts an immune response at the site of injection. nature reviews | microbiology to lack of supply, but the limited availability of financing, procurement shortcomings and ineffective vaccine management also contributed to the shortage. the low price for a bcg vaccine and limited investment has also reduced the incentive for manufacturers to redesign and improve production processes in the region. from 1988 to 2001, the 172-tokyo bcg strain was produced at the state vaccine institute in cape town, south africa; however, this was discontinued as the cost of importing the vaccine was lower than that of local manufacture. the potential impact of co-infections africa shoulders a considerable burden of co-infections. although hiv-1 and tuberculosis may be the most important infections when considering potentially enhanced covid-19 disease severity, the high incidence of malaria and helminth infections as well as multiple ongoing outbreaks of ebola virus disease, lassa fever, cholera, measles, yellow fever, hepatitis e and chikungunya virus 113 all represent infections with unknown interactions with sars-cov-2. the high prevalence of hiv-1 and tuberculosis in sub-saharan africa presents an important but largely unknown challenge for the continent with regard to covid-19. the urgent question that needs answering is whether individuals with hiv-1, or those with past or current tuberculosis, have a higher risk of infection or greater morbidity and mortality from covid-19. of the 37.9 million people living with hiv-1 globally, 25.6 million live in sub-saharan africa, and it is estimated that 64% are accessing antiretroviral therapy and 54% are virally suppressed 114 . although individuals who are immunocompetent with well-controlled hiv-1 infections may be at no greater risk for covid-19, there remains a considerable number of individuals with low cd4 counts and uncontrolled hiv-1 viraemia who may be at risk of severe disease. to date, there have been two published reports of concurrent covid-19 and hiv-1 infection 115, 116 . although the cohort was an extremely limited group of patients predominantly established on antiretroviral therapy, the pattern of clinical disease did not differ from that observed in the general population, but more research is needed to confirm this result. the severity of other respiratory infections concomitant with hiv-1 may provide some clues: although the immunopathogenesis of sars-cov-2 is probably distinct in several aspects from influenza viruses, there are some shared clinical features. hiv-1 infection is associated with a greater susceptibility to influenza virus infection, increased severity of influenza-related disease and poorer prognosis in patients who are severely immunocompromised 117 . a large south african study observed an eightfold higher incidence of influenza virus infection and a fourfold greater risk of death in the case of hiv-1 co-infection 118 . paradoxically, there is also evidence that lower inflammatory responses in individuals who are immunocompetent and infected with hiv-1 may lead to milder influenza-related disease 117 . in addition to altering the clinical course of disease, hiv-1 infections may result in poorer antibody responses that may lead to prolonged viral shedding, thereby influencing disease transmission 119 . tuberculosis, a disease that causes chronic lung damage, may also present a challenge in the covid-19 era. there were approximately 2.4 million new cases of tuberculosis in africa in 2018 (ref. 120 ). in a south african study of patients who were hospitalized for severe respiratory illness, those with influenza virus infection together with laboratory-confirmed tuberculosis had a 4.5-fold greater risk of death 121 . hiv-1 largely drives the tuberculosis epidemic in sub-saharan africa, and the 'triple-hit' of hiv-1, tuberculosis and sars-cov-2 infection is consequently of considerable concern. a preliminary study suggests that hiv-1 infection increases the risk of mortality from covid-19 by 2.39-fold, and this increased risk seemed to be independent of suppressed hiv-1 viral load due to antiretroviral therapy. individuals with current tuberculosis had a 2.7-fold greater risk of death 122 . these figures represent a modest increased risk compared with older age and co-morbidities such as diabetes in the same population, which suggests that hiv-1 and tuberculosis may not be considered major risk factors for covid-19. although this would be considered good news, further studies are awaited to confirm these initial observations. the two main potential issues for using sars-cov-2 vaccines in individuals infected with hiv-1 are safety and efficacy. however, potential safety issues are likely to be restricted to use of certain vaccine modalities, such as live-attenuated or replicating vaccines, in individuals who are highly immunosuppressed. when considering vaccine efficacy, the magnitude and durability of immunity in individuals infected with hiv-1 for both vaccination against and natural infection with sars-cov-2 is unknown. to date, there are no reports describing immune responses to sars-cov-2 in individuals infected with hiv-1. it is possible that individuals with hiv-1 may have incomplete immune reconstitution and impaired immunity that may influence vaccine safety and efficacy, even if they are receiving antiretroviral therapy, owing to persistent immune activation and incomplete recovery of t cell and b cell immunity 123, 124 . suboptimal neutralizing antibody responses have been described following immunization against influenza virus or other pathogens in individuals infected with hiv-1 (ref. 125 ). weaker antibody responses and lower influenza virus-specific memory b cell responses in individuals infected with hiv-1 were directly related to cd4 counts 126 . it will be important to test candidate vaccines for their ability to generate immune responses in a range of high-risk groups, including patients with hiv-1. several strategies may improve the magnitude and durability of vaccine responses in individuals infected with hiv-1, such as higher doses, booster immunizations and/or the use of adjuvants 127 . substantive data on the clinical and immunological interaction of hiv-1, tuberculosis and covid-19 will emerge from africa in time for improved strategies to guide clinical management of patients who are co-infected and the vaccine regimens. finally, an important additional point to note is the indirect effects of covid-19 on health in africa within the setting of a high burden of infectious diseases. the who estimates that the disruption in vaccination due to www.nature.com/nrmicro disruption in supply could put 80 million infants at risk of contracting vaccine-preventable diseases 128 . several countries have reported reduced uptake of tuberculosis testing, and patients failing to collect tuberculosis medication or antiretroviral therapy owing to overwhelmed health-care systems, lockdown interventions and public fear of contracting covid-19 (ref. 129 ). mitigating these interruptions in prevention, diagnosis and treatment, and ensuring that essential health services continue, will ultimately lower the overall impact of the covid-19 pandemic in africa. the ongoing covid-19 pandemic presents an unprecedented global humanitarian and medical challenge. although this has prompted unparalleled progress in the development of vaccines and therapeutics in many countries, it has also highlighted the vulnerability of resource-limited countries in africa. not only do these countries have limited testing capacity but the infrastructure to manufacture tests, vaccines and therapeutic drugs is largely absent, and few clinical trials are underway on the continent to combat sars-cov-2. clearly, there is an urgent need for capacity development and the available resources should focus on solutions that are specific to the needs of the continent. for example, there is an urgent need to inexpensively manufacture viral antigens for serological testing: this will determine the seroprevalence of the virus where pcr-based testing is not available for mild infections. therapeutics development should focus on repurposing existing drugs, or using convalescent plasma that can rapidly be used to treat infection and could be prioritized for individuals who are at high risk. appropriate manufacturing partnerships need to be established to produce vaccines that could be tested and licensed on the continent, to limit reliance on global initiatives that may be overwhelmed by the global demand for a vaccine. in fact, this may present an opportunity for governments to finally invest in much-needed cgmp-compliant vaccine manufacturing facilities. although the situation is unquestionably dire, africa has an important role in the global fight against covid-19, and the resilience and resourcefulness of the people are not to be underestimated. published online xx xx xxxx epidemiology, genetic recombination, and pathogenesis of coronaviruses identification of a novel coronavirus in patients with severe acute respiratory syndrome isolation of a novel coronavirus from a man with pneumonia in saudi arabia a novel coronavirus from patients with pneumonia in china epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study an interactive web-based dashboard to track covid-19 in real time a pneumonia outbreak associated with a new coronavirus of probable bat origin probable pangolin 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patients recovered from covid-19 primary exposure to sars-cov-2 protects against reinfection in rhesus macaques immunization with sars coronavirus vaccines leads to pulmonary immunopathology on challenge with the sars virus immunization with inactivated middle east respiratory syndrome coronavirus vaccine leads to lung immunopathology on challenge with live virus a double-inactivated severe acute respiratory syndrome coronavirus vaccine provides incomplete protection in mice and induces increased eosinophilic proinflammatory pulmonary response upon challenge molecular mechanism for antibodydependent enhancement of coronavirus entry medical countermeasures analysis of 2019-ncov and vaccine risks for antibody-dependent enhancement (ade) the authors acknowledge support from the south african medical research council with funds received from the south african department of science and technology, core funding from the wellcome trust (203135/z/16/z) and funding from the south african research chairs initiative of the department of science and technology and national research foundation (grant number 64815). the authors contributed equally to all aspects of the article. the authors declare no competing interests. nature reviews microbiology thanks m. baylis, g. dougan, s. jiang and l. f. p. ng for their contribution to the peer review of this work. springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. supplementary information is available for this paper at https://doi.org/10.1038/s41579-020-00441-3. key: cord-031840-k9l91unc authors: lu, li; lankala, srinivas; gong, yuan; feng, xuefeng; chang, briankle g. title: forum: covid-19 dispatches date: 2020-09-11 journal: cult stud crit methodol doi: 10.1177/1532708620953190 sha: doc_id: 31840 cord_uid: k9l91unc covid-19 pandemic is the first truly global crisis in the digital age. with death count worldwide reaching 586,000 merely 7 months after its first outbreak in china in late december 2019 and 13.6 million cases reported in 188 countries and territories as of july 2020, this ongoing pandemic has spread far beyond domain of world health problem to become an unprecedented challenge facing humanity at every level. in addition to causing social and economic disruptions on a scale unseen before, it has turned the world into a site of biopolitical agon where science and reason are forced to betray their impotence against cultish thinking in the planetary endgame depicted in so many dystopian science fictions. it is in this context that this forum offers a set of modest reflections on the current impacts incurred by the covid-19 virus. blending ethnographic observations with theory-driven reflections, the five authors address issues made manifest by the crisis across different regions, while keeping their sight on the sociopolitical problems plaguing our life both individually and collectively. taken together, they provide a grounded documentary for the archive that the covid-19 virus is making us to construct. the apparition of these faces in the crowd. -ezra pound, "in a station of the metro" the french word envoi is polysemic, defined as dispatch, the action of sending, something that is sent, a poetic dedication or dedication of a literary work, and the marking of the beginning of a process. this article is a dispatch from hubei, china, based on the author's 4-month stay in his hometown qianjiang, a small city in the middle of hubei, during the coronavirus pandemic. firsthand observations sent from the epicenter give us a clear picture of what the coronavirus has done. moreover, this article argues that the coronavirus marks a spectral moment in which a repressed trauma returns. there have been fierce debates on the origins of the coronavirus and the political, economic, and social significances of the pandemic. popular representations of the coronavirus which isolate, stigmatize, and terrify the other are symptoms of a returning trauma, which is caused by bodily memories of being victims in past disasters. a derridean reading of the envoi highlights the inherent failure of sending: what is sent can always be held up by a malfunctioning in the process of the sending or postal system, and the meaning of the trauma is lost. this traumatic failure results in a repetition in representation and the return of what is sent to the writer/sender. proposing a supplement, this article foregrounds bodily knowledge acquired through social and political trauma by virtue of fear of the coronavirus. this fear of what is familiar reminds us of the feeling of the uncanny. according to freud and derrida, the uncanny is related to the spectral working of a hidden desire that repeatedly returns as a haunting body, representation, and history. this line of thinking helps us to better understand conflicting representations of the coronavirus. the coronavirus is a ghost. this is not merely a metaphorical proposition; this is accurate in the sense that the coronavirus instantiates our phantasms, fears, and desires toward ghosts. in this regard, derrida's specters of marx provides us with a basic framework for understanding the coronavirus as a ghost. the first teaching of derrida is that ghosts do not come at just any time but in spectral moments that do not belong to time. by pointing precisely to the 953190c scxxx10.1177/1532708620953190cultural studies <span class="symbol" cstyle="symbol">↔</span> critical methodologiesli et al. present or now-time, derrida (2006) regards spectral time as "a disjointed now that always risks maintaining nothing together in the assured conjunction of some context whose border would still be determinable" (p. 1). second, a ghost is a phenomenon in the game of repetition and difference. neither exclusively situated in life nor in death, neither visible nor invisible, a ghost is "the frequency of a certain visibility. but the visibility of the invisible. and visibility, by its essence, is not seen, which is why it remains epekeina tes ousias, beyond the phenomenon or beyond being" (derrida, 2006, p. 125) . third, to "make oneself fear" is essentially ineluctable in the experience of a ghost. one becomes frightened of a ghost "on the condition that one can never distinguish between the future-to-come and the comingback of a specter" (derrida, 2006, p. 46) . in other words, what one fears is not the ghost, but the fear, imagination, and one's subject inspired by the ghost. finally, "a ghost never dies, it remains always to come and to come-back" (derrida, 2006, p. 123) . whatever repression the dead may suffer, the return of the dead is anticipated, and "this being-with specters would also be, not only but also, a politics of memory, of inheritance, and of generations" (derrida, 2006, p. xviii) . in light of derrida's framework on specters, once the coronavirus finds a host, it starts to live a ghostly life. the coronavirus pandemic irrupted during a time of turmoil. as the chinese president xi jinping has expressed, the world is experiencing profound shifts unseen in a century. while the trend of globalization is markedly receding, nationalism, popularism, and isolationism are on the rise. the eulogic discussions of "chimerica," a popular term coined by the british epidemiologist neil ferguson in 2007, are being replaced by the theories and practices of the china-u.s. decoupling. the trade dispute between china and the united states puts an end to the chinese ideal of great harmony in the world. in addition, as his campaign slogan "america first" shows, donald trump epitomizes the idea of american exceptionalism. in traditional chinese thinking, famine, natural disasters, and plague happen when the political order or legitimacy are out of joint. during this disjointed moment, a plague was anticipated, even fabricated before it came. according to a widely circulated story in the we-media during the height of the coronavirus, wang yongyan, an academician specializing in chinese medicine at the chinese academy of engineering, predicted half a year ago that a plague would come after the dongzhi (winter solstice), one of the 24 chinese solar periods. in addition, he predicted that the plague would last until next spring. in hindsight, rumors about a new virus were spreading right after the dongzhi. or, simply put, divination went hand in hand with the plague during a time of disjointing, disjunction, or disproportion. while scientists are still trying to track down patient zero, conspiracy theories about the origins of coronavirus have been spreading. bat soup and biological warfare are on the top of the list of suspected criminals. like ghosts, the coronavirus takes shape in the game of visibility and invisibility. in this game, ways of seeing determine how a virus can be understood. approximately made up of 0.125 microns, the coronavirus can only be seen under an electron microscope, made visible with the help of scientific equipment and representations. in contrast, a poet like ezra pound sees the invisible through his gifted imagination. his imaginative inspiration and aesthetic reflection allow his keen observation to become a line of poetic beauty and philosophical complexity. through this form of observation, an invisible apparition becomes visible in the faces of the crowd. similarly, the depiction of a fictional killer-virus called wuhan-400 in dean koontz's 1981 novel the eyes of darkness, re-gained popularity among those who regard it as an imaginative depiction of the coronavirus. in line with this imaginative depiction, mr. wang, well-trained in traditional chinese medicine, claimed that his prediction was based on his reading of the xiang (image) of the sky, earth, plants, animals, and human beings. visible to the naked eye, xiang functions as the visible traces from which an invisible plague becomes visible to an expert in traditional chinese medicine. in other words, with scientific support, talent, and training, people are able "to see this invisibility, to see without seeing, thus to think the body without body of this invisible visibility" (derrida, 2006, p. 187) . in this way, the ghostly nature of the coronavirus lies in the different frequencies of its visibility. however, despite our faith in being able to depict, and make distinctions between, the invisible and the visible, the way of seeing the coronavirus, especially in this time of turmoil, is politically conditioned and manipulated. when i took a night bullet train to wuhan with my family for vacation, it felt like an ordinary chinese family reunion trip during the spring festival: carriages packed with passengers, luggage, excitement, anxiety, and weariness in the air. one of the reasons for the peaceful atmosphere was that china and the united states had signed a trade agreement a few days before, sending a false message to the world that rationality and peace would return. one thing was markedly noticeable on the train: most passengers wore a facial mask for fear of an officially unidentified but unofficially sarslike virus. to my surprise, a line of masked faces was greeted at the exit by the smiling faces of relatives or friends, the indifferent faces of railroad workers, and the shrewd faces of barkers at the hankou railway station. this lack of consistency indicates that aspects of the coronavirus were kept secret. furthermore, this scenario at the station reminded me of a horrifying scene in the film the cassandra crossing, an eye-opening disaster thriller for my generation directed by george p. cosmatos. in this harrowing film, an international express carrying a virus-infected terrorist approaches a station at night. when the train reached the station, the passengers, who were kept from the truth, were confronted with members of the u.s. army in white biological hazard protective suits lined up on both sides of the platform. in both cases, the dynamic of the visibility and the invisibility of a virus was of political significance. the facial masks and the protective suits were used not only to protect people from a virus but also to make the secret of the virus both visible and invisible. in other words, political manipulation complicates the ways that a virus is seen and how the coronavirus, in particular, is seen as a political ghost. the coronavirus pandemic frightened people because it looked like the return of a specter, namely sars. because of its fatality and residua, sars remains an unresolved trauma for many chinese. at the early stages of the coronavirus pandemic, what was most frightening was its assumed high fatality rate. similarly, the short notice given for the lockdown of wuhan, a huge city of more than 10 million residents, sent a clear message to everyone that the novel coronavirus was the grim reaper. corona, the brand of the first car i owned and of the beer i had on my first visit to a mexican restaurant, was colored by images of a fearful virus, deserted streets, calm officials on tv news channels, and panicking crowds in wuhan hospitals caught on video by the we-media. unlike the countries who proposed or actually enacted herd immunity, the chinese authorities imposed very tough immunity measures, a lesson learned from the 2003 sars pandemic, when highways, the railway station, and docks in my hometown were closed overnight. nursing homes were under quarantine; no visitors were allowed in. local authorities advised avoiding public gatherings, including public square dancing and playing majiang. the most popular forms of social activity, especially for retired people, were no longer available. after the initial panic, it was discovered that the fatality rate of the coronavirus was much lower than sars. according to the world health organization, the sars mortality rate worldwide was about 11%. in early february, the chinese authorities claimed that the coronavirus mortality rate in wuhan was about 5%. subsequently, what elicited fear in the population was the future-to-come, particularly in the form of social unrest. on one hand, stricter quarantine measures were implemented: all roads were quickly blocked with cranes or tankers or stones; vehicles' use was not allowed, unless a special permit was issued; all grocery shops, markets, restaurants, and hotels were shut down; residents were not allowed to exit their residential areas except for grocery shopping at an arranged supermarket. in addition, central and local authorities watched closely for other concerns, such as food shortages and the inflation of prices. thanks partly to its rich agricultural products in a land of fish and rice, the impact of the coronavirus on food supply and prices did not affect my hometown. however, under the restrictions put in place, my hometown looked like a ghost town, and the uncertainty of the future frightened people of all social strata. in fact, what people fear most is that the coronavirus will never die and will come back again and again, either in the form of a future-to-come or a return of the dead. regardless, despite the medical or political ambition to eradicate the coronavirus, we might have to accept the fact that the virus will co-exist with us forever. for instance, the coronavirus has been mutating, and the way the coronavirus replicates itself in the cells of other organisms is ubiquitous. this mechanism of repetition and difference functions both literally and metaphorically. on one hand, the coronavirus reproduces itself through difference. merely a collection of genetic materials that seems to think with/like a human once it infects its host, the virus induces a feeling of the uncanny, a topic to which i will return later. in addition, news sources reported that infected patients tested positive again after they had been released from the hospital. robert redfield, director of the u.s. centers for disease control and prevention, admitted that some deaths from coronavirus have been discovered posthumously (cnn, 2020) . in other cases, the coronavirus acted like a whimsical tyrant who inadvertently signed a death sentence. for example, the only cases of death in my residential area was an old couple who lived in an apartment very close to that of my parents. they got infected by their son and daughter who came back from wuhan. what remained a mystery was that the son and the daughter had stayed with their parents for more than 20 days, much longer than the latent period of coronavirus. days after they were hospitalized, they died one after another. on the other hand, the coronavirus reproduces difference in its host organisms. the neighborhood my mother lives in is an acquittance community and an aging society. cadres and volunteers from the neighborhood committee have diligently attended to the needs of the old. aware of the higher fatality rate of the old, an ageist exhortation to quarantine was broadcast repeatedly through a portable loudspeaker placed at the gate of the neighborhood committee building. as stigmatized targets, senior residents were susceptible to the emotion of shame and, for this reason, chose to stay at home. the use of broadcasts and the instigation of shame illustrates how the coronavirus (re)produces, moderates, and polices the line between the public and private spheres. the coronavirus also changed the affective, moral, and power economy of the family. the spring festival is supposed to be the perfect time for a temporary family reunion of joy and harmony. when the lockdown continued longer than everyone expected, generational conflicts broke out. in extreme cases, the political infected families while they were trying to contend with the coronavirus during quarantine. for example, fang fang, a veteran chinese writer who lived in wuhan, posted her thoughts on life in quarantine on her or her friend's weibo account. those posts were later collected and published under the title wuhan diaries. public opinion on those posts varied and eventually led to a political debate between left-wing and right-wing netizens, eventually affecting family members who conflicted in their attitudes toward the wuhan diaries. along with the coronavirus, the memory of personal, generational, and political traumas returned. sars, the cultural revolution, natural disasters, and national humilities were recurring themes in representations of the coronavirus. the suffering and trauma in the epicenter deserve an envoi/dedication, and efforts have been made to achieve this goal, such as daily national and international coverage, fang fang's wuhan diaries, and we-media postings. in these kinds of representation, a rhetoric of "suffering as sublime" is usually at play. in addition, stigmatizing the suffering of others, or blaming the other for one's suffering, is another kind of dedication. both kinds of representations of the coronavirus attempt to take the moral higher ground by attempting to fix the coronavirus as a mere object awaiting to be represented. no matter what position the representation takes toward the coronavirus and its significances, the will to truth turns a dedication quickly into a testimony and even a perjury. a virus is an infectious agent that replicates only within a host organism. for the host, a coronavirus is a deadly stranger and an intimate family member at the same time. familiar, frightening, and secretive, the coronavirus reminds us of the uncanny, as discussed by freud. in his pioneering study, freud focused on the unsettling psychological state of the uncanny. distinct from the feeling of fear, the uncanny is a kind of terrifying feeling that is associated with something known and familiar. after an etymological investigation of the german words heimliche/unheimliche, and a close reading of hoffmann's story "the sand-man," freud (1964) unearthed the origins of the uncanny: "it may be true that the uncanny [unheimlich] is something which is secretly familiar [heimlich-heimisch], which has undergone repression and then returned from it, and that everything that is uncanny fulfills this condition" (p. 245). he also associates the feeling of the uncanny "with the omnipotence of thoughts, with the prompt fulfillment of wishes, with secret injurious powers and with the return of the dead" (freud, 1964, p. 247) . following the lead of freud, derrida worked on the concept of the uncanny to engage with marx's concepts of repetition, specter, and fear. refuting the claims that the tenants of marxism have died, derrida emphasizes the strange familiarity of the specter of marxism in the age of advanced capitalism. as derrida insists, the specter of marxism will continue to return from the future to visit us, to live with us, and to alert us. similarly, derrida (2006) interprets the uncanny through the concept of absolute hospitality, in which "one may deem strange, strangely familiar and inhospitable at the same time (unheimlich, uncanny)" (p. 212). remaining structurally open to future interpretation, the uncanny in derrida's account presupposes a materialism without substance, a messianic without messianism. derrida's understanding of the uncanny is critical to my reading of the coronavirus as a ghostwriter of envoi. as a ghostwriter, the coronavirus is a ghost who writes from the future. as a stranger and a family member, it writes with and in the place of the host. by writing an envoi, a kind of writing haunted by failure and repetition, the coronavirus makes itself visible and frightening in a spectral moment. however, the envoi is not exclusively governed by a ghostly logic that is followed by and instantiated through the coronavirus. in critiquing the tendency to unearth an ultimate truth, eve kosofsky sedgwick & frank (2003) regard affects as a possible way out of the binary opposition of truth and falsehood in representation. by invoking the power of the performativity of shame, they highlight the negative affects neglected by identity politics, dismissed and stigmatized: without positive affect, there can be no shame: only a scene that offers you enjoyment or engages your interest can make you blush. similarly, only something you thought might delight or satisfy can disgust. both these affects produce bodily knowledges. (sedgwick & frank, 2003, p. 116) in their view, shame is neither subversive nor mandatory; it works with other affects, drives, and representations to adapt the body to its situation. foregrounding bodily knowledge acquired through trauma commits us to thinking differently about representation and the envoi in question. fear of the coronavirus is not only the fear of a returning trauma as a ghostly logic in representation. more importantly, the coronavirus writes itself and writes about bodily memories of trauma in a constant play of materialization: inscribing fear in itself and on the body of the host permanently. with the end of the lockdown in hubei, the coronavirus pandemic is almost over in china. however, the coronavirus has been sending, and will keep sending, its fearful envoi. the enduring sign of the coronavirus pandemic for indians was not related to medicine or public health. it was the unprecedented exodus of migrant workers from metropolitan centers to their native rural districts, sometimes hundreds of miles away (mukhopadhyay & naik, 2020; petersen & chaurasia, 2020) . the scale of this migration was vast and is still being understood. it certainly provokes disturbing questions about urbanity and the fragility of a political compact that kept people in their place through calibrated deprivation (dahdah et al., 2020) . but for our purposes here, i will explore the ways in which it underscores the varying effects of the pandemic on different classes of people and the diversity of its signification. the virus in india is both a medical event to be dealt with through appropriate public health measures and a mediated discourse that has developed its own ramifications and responses. i argue that both forms of the virus have had tragic and miserable consequences, but on different classes and groups of people. like the televised persian gulf war of 1991 that jean baudrillard found to be a distinct and distorted signifier of the actual fighting on the ground, 1 the virus itself is not the same phenomenon once it is transformed into a signifier for other meanings and purposes. the novel coronavirus later named covid-19 emerged in the public consciousness as a distinct problem with the rapid rise in infections in several indian states by february 2020. in march, the government of india mandated an immediate "lockdown" of the entire country. this new term burned itself into the national consciousness and its many vernaculars almost instantly, as its meaning became physically apparent. it involved the physical arrest of people wherever they happened to be at the moment, and the prohibition of all commerce, traffic, and circulation. it was announced with a 4-day notice period by the prime minister, in an eerie echo of a similar announcement in 2016 of the withdrawal of paper currency. 2 that tragic farce had laid a historical precedent for this second tragedy to come. as a deeply iniquitous society and economy were forced to a halt, the effect was expectedly unequal. metropolitan indian citizens soon learned to cope with the new hardships of "work-from-home," homeschooling, online classes and meetings, and such social-media-driven innovations as cooking and cleaning without domestic servants and entertaining themselves in their houses and apartments. the government also encouraged the adoption of derivative coping mechanisms as soon as they were observed in other countries: applauding medical workers from the safe confines of apartment balconies and terraces; singing, chanting and clanging metal plates and dishes with utensils in cacophonous, solidarity of the gated classes; lighting lamps and candles; and waving mobile phone flashlights at appointed times (krishnan, 2020) . however, the actual effect of the virus became inseparable from the effect of the "lockdown." the sudden impoverishment of the majority of the country's population led to starvation, medical neglect, and a national panic. while invisible to the citizens in its first few weeks, it became impossible to ignore, when workers across indian cities started to simply walk back to their native villages. their exit from cities also emphasized the fragility of urban belonging: that in a crisis, indian cities were fundamentally empty shells, drawing people not through cosmopolitan attractions or civic rewards but by rural misery. 3 at this point, the virus was still largely a media phenomenon, while the "lockdown" was what had directly affected most indians: the sudden disappearance of work, wages, commerce, and circulation magnified the precarity of urban existence. the largely informal national economy quickly unraveled in a crisis. this crisis was exacerbated by the role of the virus in continuing the ideological and political discourses of the chaotic period immediately preceding the lockdown. the use of the virus to carry out "politics by other means" can be seen in other polities as well, but its entanglement with indian politics is particularly useful as a means to understand the virus as a set of signifying practices. the context of this political use of the virus as a signifier is also inseparable from the highly mediatized nature of indian politics and society. 4 the virus emerged as a discursive phenomenon in india at a crucial juncture in a national conflict over changes to the country's citizenship laws. with the rise to national power of the ruling rashtriya swayamsevak sangh (rss, or the national volunteers organization-a fascist group founded in 1922), india's national government had been attempting since 2014 to achieve its political goal of abolishing its secular and liberal constitution through a steady dismantling of public institutions (roy, 2020) . this conflict worsened in 2019 with the re-election of the rss-controlled government headed by the current prime minister, and the consequent repeal of laws that had hitherto guaranteed the autonomy of the occupied territory of kashmir. this was followed by a critical change to citizenship laws to specifically exclude muslims from gaining indian citizenship and institute a new "citizens' register" to determine afresh the legal status of all residents. 5 with reports of the parallel construction of detention camps outside major cities, the fascist inspiration and ominous intent of the new laws became clearer and more immediate. 6 protests and political resistance to the new measures emerged across the country, and were met with violent responses from the police and rss groups. matters had reached a head when the nationwide lockdown was suddenly imposed. except in a few indian states such as kerala, with still functioning local health systems, the lockdown did not involve any public initiative to test or prevent the spread of the virus. instead, in keeping with the ruling ideology of our time, citizens were mandated to protect themselves, on pain of being brutalized by the police if they failed. in this chaotic sauve qui peut scenario, the rhetoric of basic preventive measures took on ominous ideological connotations depending on who you were and where you lived. as it became clear that only access to clean running water, adequate space, and a home to live in would guarantee the efficacy of the public health guidelines, medical advice became meaningless for much of the country's population, especially the inhabitants of vast informal urban settlements in the metropolitan cities. in effect, a dual situation emerged: a parallel virus had infected the classes who lived in gated urban communities and formal neighborhoods and who followed its progress in daily primetime news trackers. positive cases, testing ratios, death rates, and other numbers soon flew across television and website screens in macabre charts, graphs, and complex animations, as breathless studio anchors enthusiastically tracked the competitive fatalities across states, regions, cities, and countries. as the formal state and civil society response to the virus grew more and more into a media discourse, its actual effect on the population was determined by existing social conditions and ideological practices than by the ideals of public health. 7 in the early period of its spread, the illusion of its control was maintained through the interpellation of the mass television audience as ideal national subjects. in a series of televised speeches, the prime minister exhorted citizens to planned acts of mass discipline, such as the applause, noise-making, and lamp-lighting exercises mentioned earlier. it took several costly weeks for the citizens to realize that this national son-et-lumière had only served to deafen and obscure a different and more real virus that had silently spread illness and death among urban populations who did not have houses or apartments with balconies. a starved public health system soon proved inadequate and unprepared. because this real crisis was not mediated or televised, there was no appropriate or meaningful response to it. the easy congruity of the eagerly adopted virus prevention measures with the practice of caste-based rituals of discrimination was not lost on most indians (george, 2020) . this fortunate coincidence enabled the easy normalization of virus prevention as a legitimization of existing hierarchical practices. the convenient prescription of social distancing appeared to keep the privileged class of wealthy and respectably middle-class white-collar workers as far away as possible from the physical contact or proximity of their social inferiors. the pandemic thus seemed tailor-made for defenders of hindu caste hierarchies, a righteous and suitably scientific legitimation of social discrimination. the fantasy of caste purity would have remained an abhorrent social remnant if it had not become part of state policy in the last few years. but in the context of the stateled legitimation of religious hierarchies and the consequent onslaught on emancipatory laws, this entanglement of the virus with caste and with the violent hate crimes against muslims acquired a dangerous dimension. it is this distrust of and disgust with a compromised public health system that drove so many indians streaming out of cities and into the relative safety of their impoverished rural communities. the alienation of muslims as a national other has been a part of the basic doctrine of india's current ruling group ever since its founders, awed by the nazi policy of extermination, adopted a similar goal for the erasure of non-hindu communities in india. the mass protests and popular uprising against the rss's attempts to irrevocably alter the basic structure of the country's republican constitution had reached a tipping point when the covid-19 epidemic was suddenly deemed emergent enough to impose an unprecedented "lockdown," in effect a de facto police state across the country. the imposition of the lockdown allowed police to destroy protest sites, detain protestors, and unleash a reign of terror across indian cities. caught in the initial crossfire were members of an apolitical muslim religious group, the tablighi jamaat, whose convention in delhi had been interrupted by the lockdown. jamaat members trapped in the organization's premises by the curfew were found to be infected with the virus. the consequent media narrative of the discovery of the infection among the jamaatis veered into the fantastical, with nightly news anchors debating the strategies of a "corona jihad" that was to be waged by militant muslims using the virus as a weapon (perrigo, 2020) . this dog-whistle narrative of muslim bodies as unclean spreaders of a foreign disease dovetails with similar narrative frames used to portray hindus from laboring and working castes as well. the manufacture of conspiracies surrounding the coronavirus can be seen across the world and is not unique to india. a disturbingly large proportion of americans, for example, appear to believe that the virus has been manufactured to enable mind-control through vaccination and 5g cellular signals by a ruling elite (fisher, 2020) . on rare occasions, these conspiracies do spiral out into real effects such as the bombing of cellular towers in britain and the anti-vaccination movement in the united states. in india, however, the covert encouragement of such theories by the state itself, to legitimize the hatred toward muslims, exacerbates and normalizes the rumors as mainstream prime time news which is then amplified and shared through an organized social media campaign (ellispetersen & rahman, 2020) . the vilification of the muslim other serves two purposes, one of furthering the state's broader agenda of religious and caste purity, and the other more immediate goal of providing a scapegoat for the inescapable rise in infections and deaths due to the virus and the inability of the state and society to understand the crisis. the brutal police crackdown that accompanied the lockdown and the violence of its imposition across the country were a small reminder of the routinization of the "lockdown" as a way of life in the occupied valley of kashmir, part of the only muslim-majority state in the indian union. the effects of the police state as a normalized entity have been multiplied since the abrogation in 2019 of constitutional laws guaranteeing the region's autonomy, even if such laws were honored more in the breach in preceding decades (zia, 2020) . the uncanny resemblance of a public health curfew to a military occupation is not coincidental, but the result of the colonial origins of both, and of the state institutions they represent. the symbiotic existence of caste-based discrimination, the extermination of a religious minority, and the colonial occupation of an entire province within the same body politic is made possible by the continuous interpellation of the mass of people to become national citizen-subjects. this call to obedience, broadcast daily through primetime television and magnified through the near-mandatory use of mobile phones, 8 is the only sign of a nation-state that is otherwise absent in the real world. the failure to stop the spread of the real virus is obscured as the interpellated citizen is urged, cajoled, and threatened to participate in the simulacral fight against a mediated virus in a purely semiotic realm. the washing of hands without the precious reality of running water, the maintenance of "social distance" in the absence of space, the exhortation to "work from home" for a population that is not housed, and the discourses of online socialization and commerce are all much more than signs of mere denial: they are the components of this new semiotic space, enabling the call to national belonging in a new domain, bereft of its mooring in the world. from a broader historical perspective, the coronavirus epidemic does not appear to have affected indians as much as the far greater fatalities caused by more prosaic diseases, hunger, and the increasingly toxic air and water (rukmini, 2020) . what has caused the greatest pain and panic is the response to the epidemic. this response has been not to the virus itself, but to a simulacral virus that appears to occupy the same space and shares the same name as covid-19, but which is a mere signifier, pointing to other, older evils. like baudrillard's hyperreal war, it has surpassed the real virus itself and has come to occupy its place. it cannot be wished away or prevented with a vaccine, it needs a response in kind: of new counter-signs and counter-discourses. a catastrophic pandemic unseen in a century, the current raging of covid-19 around the globe has undoubtedly produced a unique symbolic site for global, regional, and national imaginations. as the earliest epicenter of this infectious illness, china has witnessed the proliferation of discourses about the evolution of the pandemic on various media platforms, through which the chinese public has the rare chance to reflect on important issues regarding identity construction, social reformation, and nation building. while much attention has been paid to the stigmatization of china in euro-american politics, media, and everyday whisper that label the natural coronavirus as a cultural and ethnic fault (fu, 2020) , what has been overlooked is how china has portrayed other countries in this global health crisis, especially those surrounding nation-states in the same geopolitical area. east asia, or the sinosphere in the broader sense, with the collective memory of fighting sars in 2003, is thought to have responded to covid-19 more efficiently than many western countries (salmon, 2020) . how, then, is the east asian encounter with covid-19 depicted in the chinese public discourse? how does such depiction envisage china's relations with neighboring countries and its position in the area? in this essay, i discuss the ways in which the coronavirus pandemic has been appropriated by the chinese public for a (re)imagination of east asia. by exploring the evolving representations of its neighboring countries throughout the epidemic on chinese media platforms including weibo, wechat, and zhihu, i argue that the talk of the regional responses to covid-19 envisions a china-centered union of selected east asian countries in parallel with the historical tributary system of the sinosphere. through the expression of the nostalgia for imperial china, the discursive reconstruction of the east asian identity is a ratification of china's contemporary ambition to reclaim its geopolitical dominance. synchronized with the rapid transmission of the coronavirus in china and east asia between january and march 2020, the chinese public in this early phase drew close attention to the unfolding of the epidemic in its nearby countries, and japan and south korea in particular. with the disease breakout involving diamond princess (japan) and shincheonji church of jesus (south korea) frequently making news headlines, the discussions of how those countries responded to covid-19 flourished online, which, in combination with the continuous debates over china's own pandemic threat management, contributed to the imagination of the covid-19 rampancy as a regional challenge that china and its neighbors faced together. central to the discursive formation of this imagined community was the celebration of the incessant interaction and cooperation between china and some east asian countries to combat the virus collectively. in the wake of the outbreak when china was threatened by the crumbling of its health care system, the countries under the spotlight-japan and south korea-were widely appraised for the sympathetic and supportive approaches they took to help china overcome the severe shortage of medical resources. the media reports of japanese and south korean governments leading the international aids to china (gong, 2020) were echoed by numerous warm anecdotes on social media championing the heartfelt support from their people. perhaps the most well-known story of this kind, a japanese institution wrote a chinese-language verse on the boxes of masks it donated to the province of hubei: "rivers low, mountains high; the same moon in the sky" (trans. zhao, 2020) ("山川异域，风 月同天"), which immediately went viral online because of its signification of the long-lasting friendship between china and japan. according to account of the expedition to the east by the great master (唐大和上东征传) written by omi no mifune (淡海三船) (see wong, 2018) , this sentence was from an ancient poem written on the edges of the buddhist robes japanese missions (遣唐使) brought to tang china as the tribute from prince nagaya (長屋王). given its profound roots in the history of japanese envoys to imperial china learning from the chinese culture and civilization, this verse went beyond re-fostering the traditional sino-japanese solidarity. analogizing japan's mask donation with ancient japanese envoys' gifts, it also evoked the retrospective commemoration of the hierarchy between china and japan in history which almost vanishes in the modern era. therefore, the popularity of this verse may indicate the aspiration for the reoccurrence of such bi-lateral relations. indeed, this was only one example of the ubiquitous imaginary of the pan-east asian cooperation and exchange of goods and information as a modern emulation of the tributary system through which imperial china maintained its diplomatic and trade relations to neighboring countries and consolidated its dominance in the region for over a millennium. after china started to keep the pandemic under control and resume the production of medical supplies, this metaphor was further perpetuated in an attempt to accentuate that china's supplies of medical goods and anti-epidemic lessons to nearby countries drastically outnumbered what it was initially given. on weibo, china's return of masks and respirators to its neighbors was often explicitly compared with the "vassals' gifts" chinese emperors assigned to tributary states in posts like this: tribute is both the highest form of alliance and an advanced way of investment, but (this time) it is based on masks! recently, xinwu district in wuxi, jiangsu province donated 50,000 to toyokawa, aichi prefecture in japan in return for the 4,500 masks, protective clothing and other anti-epidemic materials toyokawa donated to xinwu district in february. (weibo source, march 25, 2020) this nostalgic use of metaphor implies a crucial undertone of sinocentrism of the public imagination of the community comprising china and bordering countries fighting against the coronavirus. the tracing of the origin of east asian solidarity to the past is suggestive of the ambition of the present. the chinese public not only fantasizes about a reunion of china, japan, and south korea for covid-19 but more importantly yearns for the recovery of their nation's leadership and centrality in this battle. as the coronavirus expands rampantly to the rest of the world from march 2020 onward, chinese media coverage quickly catches up with the shift of the epicenters from east asia to europe and north america and reformulates the pandemic as a global health crisis. against the depiction of how covid-19 created chaos, helplessness, and dysfunction in western societies stands the stark contrast of east asia as a safer zone where the outbreaks have been largely contained with success. with the similar control of cases less than 20,000, japan and south korea remain at the heart of this imagined safe zone in company with china even though the reality has seen even fewer confirmed cases in other parts of asia as well as the recent resurgence of virus spreading in all these three countries. this rhetoric is in concert with the prevalence of online deliberations about why east asia as an area has performed better than other parts of the globe in the containment of the virus. at the core of these discourses lies the construction of an east/west binary which frames the global responses to the pandemic into a competition in which "we" (the east/ east asia) have triumphed "them" (the west/euro-america). although china and neighboring countries diverge in the official approaches to handle the pandemic, their relative efficiency in virus containment in comparison with the west is considered to be guided uniformly by the cultural values they share as part of the "confucius east." in particular, collectivism-the principles of prioritizing community interests to personal interests, pursuing social harmony, compliance to authority, avoid causing inconvenience to others-has been glorified as the main drive for the people in east asia to more effectively cope with the governmental strategies in contact tracing, testing, social distancing, and mask wearing. similarly, the regional cooperation in the pandemic management is regarded as a manifestation of these values. for example, the reflections on how south korea has set a model of disease control using mass tracing and testing tend to recognize the smooth uptake of this procedure facilitated by koreans' collectivist mind-set that downplays individual privacy and complies with the data-mining measures to track and publicize their locations, activities, and close contacts. meanwhile, other popular discussions blame the religiosity of the shincheonji church members whose gatherings caused the initial covid outbreak in south korea, which is reflected from the titles of zhihu posts that describe the diffusion of the virus through "hallelujah" such as "the occupation of south korea by covid-19, everything has to start from 'hallealia'" and "south korean cult hallelujah devastated the country." apparently, these titles have no intention to mask the underlying tone mocking at the role of christianity in the acceleration, not mitigation, of disease spreading, which further serves as a foil to the power of confucianism to help south korea navigate away from the disaster. in fact, satire targeting at christianity represents the broader criticism of western cultural values in hindering the efficacious enforcement of restrictive and surveilling measures against the coronavirus. the east asian identity is thus reaffirmed through the clashes between the eastern and western civilizations. however, it is worth noting that the narratives about the east asian conquest of covid-19 are again permeated with the metaphor of the tributary system delineating china as the leader and role model in this imagined "safe zone." not only does the attribution of the regional success to confucianism call up the historical chinese centrality in the sinosphere but the emphasis on china's ability to offer lessons and instructions from its early experience for its neighbors to benefit from also ratifies the restoration of the "teacher/student" relation between imperial china and pre-modern japan and korea. far from a total reenactment of the historical sinosphere, this chinese imaginary of east asia engages with a purposeful selective process that amplifies china's solidarity with some east asian countries but simultaneously mutes others in the same region. as remarked earlier, a majority of the online narratives about the cooperative responses to covid-19 in east asia revolves around china, japan, and south korea, with less frequent inclusion of singapore as well as occasional reference to such countries as mongolia and myanmar. this emphasis on forming a coalition with japan and south korea is compatible with china's longterm agenda of promoting and dominating the china-japan-south korea union (中日韩一体化), which was recently reiterated by the three governments' consensus to speed up the negotiation of the free trade zone (中日韩自贸 区) (wang, 2019) . in this sense, the covid-19 crisis has offered a discursive site for the chinese state to rebuild this trilateral bond and remodel its significant neighbors whose national images, due to the respective disputes around diaoyu islands and thaad (terminal high altitude area defense), have been negative in china for almost a decade. while the china-japan-south korea triangle is romanticized in connection with other small countries, the alienation of some confucius societies from this imagined "cooperative" east asia is quite striking, especially given the outstanding results some of them have produced in the prevention of disease transmission. the first excluded category includes taiwan, hong kong, and macau-the territories outside the mainland in the great china area. whereas macau is often forgotten by the media as it has always been, both taiwan and hong kong are widely criticized and mocked for their attempt to politicize the pandemic as a weapon to confront beijing and increase international recognition. the second group pertains to north korea and vietnam-the authoritarian states that have close political and ideological bonds with china. for instance, north korea has been constantly questioned and satirized because of the lack of transparency in the disclosure of its epidemic circumstances. vietnam's outstanding handling of the virus which led to only 334 confirmed cases and 0 death was nearly silenced in the mainstream media coverage. in the unusual reference to vietnam in some zhihu conversations, vietnam's success was rarely celebrated but considered as a "threat" to china's leadership in containing the pandemic in the area. the trivialization and exclusion of these countries/ regions from the chinese imagination of east asia as a collective force fighting against covid-19 is not unexpected. in the first place, the negative attitudes toward them (except macau) reflects a backlash against the restrictive, noncooperative methods those governments have enforced to block the virus from mainland china (e.g., full border closure; ban on exports of medical supplies), which signifies their resistance to be incorporated into the modern tributary system chinese people have aspired. yet for taiwan and hong kong, this exclusion repeats the endeavor of chinese official propaganda to erase the distinction between them and the mainland and disavow their political autonomy. instead of being completely out of the picture, their responses to the coronavirus are mainly discussed as part of the chinese experience to consolidate the national identity. for north korea and vietnam, the negative impression may partly result from china's ongoing diplomatic conflicts with them in recent years regarding the south china sea and denuclearization, respectively. nevertheless, the shaking of the "socialist brotherhood" on the matter of covid-19 also implies the reluctance of the chinese public to articulate a regional identity around the axis of a shared political regime. in fact, assimilating itself with ideological and political allies is likely to obscure the focus of this imaginary on china's historical and cultural alignment with japan and south korea. as covid-19 begins to shift both the scholarly and media focus on an international scale to reconsidering the dark sides of globalization (chan & haines, 2020) and mourning for the disruption of european union (trofimov & pancevski, 2020) , china's reversed agenda of imagining a regional union is stunningly intriguing. on one hand, the eagerness to build solidarity with east asian countries represented by japan and south korea might be a strategy to react to the racialization of covid-19 as a "chinese virus" and the demonization of china as a "public enemy" and "trouble maker" in the euro-american political and media agenda (viala-gaudefroy & lindaman, 2020). by articulating china's resemblance (and collaboration) with the bordering democratic capitalist states (rather than the "socialist brothers") in the "confucius-inspired" success of halting the virus, the public discourse strives to construct a collective identity of the east so as to brush off china's label of the other imposed by the western imagination. ironically, this consolidation of the eastern identity also serves as a repercussion to otherize the west as the loser to the coronavirus. on the other hand, the rise of this east asian imaginary centering around china's historical and cultural bonds with japan and south korea has far-reaching implications for china's geopolitical strategies beyond the covid-19 pandemic and the realm of public health. rested upon the trope of the imperial tributary system, this imagination reflects how the chinese public discourse echoes the state ambition to recuperate the historical dominance of china in the sinosphere, which is part of chinese communist party's long-term project of "the great revival of the chinese nation" (中华民族伟大复兴), or in xi jinping's term, the "chinese dream" (中国梦). incorporating japan and south koreathe most important american allies in east asia-into the imagined tributary network might serve the specific purpose of weakening the u.s. hegemony in the region (see ikenberry, 2004) , whereas the tactic exclusion of north korea and vietnam indicates the indifference of many chinese to the state's political and ideological "comrades" (whose traditional alliance with china has often proven itself unstable and delusionary in the changeable economic and political dynamics in east asia). more importantly, this selective reimagination of the eastern union expresses the chinese public's nostalgic ideal of the nation's revival, which dreams of a return to the middle kingdom, the empire that reunites and leads east asia through culture and history. during the year 2020, which is anticipated to be the warmest year in human history, we failed to stop the rampant spread of a coronavirus called covid-19 and its disastrous impact on societies and individual lives. unlike its "cousin" sars, which broke out in early 2003 and vanished into thin air largely because of rising temperatures, the current respiratory epidemic has yet to show any sign of amelioration with the arrival of summer. news photos have shown audiences an incredibly bleak, bizarre, and somewhat surreal picture of life during the pandemic. streets are evacuated. stores are closed. public services are paralyzed. modernized cities have become empty and ghostly quiet. only scattered people equipped with medical face masks walk anxiously in this futurist, apocalyptic scene. to use timothy morton's concept, the covid-19 pandemic has become a "hyperobject," a phenomenon that possesses an ahuman time scale and an extremely diffused quality in occupying space. in such a space-time reconfiguration, or, in plain language, during this type of disaster, humankind becomes an obsolete idea, as humans no longer play a meaningful role in the space-times created by and for "hyperobjects." unfortunately, such a concept bares relevance in light of the uncontrollable proliferation of the coronavirus across the globe at this juncture. worse still, some epidemiologists warn that a new round of outbreak will likely occur soon in the coming fall. a possible scenario could repeat the conditions after the 3/11 fukushima daiichi nuclear disaster, when breathing with face masks, people eventually became accustomed to a state of emergency as the conditions for living and dying in the anthropocene. "[p]oison has become a normal feature of daily life, the second nature we have to inhabit" (berardi, 2012, p. 12) . while one can attribute the deterioration of nature to neoliberalism and its disastrous governance, this essay, rather, speculates on what foregrounds the involutional relationship between humans and the earth beyond the "nature-culture" divide. whether one is willing to admit or not, viruses are neither creation ex nihilo nor culturally and politically constructed representation. instead, they are beings that have always been part of earth's composition. in a prophetic book, the natural contract, the late philosopher michel serres (1995) describes the evolution of the earth's composition. in ancient law and modern science, nature was treated as an objective reference point, because it had no subject. existing objectively "out there," the earth was a space that did not depend on humans but only acted passively in relation to causality. yet, witnessing the ecological crisis arising in the 20th century, humans realized that the earth has been affected by our behavior and is now behaving like an aberrant subject! in recent scholarship, this subject has been referred to as gaia, the capricious goddess of the earth (see latour, 2014, p. 3) . the earth is full of action and so is covid-19. as described in news reports, the coronavirus looks for and hijacks its hosts; it finds easy purchase on, and takes control of, human bodies; it kills many, but not all, of its hosts so as to keep moving, spreading, replicating, and surviving. it would be impossible to talk about the virus without referring to those actions. cited by the washington post, a virologist came up with a vivid analogy for viruses by comparing them with destructive burglars. "they break into your home, eat your food, use your furniture and have 10,000 babies" (kaplan et al., 2020) . as the word "object" refers to entities that are inanimate and subject to chains of causality, viruses, in this sense, hardly fit into this definition. for instance, covid-19 remains mostly enigmatic, not least because it is considered strikingly sneaky-"the virus doesn't really want to kill us. it's good for them, good for their population, if you're walking around being perfectly healthy," said another virologist in the same washington post article (kaplan et al., 2020) . besides doing things such as breaking-into, eating, and having-babies, the virus is further endowed with intentions-it does not want to kill us! however, the coronavirus should not be mistaken for a subject, especially a subject-agent, which is historically associated with liberal humanism since the enlightenment and which is deeply rooted in the "nature-culture" divide, an ontological regime referred to by latour as "the modern constitution" (see latour, 1993b) . the idea of the subject as a product of euro-american modernity is indivisible from its aim to achieve individual sovereignty and autonomy. in a politico-legal sense, bounded individualism is the most evolved form of this idea in the wake of the global expansion of capitalism. faced with an unprecedentedly active earth in the late 20th century, nonetheless, this anthropocentric conception of the subject-agent has been confronting exponential challenges, among which the current coronavirus pandemic constitutes the latest one. to be clear, the term "subject" is a mismatch for covid-19, not because it is agentless and incapable of doing the same things that humankind does. the contrary is true: the state of being of the virus-what it is-can unfold only through its actions and long after its performances. at stake for the virus and humans is that there are "no pre-constituted subjects and objects, and no single sources, unitary actors, or final ends" (haraway, 2003, p. 6 ) far from being a de-animated object, or an anthropomorphized subject, gaia, the increasingly "rioting" earth, is a collective of actions that distributes agency in heterogeneous and surprising ways. as a result, "we must not believe in advance that we know whether we are talking about subjects or objects, men or gods, animals, atoms, or texts" (latour, 1993a, p. 167) , and also viruses until their actions are captured, and rendered into shapeswhether the shape of a human or of a virus. the story of the human-centered history is being replaced by an explosion of narratives about the increasingly animated and animating earth. however, the dualism of the subject versus the object, unfortunately, is still perniciously conserved in the mainstream reaction to the covid-19 pandemic. when societies are forced to act on the pandemic, the virus is almost exclusively treated as an object subject to the chain of causality. this tendency is clearly reflected in the mobilization of wartime rhetoric and discourses in conjunction with governments' anti-epidemic measures. for instance, when visiting wuhan right after its lockdown, sun chunlan, china's vice premier, warned that the country was facing "wartime conditions." likewise, only 1 month later, president donald trump declared a national state of emergency over the coronavirus outbreak in the united states. in this antagonistic discourse, contending with the virus, a not-yet-tamed and potentially threatening other, is framed as a relationship between humans and their enemies. for those who believe humans and only humans make history, a self-proclaimed war on the virus is unavoidable! peace, accordingly, is only imaginable to be reached, or more precisely restored, to an already existing order, established primarily for humans. mobilized to describe the relationship between covid-19 and humans, "war" is a terrible and even dangerous choice in terminology, due to its undertone of human exceptionalism. in fact, nearly 90% of the cells in a human body is "part of a vast community of companion species, particularly bacteria and viruses" (smart & smart, 2017, kindle 72) . unfortunately, most humans have yet to learn the meaning of living and becoming-with these beings who are made by and making humans at the same time. in her book staying with the trouble: making kin in the chthulucene, donna haraway (2016) invites readers to contemplate our troubling present, the chthulucene, an emerging regime of naturecultures, as opposed to the "nature-culture" divide. contrasting to the discourse of the anthropocene and the capitalocene, both of which are conceived as human-induced condition, the "chthulucene" is, first and foremost, concerned with earth beings who live in "manifold forms and manifold names in all the airs, waters, and places of earth"-they are monsters which "demonstrate and perform the material meaningfulness of earth processes" (haraway, 2016, p. 2) . the vicious coronavirus is evidently one of these monsters. despite the havoc it is creating in the present, the epidemic is a manifestation of the biotic and abiotic powers inherent in earthly actors and is part of "ongoing multispecies stories . . . in times that remain at stake" (haraway, 2016, p. 55) . as implied by the title, one of the valuable lessons of haraway's book is that, for humans in particular, there might be no better option other than to stay with troubles, of which humans are never innocent. staying with the troubles demands caring for all the threads that bind us together and make our existence possible in the first place-humans are made by countless earth beings and vice versa. it also means that we are required to weave unexpected and even dangerous connections with others, in haraway's (2016) words, making kin as oddkin "in unexpected collaborations and combinations . . . we become-with each other or not at all" (p. 4). this insight is particularly useful for thinking about viruses. because viruses have "no cellular machinery of their own, they become intertwined with ours. their proteins are our proteins" (kaplan et al., 2020) . in this sense, the evolution of humans and viruses is inseparable from the process of involution of the two into one. in other words, becomingwith means that, by definition, a "we" always precedes an "i," a "you," or a "they." the so-called "asymptomatics" provide an excellent example of this point. asymptomatics refer to those who test positive for covid-19 but, confusingly, do not suffer from illness or show any symptom of the disease. asymptomatic infections or carriers are possibly greater in number than those with symptoms. at this point, it is impossible to decide which of the two types is more typical of covid-19 infections, because, as a researcher at the university of oxford says, "there is not a single reliable study to determine the number of asymptomatics" (shukman, 2020) . in the same news report, neil hall, a biomedical expert, suggests considering asymptomatic cases of the coronavirus as the "dark matter" of the epidemic, as invisible and not-yet identified dark matter is believed to make up most of the matter in the universe. despite the fact that no conclusion has been reached about the enigmatic phenomenon of asymptomatics, the differences that manifest among patients reveal that the virus, and the particular cases of infection, should be examined as specific units. in other words, between the virus and humans, the specificity of an encounter matters. unlikely to be autopoietic systems that reproduce autonomous units, the virus and an infected body constitute a collectively produced, sympoietic system that does not have self-defined spatial or temporal boundaries. in these cases, and from a non-anthropocentric, philosophical point of view, the idea of bounded individualism has to be discarded for good. beyond the divide between the subject and the object, what emerges are ontologically heterogeneous practitioners who are involved in each other's lives. besides evolution, living also relies on involution. without any intention of "romanticizing" covid-19 and the current pandemic, staying with the trouble, as articulated by haraway (2016) , is "to make kin in lines of inventive connection as a practice of learning to live and die well with each other in a thick present" (p. 1). the coronavirus does not happen as a matter of fact, which "passively" waits to be discovered, investigated, tamed, or neutralized by "active" humans. what we call the covid-19 pandemic manifests itself as a differentiating and relational effect because it matters by bringing into being various relations between humans, and between humans and their oddkin. in this view, science is only one practice among many others to capture the efficacy of its mattering. in addition to biomedical measures, a more critical question for the coronavirus crisis is "what method does the matter demand" (thompson, 2018, p. 13) ? proposed by haraway for living in the chthulucene, the string figure might also serve as an appropriate method and image for the pandemic, characterized by its exceptional contagiousness and interactivity. consisting of "passing on and receiving, making and unmaking, picking up threads and dropping them," the string figure is all about "becoming-with each other in surprising relays" (haraway, 2016, p. 3) . crucial to this method is that it does not guarantee what is obtained turns out to be good in the end, because living itself has become so dangerous in this very thick present-agencies are distributed, conflicting, and entangled in a myriad of practitioners, human and non-human alike. in this pandemic, we are all playing the game of string figures with our oddkin. it is not beneficial to judge in advance who is a subject and who is an object, or which one is active and which one passive, as all participants might be capable of something that matters in one way or another. for example, one thing that the respiratory disease teaches us is that not only breathing matters but also the manner how one breathes matters to others. life and death happen inside specific connections and their mattering in mundane, and even fleeting, encounters. making covid-19 matter requires us to reanimate "what is coming into states of matter and mattering in bodies, stories, acts, and events" (stewart, 2018, p. 24) , in other words, in the vicissitudes of our ordinary lives. for the future of this thick present, one key is to stop imagining the crisis of the coronavirus as something wholly predicated on effective vaccines and scientific solutions. instead, humans must learn to connect and also care for threads, some of which are obvious, some elusive, some vicious and dangerous, and some fictional. we may need to discard terms such as "overcoming" or "solution," and turn to terms like "participation" concerning all that we are uncertain of but have to live and become with, together, in the "metamorphic zone" called the earth (latour, 2014, p. 13 ). what does it mean, the plague? it is life, that is all. the most abundant biological entities on earth, viruses are forever and everywhere. suspended between living and being dead, they are simply there, a slimy strip of ribonucleic acid (rna), as biologists tell us. poorer in life than tardigrades, incapable of movement, and having no logistic of their own, they ride on and feed off others to replicate themselves, to become the viruses that they are. as smart schoolchildren know, they are transmissible and must be so transmitted as to go viral, to become the viruses as we know them. dependent entirely on carriers, that is, exploiting others' hospitality, without which they have no life (but also no death either), viruses exemplify transmissibility. they live and thrive, as it were, only if their hosts are susceptible, in motion, and in contact and they die or die down when susceptible hosts are either unavailable or no longer hospitable. defined, that is, made finite, by transmissibility, and yet transcending its barren finitude through parasitism, viruses exist and operate like pure media, self-generating and selfgenerated by being entirely coterminous with the channel through which they flow and multiply. interpolating and encoding themselves in the metabolic cycle of others, thereby reproducing themselves passive-actively, they mediate by colonizing others and, in so doing, mediate themselves by proxy, going about so energetically and indiscriminately as to cause the demise and thus thwarting unwittingly their own propagation. if viruses communicate anything, if their shadowy occupation of host bodies sends any message, it is their very own communicability, their ability to disseminate themselves over a large population with effort less than minimal. although all over creation and in abundance, most of the viruses cause us no harm and we pay them little attention, even though they populate our body and capitalize on its resources. they become a matter of grave concern when they infect us, when they not only put themselves inside (in-ficere) our body and stain its normal functioning, but also threaten to afflict as many people as their "infectivity" attacks. more dangerous and less tamable than most microbes, viruses invade our body and compromise it at the cellular level. they do not just make us sick; they bring about plague. once seen as a cause of infection, viruses accrue significance and take on the label "pathogens." to refer to viruses as pathogens implies that they are "medicalized," that they not only enter into a relation with humans who regard them as toxic and virulent, but are also seen as a problem to be addressed in a methodical, systematic, that is, "scientific," manner. it is through this medicalization that viruses are individuated and identified as a distinct biological entity and, having been so captured and given a name-for example, h1n1, mers-cov, sars-cov-2, covid-19, and the like-by what might be called the "clinical gaze" and its taxonomic procedures, they enter into sciences and become a focus of medical research, made all the more pressing if and when they create public health crisis. more than one hundred years after martinus beijerinck gave the name contagium virum fluidum (contagious living fluid) to the incitant of tobacco mosaic first discovered by adolf mayer and dimitri ivanovsky, viruses are now actively collected, classified, and manipulated by scientists in highly restricted spaces called laboratories, most of which, like the viruses housed carefully therein, are hidden from public eyes. while slimy poisons were once thought to be sent down by god to punish us for our sins, we now see viruses not only as an object of scientific investigation but also as a medical challenge that nature poses to us as biological creatures on earth. like birds, bats, and rats, we are all equal opportunity hosts to killer germs. not all viruses are fully pathogenic, but pathogenic viruses are ever ready to go viral when the conditions are ripe. however, although viral infection may break out and spill over, it does not mean that there is a pandemic. "pandemics," as virologists tell us, "begin when a brandnew virus infects a human who also at that point is able to transmit the virus to other humans" (buettner, 2020) . two points should be noted without delay. first, pandemics are not created by transmission of viruses from some source to humans, but from humans to humans. breakouts of viral infections among members of a primate community deep in the amazon rainforests, for example, may be large scale and may disturb ecological balance alarming to conservationists, but they do not for all that count as pandemics in the sense that the term is properly used. viruses might infect one or more individuals, but humans are responsible for creating the conditions that transform infections to outbreaks and outbreaks into pandemics. pandemics, in other words, are not natural or biological phenomena; they name a human crisis, a contagious malady plaguing humans who are both agents and patients at the same time. contagious diseases are disastrous to all, locked, as we are, in the same bubble in which microbes live and grow, but pandemics are decidedly more pernicious in that we become, often unknowingly, the source and the cause of our own infestation. second, pandemics are "declared." as is the case with catastrophic events in history, like wars, famines, or mass cultural anomaly as bizarre as the chinese sorcery scare of 1768, whose duration and identity result from an act of punctuation and sense-making entirely sociopolitical in nature, pandemics too begins with a performative act that announces their beginning and, having made them to begin in this way, determines when they reach their end, even though the viruses and their carriers may still be with(in) us (see kuhn, 1992) . naming not microbial activities in nature but a crisis for humans, pandemics are events made real, public, and urgent, as just said, by a performative-a speech act, to be exact-whose authority in pronouncing their beginning and end depends on the very force that makes the declaration authoritative and forceful in the first place. brought into being by discourse and public communications, pandemics are social constructions; they signal a state of emergency-appearing, first, as physical ailments on the part of individuals, subsequently identified and ratified by medical and scientific community as a real health problem, and finally materialized by authoritative broadcast and public acknowledgment, thereupon becoming a public policy issue to be addressed by political leadership, all these over a determinate territory. once established as such, a pandemic individualizes a collective paroxysm, making it a public enemy by giving it a face, a name, a certain life span in the social calendar, without which the havocs wreaked by the virus would not be the crisis its name designates and invokes. it is in this declarative nature of pandemics that we can see how viruses, once medicalized and publicly acknowledged, are inevitably entangled with science, history, culture, and politics. socially constructed by a decision, by a cut or break into regular time, they mark a "zone of exception," a temporal heterotopic, as it were, where we, individually and collectively, stand to one another as equal subjects to illness, unfreedom, and death in the unending drama of man against nature and its hostile elements. viruses are viruses are viruses. they have no political content; operating according to the laws of physics, chemistry, and biology, they come and go on their own rules and on their own times, as nature dictates. in sharp contrast, pandemics are biopolitical phenomena; they are moments of discontinuity or rupture in social order, shot through from start to finish with forces and factors that shape culture, history, and economy, which in turn determine what they mean and how they come about and come to pass. moreover, and importantly, a pandemic is not a single, monolithic event; it is a series of localized epidemics, each with its own point of origin, its own history, its own epidemiological pattern and impacts. further still, all these factors crisscross one another in a complex, nonlinear fashion, amassing multiple agents and stakeholders in such a critical fashion that the language of war is often used by the authority in charge to quell the infectious assault. 9 pandemics force social changes precisely because the changes they incur invite resistance. it is for this reason, perhaps for this reason alone, that pandemics inevitably appear as a site of social contestations, politicizing and politicized by the heterogeneous constructions barely betrayed by the name of a single virus. 10 it is for this reason too that pandemics assert themselves as a sign of generalized cultural and economic strife, a symptom of social struggle underlying the health terror that a viral breakout unfailingly induces. covid-19 is a novel virus, novel in that scientists do not fully understand how it afflicts the body and therefore cannot predict its epidemiological paths. to control its spread, we have no choice but to employ methods developed from past experiences, such as quarantine/isolation, social distancing, face coverings, and contact tracing, to name a few now well-known. because viruses are infectious, to control its spread is, understandably, to separate and to isolate. this means that people be kept away from one another. instead of gathering or being together, we make ourselves scare; better yet, we isolate ourselves, even if begrudgingly. more than that, the injunction of isolation leads straightaway to insulation in that the ultimate, foolproof means of isolation is to literally atomize ourselves, to turn ourselves into windowless monads. indeed, all the mitigation measures we hear about of late-quarantine, mask wearing, hand washing, and social distancing-are in reality anti-social measures. don't reach out and don't touch anyone! cover up your face! just as social distancing-a contradiction in terms of sorts-means keeping physical distance, and just as mask wearing reduces mutual recognition based on simple vision to its unnatural minimum, (self-)isolation and quarantine all but eliminate human contact of all kinds. when the plagues struck, we were all lepers; when covid-19 strikes, we are all windowless monads. pandemics are born of communicable diseases, yet for this reason, they force us to be incommunicable. flattening individuals and bringing to a halt exchange and commerce of every kind, they turn a society into one that is against society. if there is a history of pandemics, it is a history of anti-social history. neither alive nor dead, neither this nor that, viruses are by nature improper. never proper, that is, never being (of) themselves, they appropriate-always ready to make others their own. they are pure media, as suggested earlier. viruses are pure because they mediate unconditionally. however, inasmuch as unconditional mediation performed by viruses leads to the demise of their host, upon whom they depend for their parasitic reproduction, viruses end up annihilating themselves by their very nature; they are always already their own collateral casualties. rendering themselves nil by simply being and subsisting as themselves, pure media are no (longer) media. unconditional mediation ends all mediations. by bringing society to go against itself, viruses commit suicide, so to speak, by killing their host, by the unconditional abuse of others' hospitality. and, alas, weat least some of us-are spared. covid-19 is a new virus. but, unlike the known flu viruses, or h1n1, sars, and the like, covid-19 is considered "novel," not the least because, as indicated earlier, it frustrates scientists' understanding. "it has been like nothing else on earth," says an infectious-disease expert, who falls victim to the virus; "i knew i had the disease; it couldn't have been anything else," but "i don't understand what's happening in my body" (yong, 2020) . there are many things, inanimate or living, on earth that are like nothing we know so far, and there are many things happing in our body that we do not understand at all. covid-19 can justifiably be called "novel," but isn't every virus novel in its own way and at some moment in time? isn't being novel the normal course of event in life and in life sciences as well? "there is novelty here," remarks a prominent epidemiologist karl friston upon leaving a lab meeting about covid-19, but he quickly adds, "so this, from my point of view, is just an average day" (kosner, 2020) . being novel is the very characteristic of all viruses and many other things in nature as well. the novelty of covid-19 may not be as novel as we think. what is possibly novel about covid-19 is the fact that it gives us the first pandemic in our truly globalized age. the global village, in which we now live, is so hyper-connected-not only by technology but also through affluence, commerce, and global travel-that an infectant can travel from one city to another as fast as jet streams flow. connectivity translates qualitative diversity into measurable multiplicity, reducing distance and difference for the formation of the common, which in turn strengthens connectivity. to be alive, as few would disagree, is to be connected, literally and in every other sense. but this means that we must live in and with the risks that global connectivity brings to us. to be connected brings with it the possibility of being stranded in harm's way. as covid-19 makes clear, "connectivity is the killer" (kosner, 2020) . after all, life depends on maintaining boundaries and keeping differences. deadly viruses are deadly because they breach them. as infection rate rises, so does anxiety. and bleak scenes spread as wide as the virus goes. deserted streets, boardedup stores, closed factories, shot-down public transportations; remote learning, work-from-home; stock markets crashed . . . and, worse yet, "i just lost my job." individual solation leads quickly to desolation across the board. and economy bears the brunt of a colossal coronal attack. shortly after covid-19 spread out of wuhan, china, to europe in january 2020, stories about the economic plight began to top the list of topics in public forums and news media. the future we face seems to lie in one of the two choices: to die from hunger or to die from the disease (餓死 或病死), as the expressions go in chinese media. it is not for no reason that a policy brief released in june 2020 by the united nations on the impact of the pandemic is given the title "the world of work cannot and should not look the same after this crisis" (guterres, 2020) . the address on the launch of this brief, given by the secretary-general antónio guterres (2020) , begins as follows: the covid-19 pandemic has turned the world of work upside down. every worker, every business and every corner of the globe has been affected. hundreds of millions of jobs have been lost . . . many small and medium-sized enterprises-the engine of the global economy-may not survive. after painting a depressing picture of the future and explaining how difficult it will be for the world economy to return to "normal," guterres's (2020) address makes a hardly perceptible turn when he says "let's not forgot the pre-covid-19 world was far from normal." it seems then that, rather than shattering the world of work as we know it, the covid-19 pandemic simply exposes in higher resolution the "tremendous shortcomings, fragilities and fault lines" that have been eroding society and economy from the bottom-up for decades. the pre-covid-19 world, in which we thought we lived a normal life, is not as normal as we think (see guterres, 2020) . to save the economy under siege is to "return to normal" as soon as possible, so cry the bureaucrats and journalists alike. but what is "normal" in this case? what does "being normal" mean exactly? is the world, old or new, ever normal? there are norms regulating life, but has there ever been a "normal life" as such? the so-called normal life, a life before covid-19, to which we pray to return, is in truth one of recollection, a romantic one at that, as the un policy brief readily admits. just as a viral infection may display more than one symptom on the part of its victims, embody more than one single illness, and create more than one single public health challenge, life, as it is actually lived, is hardly reducible to one normal life. in fact, the socalled normal life is the one that brought us the pandemic in the first place. to live is to live normally; to return to normal is what living is all about. the so-called new normal is both new and not so new, which is to say, it is neither really new nor really normal. perhaps the world has never been and will never be normal, whatever our idea of "being normal" means. if a pandemic can turn the world upside down, it is because life has been turning and turning again. and anything that returns cannot be entirely new. humans have been haunted by viruses since time immemorial. from the prehistoric pandemics in northeastern china 5,000 years ago, uncovered at sites now called hamin mangha and miaozigou, to the justinian plague (541-549 ad) that may have helped to bring down feudalism, or the small pox outbreak that finally toppled the aztec empire before hernán cortés returned to the region in the spring of 1521, viral infections have tormented the lands and their people over millennia. traveling with host animals and humans, viruses had gone global long before globalization became a fact. there are 10 known pandemics in the last 250 years, all displaying the same pattern of spiking in seasonal waves after the initial attacks. covid-19, and some of its coronal cousins, will undoubtedly expand the list. to those who are living through its assault, the impacts brought about by covid-19 are more or less clear and more or less measurable. but what is the meaning of covid-19 when the current pandemic is over? will it be remembered? if so, in what way and to what extent? if the history of pandemics has taught us anything, it is that history tends to repeat itself, that viral outbreaks are an ineliminable part of the natural history, in which humans are a part and in which no "zone of being" is free from viral infection. recall the spanish flu of 1918, the worst pandemic during the last two centuries. it is estimated to have wiped out 50 million people worldwide, meanwhile infecting 500 million, a third of the world's population at the time. however, despite its short distance of mere one hundred years from us, few people today know much about it, and still fewer are able to understand or feel the impact it had at that time. its centenary a short time ago passed noiselessly, certainly not for lack of stories or records. like the many plagues before it, the spanish flu, it seems, never quite made itself into what reinhart koselleck (2018) calls the "the space of experience" (p. 34). failing to make its way into collective memory, it is also helpless in figuring into our "horizon of expectation" (koselleck, 2018, p. 14) . if the spanish flu faded largely from memory, all the woes caused by covid-19 are, likewise, likely to dissipate in time, regardless of how we feel and say about it now. there was a pre-coronavirus world, and there will be a post-coronavirus world, but viruses, known or novel, will outlast our worlds. viruses are everywhere and forever. so, plagues will never disappear for good (camus, 1991, p. 307) . but what then does it mean, the pandemic? it is life, that is all. a troubled memory, fading, under the vast indifference of the sky. until the gate of oran closes again. assembled in this forum, the five short essays provide some modest reflections on the coronavirus pandemic and its still unfolding consequences. committed to a variety of disciplinary perspectives and interests, the authors did not set out by pursuing any preset direction or common agenda supposedly carried out collectively in our intellectual labor. rather, what unifies the diverse inquiries in these essays is the shared awareness about the confusion in the public discourse that constantly fails to distinguish a coronavirus called covid-19 from the covid-19 pandemic, or as briankle reminds us in his essay, from "a series of localized epidemics." this alertness constitutes a common ground in addressing specific issues or phenomena in these essays. this forum is anything but comprehensive. if it can contribute to the discussion of the crisis, it is most likely because all the essays refuse to bind the pandemic exclusively with the coronavirus and to position the virus and humanity in rigid opposition to each other. in her multispecies ethnography, anna tsing tells a marvelous story about matsutake mushrooms. "when hiroshima was destroyed by an atomic bomb in 1945," says she, "it is said, the first living thing to emerge from the blasted landscape was a matsutake mushroom" (tsing, 2015, p. 3) . when human history temporarily comes to a halt in disasters, matsutake, and also viruses in our case, may well survive and continue to thrive with their own stories. histories are being made every day by humans and non-humans alike; however, the future for those histories to converge has still yet to come. as demonstrated in the essays gathered here, while governments and the public are desperate to frame the virus in their own social and political narratives, the virus also works hard to inscribe its historicity on the earth and humans too. if a message must be dispatched out to all at this juncture, it is that for a future of collaborative survival, the stake of living together has nothing to do with harmony and conquest, but is derived from "disturbance-based ecologies" (tsing, 2015, p. 5) , that is, plagues. plagues are life, that is all. the author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. the author(s) received no financial support for the research, authorship, and/or publication of this article. gong yuan https://orcid.org/0000-0001-8352-3541 xuefeng feng https://orcid.org/0000-0002-7692-052x notes 1. in a trilogy of contemporary essays, baudrillard (1995) argued that the war in the desert was a new phenomenon, because it was defined and shaped by its discursive aspect as a form of television programming, regardless of what happened on the ground. 2. that earlier announcement called "demonetisation" led to a vast contraction of commerce and an immiseration of a majority of the population which has still not recovered, and is now widely considered an unnecessary exercise of personal whimsy. for an analysis of the economic consequences, see ghosh et al. (2017) . 3. the decline of indian agriculture is not adequately discussed in the celebration of urban growth. its effects are however inescapable and directly lead to the growth of informal settlements in cities (balakrishnan, 2020; jaffrelot & thakker, 2020) . 4. mediatization, or the analysis of events with their mediated construction as the starting point, is a phenomenon that has grown in importance across cultural contexts, as media theorists attempt to understand the increasing influence of media forms on culture, especially with the virtualization of human interaction and the redefinition of community through the use of social media and mobile communication. for a fuller discussion, see couldry and hepp (2013) . discontents: an indian history (2013), jayal (2019) traces the current shift in the discourse of indian citizenship from an egalitarian rights-based model to a new regime predicated on religious and cultural identity, given shape through the concomitant technocratic frames of transactional welfare and biometric identity. 6. four short essays provide further context and narrate the response: shankar et al. (2020) . 7. partha chatterjee's (2004 chatterjee's ( , 2011 insightful categorization of indian society separates the distinct ontological domain of a small formal "civil society" that includes rights-bearing citizens, from the vast undifferentiated mass of the population that constitutes "political society" and which forms the actual locus of democratic practice. 8. the current indian government has dramatically increased the acquisition and use of big data in governance, including a reliance on biometric identification for access to welfare programs and the use of mobile phones for access to services: part of the government's covid-19 response was in the form of a mandatory mobile application that purported to use location tracking to show active virus infections in the user's vicinity. an analysis of its invasive nature can be found in a working paper by deb (2020). 9. societies always declared war on problems they cannot solve: war on drugs, war on poverty, and the like. it is no surprise to see donald trump refers to covid-19 as an "invisible enemy" and calls himself a war-time president in his speeches on the covid-19 pandemic. similar examples abound across the board throughout history. it is widely recognized by epidemiologists today that the model developed by john snow based on the cholera outbreaks between 1831 and 1853 in england is too linear to be of any use in contemporary pandemics. like the global climate instability or financial market volatility, pandemics are nonlinear phenomena, displaying a high degree of uncertainty that defies simple causal explanation. on this, see kosner (2020) . 10. it is therefore not surprising that we observe donald trump repeatedly refers to covid-19 as wuhan virus or kung flu in reaction to his rise and fall in poll and public opinion as he tries to find scapegoat, in this case, china, for his sorry failure in handling the crisis. a virus is always more than a virus when it enters the body politic. india's brutally 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never been modern agency at the time of the anthropocene migrant workers distrust a state that does not take them into account it was already dangerous to be muslim in india. then came the coronavirus india racked by greatest exodus since partition due to coronavirus. the guardian india: portents of an ending: modi, the rss and the rise of the hindu far right. the nation how covid-19 compares against other killer diseases in india why east beat west on covid-19: east asia has handled and contained the pandemic far better than the west on nearly all metrics shame in the cybernetic fold: reading silvan tomkins the natural contract the demagogue and his labyrinth. the baffler coronavirus: the mystery of asymptomatic "silent spreaders posthumanism: anthropological insights mattering compositions labyrinth of linkages: cinema, anthropology, and the essayistic impulse coronavirus crisis threatens to split an already fractured eu the mushroom at the end of the world: on the possibility of life in capitalist ruins donald trump's "chinese virus south korea agree to continue push for free-trade deal despite ongoing tensions across region. south china morning post buddhist pilgrim-monks as agents of cultural and artistic transmission: the international buddhist art style in east asia, ca covid-19 can last several months the popularity of "rivers low, mountains high; the same moon in the sky" and its english translation the hindu rashtra comes of age. contending modernities li lu is an associate professor of literary theory at the school of chinese language and literature and a research associate at the center for literary theory at beijing normal university. he teaches courses on marxian aesthetics, critical theory, and translation theories.srinivas lankala teaches in the department of communication at the english and foreign languages university, hyderabad. he works in the areas of semiotics and critical theory, and engages with questions of politics, history, and nationalism. key: cord-018332-893cckyz authors: price, jason d. title: desire and the law: creative resistance in the reluctant passenger and the heart of redness date: 2017-07-16 journal: animals and desire in south african fiction doi: 10.1007/978-3-319-56726-6_5 sha: doc_id: 18332 cord_uid: 893cckyz this chapter offers a critique of animal rights approaches for their weakness in relying on the passage of laws, and in depending upon their proper administration by legal authorities to attempt the protection of animals. where some thinkers espouse an animal rights perspective, this chapter argues that postcolonial desire is vital to protecting communities in ways that rights discourse and the law cannot in the context of the biopolitical workings of the state and globalized capitalism. drawing from deleuze and guattari’s work on desire and the law in kafka (1986), the chapter considers the potential of desire to offer creative alternatives, outside of legal discourse, toward the protection of animals and the larger community. additionally, it recognizes how indigenous environmental knowledge and notions of desire offer ways of relating to animals that can challenge capitalist instrumentalization. by zakes mda portray communities that struggle to protect themselves, their lands, and the animals with which they dwell from being used and abused to turn a profit for businesses. both novels portray competing claims for land as business proposals attempt to develop potential tourist locales by disenfranchising their current inhabitants through the rhetoric of western notions of "development." as in chap. 4, the role of desire as "eating" appears here as government officials are bribed by business owners to approve their land-development proposals, and at the cost of sacrificing the homes, protection, and interests of the local inhabitants of these lands. these stories perform what graham huggan and helen tiffin identify as " [o] ne of the central tasks of postcolonial ecocriticism" as they "contest-also provide viable alternatives to-western ideologies of development" (27) . the capitalist proposals for wealthy tourist destinations continue in a colonialist view of these lands as blank spaces awaiting appropriation and transformation into capital. this chapter explores how characters in both novels successfully work within and beyond the law to prevent the destruction of particular environments which they have come to know intimately. the protagonist of the reluctant passenger, an environmental lawyer, critiques the political scene that the novel sets up involving unethical environmental rulings and other legislation influenced by big business and bribery. heyns' novel highlights many environmental concerns, particularly the legal status, or lack thereof, of animals (specifically baboons) in south africa. as the protagonist struggles to help maintain the nature preserve for the troop of baboons at the request of his client luc tomlinson, the novel portrays luc's experiences dwelling with the baboons, demonstrating his great respect for their lives and culture. similarly, camagu, the protagonist of the heart of redness, argues against the development of the small village he has grown to love into a gambling city. offering a more ecocritical alternative to the tourist town, camagu expresses his view, informed by qukezwa's political analysis and knowledge of local culture and nature, that the town developed by outside businesses will offer little work or profit for the townspeople and be detrimental to their environment. in contrast, he proposes a smaller measure of a resort built with local materials by the villagers appealing to a different type of tourist who "like[s] to visit unspoiled places for the sole purpose of admiring the beauty of nature and watching birds without killing them" (239). these novels consider the available avenues for opposing the late capitalist thrust to transform all the world and its inhabitants into objects that are available for consumption and for turning a profit. the communities in these works offer ways of thinking about promoting sustainable futures against the overconsumption of the environment associated with most capitalist development projects. as animals are valued highly by the characters in both texts, heyns' and mda's novels argue persuasively for sustainable futures for the humans and animals (and in heart of redness also the flora) that are part of their communities. characters in both understand community in a broader sense, including humans and non-humans, and recognize that they are all potentially disposable in the logic of profit-seeking capitalists. where some approaches to the stories espouse an animal rights perspective, i argue that an ethics of sustainability and a biopolitics informed by deterritorialized or postcolonial desire, here specifically the desire for animals, is essential to protecting communities in ways that rights discourse and the law cannot guarantee. in the reluctant passenger, the protagonist, an environmental lawyer named nick morris, somewhat contradictorily dislikes the ungovernable or disorderly aspects of the environment and animals. for example, he has a discussion with his friend and fellow lawyer, gerhard, about masturbation that turns into an analysis of romantic poets where morris discloses that he masturbates to the lake district of england. in response, gerhard encourages him to consider blake's poetry and to "try the tiger next time" (173). nick explains his disregard for unruly nature: i am not a tiger type of person, and such fantasies as i have tend towards the tame. for this reason my involvement in the ever-deepening intrigue surrounding luc tomlinson's baboons was as unusual as it was unwelcome. as far as i'm concerned, the environment should behave itself if it wants us to look after its interests. as a matter of fact, the lake district is just about my notion of an ideal environment: well-mannered, contained, placidly packaged, officially protected and signposted. (173) as the novel progresses and nick becomes increasingly involved with luc tomlinson and the case for the baboons, the lawyer discover the law's limited ability to protect the animals. " [t] he rights of animals are a much debated area in law" (259) is the best that nick can offer in response to luc's query about protecting the baboons in a legal manner. where the law fails them, i'm interested here in how and why the characters work to protect the baboons extralegally. in light of nick's discomfort with "wild" or untamable nature (or zoe) and his sexual fantasies about ordered and "contained" environments, his reassessment of the unmasterable aspects of the world including his own desires and "self" leads him to break several laws in the course of rescuing the baboons with luc later in the story. where nick once lived a life of abstinence to avoid the messiness and feelings associated with a sexual relationship, he ends up having sex with luc in his house while the rescued baboons they have secured in the second floor of his house dirty, rearrange, and otherwise mess up his home, which had once been so clean and ordered as to appear uninhabited. this scene indicates the importance of a positive appraisal of desire to protect animals in relation to the limits of legal or animal rights approaches, positions which i analyze below. in the animal gaze: animal subjectivities in southern african fiction, wendy woodward reflects on the interiority and sense of "self" of the animals in southern african fiction, including the reluctant passenger and the heart of redness. for her, these literary representations of animals do important work toward changing the way we think about animals and their rights. woodward argues that animals have subjectivities, so they should be recognized in the south african constitution and be accorded rights. in support of her animal rights approach, she draws from martha nussbaum's philosophy of "moral agency," a philosophy which, as i'll discuss later, braidotti criticizes heavily early on in transpositions. for example, woodward recounts how martha c. nussbaum critiques utilitarian approaches to rights which position animals as having "moral standing." she summarizes the utilitarian position through a quotation of nussbaum: because they are subjects of social justice "if a creature has either the capacity for pleasure and pain or the capacity for movement from place to place or the capacity for emotion and affiliation or the capacity for reasoning and so forth (we might add play, tool use, and others), then the creature has moral standing" (362). nussbaum quite rightly argues for the importance of the agency of the nonhuman animal; in moral agency, then, the animal is active in this sphere, whereas "moral standing" is conferred on the nonhuman animal for the characteristics he or she embodies. (woodward 68) this preference for active instead of passive qualities in "moral agency" over standing or capacity is certainly a more interesting approach regarding the question of animal morality because agency suggests a recognition of the moral life and behaviors of animals, yet "moral agency" still suggests that animals should be granted rights because they have similar agency to that of humans. élizabeth de fontenay also critiques this position in without offending humans: a critique of animal rights: without useless brutality toward metaphysical and legal humanisms, a pathocentrist perspective does in effect allow us to establish the fact that the moral community is constituted not only by "moral agents" capable of reciprocity, apt to enter into contracts with full knowledge of what this means, but also by "moral patients," which includes certain categories of human beings and animals. (67) fontenay's argument here is that this approach to rights from the perspective of "agency" leaves out some humans and animals from being protected because they do not possess this agency. she further critiques this in her response's to peter singer's philosophy, arguing that such rights approaches are "offensive" to humans as they run the risk of sanctioning the poor treatment of non-normative humans, such as those with different mental abilities who may not necessarily be included in the category of "moral agents." posthumanist accounts of subjectivity, such as rosi braidotti's nomadic subjectivity, that involve a radical immanence, offer a fluid notion of the subject where subjects are interdependent, existing in assemblages with other humans and the non-human, instead of a fixed view of subjectivity in the liberal individual tradition. the law constructs dominant, discursive subjects which fail to do justice to or fully account for the fluidity and complexity of our subjectivities. braidotti argues: the becoming-animal axis of transformation entails the displacement of anthropocentrism and the recognition of trans-species solidarity on the basis of our being environmentally based, that is to say: embodied, embedded and in symbiosis … "life," far from being codified as the exclusive property or the unalienable right of one species-the human-over all others or of being sacralized as a pre-established given, however, is posited as process, interactive and open-ended. (99) while woodward does discuss deleuze and guattari's becoming-animal briefly at times, she looks for more human qualities or attributes of human subjectivity in the animals in the literature she analyzes, which approaches a kind of becoming-human of the animal. rights discourse, while oriented toward protecting animals from violence, ends up humanizing animals, leaving this political approach perhaps less effective than other creative options. braidotti also critiques martha nussbaum's universalism (after kant), which assumes a stable humanist subject. nussbaum's formulation seems to view animals as fixed, individual subjects who possess agency, whereas the vital materialist deleuze views both subjectivity and agency as dispersed, interdependent, and the subject as a process in assemblage. braidotti also critiques nussbaum's position for the way she tries to intimidate new or experimental approaches and philosophies by asserting that they are relativist. another problem with universalism is the failure to appreciate local knowledges and hence a tendency toward a monocultural, dominant view of the world. woodward, however, nicely avoids this by recognizing and analyzing the importance of shamanist traditions and the indigenous knowledges of south african peoples. in essence, woodward's somewhat humanist approach and the posthumanist approach i espouse are after the same goals-the protection of animals-although her project seems limited to that particular kind of life that possesses "moral agency," whereas mine seeks to protect the community in a broader sense. that is, i am concerned with the protection and improvement of the conditions and treatment of animals, the environment, and the others of man that have been excluded from man's central position in humanism and therefore viewed more easily as disposable because of the negative valuation of difference that results in racism, anthropocentrism, and phallogocentrism. while the reluctant passenger and the heart of redness offer a view of animals as deserving of rights, and the reluctant passenger engages in this discourse of rights more directly, both novels also offer more creative ways of thinking about sustainable futures. thus they call for working inside the law and also other creative ways of protecting the animals, human and non-human, of their communities. for braidotti, sustainability consists of multiplying subjectivities "not for profit" and increasing the possibilities of positive attachments. a significant part of her project entails establishing a positive view of zoe, in contrast to negative views of it espoused by agamben and others. for braidotti, the others of man-women, native others, animals, earth others, and so on-are closer to zoe, whereas man is closer to bios or discursive life (104). she explains that [w] hereas "life" or bios has been conceptualized as a discursive and political notion ever since aristotle, zoe is the non-or pre-human "outside" of the polity. it has been rendered in figurations of pejorative alterity as the "other of the living human", which means the inhuman or divine and the dead … . against this forensic turn in contemporary philosophy [agamben's association of zoe with death, for example], … [is] the need to cultivate positive political passions and ethics of affirmation. (transpositions 265) she also explains how zoe disrupts a "unitary" vision of the subject-a non-humanness at the heart of the human that flows through bodies. this sustainability perspective replaces one of rights, as she argues: "the notion of co-dependence replaces that of recognition, much as the ethics of sustainability replaces the moral philosophy of rights" (123). in contrast to a rights perspective that argues that animals be included in the community and be granted protection because of their similarity to humans under our notion of humanism and the law, this approach of co-dependence recognizes that the "human" has never been human, never existed independently, but always depends on a relation with the non-human. part of nussbaum's approach to animals also includes the argument "that animals be recognized as subjects" (13). thus woodward bases her "rights" approach to animals on their subjectivity, and therefore their being subjects in the law. cary wolfe argues that this approach to protecting animals is not sensible: i think we would all agree that an admirable desire of humanism would be to respect the standing of at least some nonhuman animals and to protect them from exploitation, cruelty, and so on. but the attempt to articulate that desire, which is an admirable one, in terms of the rights framework ends up foreclosing and undercutting that desire by reinstating a normative picture of the subject of rights that ends up being humanist and anthropocentric through and through, that ends up with a being that looks a lot like us, so that, in the end, nonhuman animals matter because they are just a diminished version of us. it seems to me self-evident that trying to think about the value of dolphins in terms of their being diminished versions of homo sapiens makes no sense. ("after animality" 186, emphasis added) for wolfe, rights approaches then inevitably begin to look for human characteristics in animals as a means of securing their protection. while his reading of the law and animal rights perspectives often focuses on the work of derrida, specifically derrida's essay "before the law" from which he derives the title of his book on biopolitics, wolfe's emphasis on the "undercutting" of desire is something worth taking up from deleuze and guattari's perspective. both derrida, and deleuze and guattari, write about kafka's the trial, which includes the story entitled "before the law," as a starting point for, or in the course of, their thinking about the law and what it means to be "before the law." wolfe spends much of his work on biopolitics describing derrida's position, noting, for example, the lack of response in law as, constructed in the technicity of language, its automatic nature leads merely to reaction. yet in this interview he emphasizes "desire" in relation to the law. as this project has explored the role of desire throughout, deleuze and guattari's writing about desire and the law, specifically their kafka: towards a minor literature, adds another fold to biopolitical thought. while he doesn't consider deleuze and guattari's writing about kafka, and therefore their specific writing about the relationship of their vitalist project to the law, wolfe does address how deleuze's work, which might seem at first to promote the equality of all life in an affirmative biopolitics, is useful in terms of biopolitical thought. he explains how a pragmatic application of deleuze's philosophy bypasses the potential problems of an affirmative biopolitics: "by a pragmatist account, philosophy for deleuze, as paul patton puts it, 'is the invention or creation of concepts, the purpose of which is not accurate representation' but rather to provide 'a form of description which is immediately practical,' one 'oriented toward the possibility of change'" (before the law 93). in other words, while their ethics of affirming zoe might appear to promote the flourishing of all life, this is not an accurate portrayal of life but instead a practical politics for resisting dominant thought, capitalist logic, and the consumption of everything that lives. desire poses a more direct and revolutionary threat-one that works outside of the rationality of the law, an authority which currently excludes most animals from the community. that is, rather than appeal to the authority or work within the confines of the law which has rendered animals in their current position, which has, through its exclusionary violence, failed to protect them, staying with that desire and its productive nature offers opportunities for working toward this protection in new ways, outside of the law. in kafka: toward a minor literature, deleuze and guattari argue more specifically against the law as a means to justice. they offer a corrective to the view that the law secures justice: "where one believed there was law, there is in fact desire and desire alone. justice is desire and not law" (kafka 49). this perspective on law agrees with wolfe's discussion of the "undercutting" of desire that pertains to rights approaches. the law, when viewed as the only outlet to protect animals, "undercuts" desire, then, by reterritorializing desire into the existing legal framework, appealing to its authority or authorities, thereby undermining its revolutionary potential. or more specifically, for deleuze and guattari, the law does not undercut desire but instead is one of two kinds of desire: the transcendental law or the schizo-law. they argue: we should emphasize the fact of these two coexistent states because we cannot say in advance, "this is a bad desire, that is a good desire." desire is a mixture, a blend, to such a degree that bureaucratic or fascist pieces are still or already caught up in revolutionary agitation. it is only in motion that we can distinguish the "diabolism" of desire and its "immanence," since one lies deep in the other. nothing preexists anything else. it is by the power of his noncritique that kafka is so dangerous. (60) in other words, for them, the law itself doesn't necessarily undercut desire, but the law perhaps is one arena where desire is either reterritorialized or takes off on a line of flight. the non-critique here gestures to the potential of desires to transform to positive ends or conversely to become violent. continuing their reading of the trial, they argue: from this point on, it is even more important to renounce the idea of a transcendence of the law. if the ultimate instances are inaccessible and cannot be represented, this occurs not as a function of an infinite hierarchy belonging to a negative theology but as a function of a contiguity of desire that causes whatever happens to happen always in the office next door … if everything, everyone is part of justice, if everyone is an auxiliary of justice … this is not because of the transcendence of the law but because of the immanence of desire. (kafka 51) this position radically calls into question nussbaum's moral universalism, or "universal rights," as it is revealed that law is just an arena of sorts for desire that springs forth from the immanence of the body. desires that are not reterritorialized, that remain schizo-law, are therefore specific to the singularities of the material assemblages "next door" and, as they privilege deterritorialized desire and schizophrenia throughout their work, schizolaw provides the possibility for political action against dominant thought and dominant constructions of desire which have resulted in the failure to protect particular members of the community. 1 what's at stake in this understanding of law as nothing but desire is the realization that a rights approach needs to be backed up by the desire to enforce it for it to work toward the protection of animals or the environment. the import of deleuze and guattari's insight into the law, however, is that the law itself is empty, is nothing but desire. in other words, and i'll discuss this further in my treatment of the novels below, if the desire to protect animals, the environment, humans, and so forth does not exist in the exercising or administration of the law, the law itself (and the passing of more laws ad infinitum, even) will surely fail to protect them and ensure their futures. if those positioned as authorities of the law are colonized by oedipus and their desires are therefore reterritorialized by capitalism, the laws themselves will not stand a chance against the disposing of these others for the accumulation of pleasure and profit by the arbiters of the law. if the law is really desire and its officials are colonized by capitalism's definition of desire as lack that must be filled through consumption and accumulation, their authority in the law enables the potential of capitalist desire to render all that lives "disposable" to their personal interests and make everything available for consumption and profit in a logic of exchange. thus it becomes all the more important to theorize desire differently and to think outside of capitalist logic which defines desire as lack, viewing desire instead as an opportunity to make ethical attachments toward sustainable futures. since what appears to be law is really desire, if we take that observation seriously, decolonizing desire or resisting its colonization toward a postcolonial desire then becomes a significant intervention into the political field as part of a project to protect the others and the environments of our communities. since capitalism bombards us with its definition of desire constantly, portrayals of what i'd like to call "postcolonial desire" in these novels offers a line of flight away from capitalist logic: a field of desire which can reorient one's sense of self and relationships to others, animals, and the environment woodward argues that animals can be focused on in literature and writing because human rights have been secured in south africa. she writes: now that human rights appear to be in place in a democratic south africa-even while much of our racialised history remains intact-writers can represent animals more expansively without engendering criticism of foregrounding animals at the expense of humans. white writers in particular may have felt constrained not to portray animals as ethical subjects when the majority of south africans were without rights. (14) to be sure, the putting in place of human rights is a significant achievement, and yet, as she seems to acknowledge here in recognizing that the "racialised history" has not changed much with the advent of rights, the securing of these rights doesn't radically alter the state of affairs or ensure the protection and improved treatment of those now granted rights. additionally, the secondary consideration of rights for animals continues to privilege the human over the animal, ensuring the continual deferment of protections for animals. similarly, calls for the addition of more kinds of right, like elke zuern's argument for the case of "socioeconomic rights' (66) as part of human rights, while certainly important in their attempt to redress economic inequality and its violence, which much current rights discourse overlooks, require their enforcement by the authorities of the law. zuern summarizes her research: south africans argue "that freedom can only be realized when civil, political, and socioeconomic rights are protected and enforced" (xii). the phrasing of this observation gets to the heart of the matter in that the passage of the rights in law, if we agree with deleuze and guattari, guarantees nothing without an accompanying schizo-desire that would desire to protect the community. to further extend these rights to animals, then, without thinking desire differently toward a postcolonial desire does little to protect them or the locations where they dwell. where the recognition of rights is important in a legal sense, poor conditions obviously still persist for many of those who are now extended rights in south africa. for example, the poor conditions for miners which led to the strikes at many mines, including the marikana platinum mine in august 2012 where several strikers were shot by the police, are evidence that the putting in place of human rights has not guaranteed the protection of south africans formerly left outside the law's protection during apartheid. deterritorializing and decolonizing desire is a necessary part of any approach to protecting the inhabitants, human and non-human, of south africa. the law "manifestly lacks balls" (260), as gerhard puts it in the reluctant passenger in his summary of luc's description of the law as a "eunuch." michelè pickover reveals evidence of this powerlessness of the law throughout animal rights in noting the complicity of the law with corporate interests. she explains how in many animal protection issues such as vivisection, factory farming, the trade in wild animals, and conservation, the government officials who oversee and make laws protecting animals are often also involved with the corporations; or indeed in many cases, such as factory farming, corporations are often left to follow the laws on their own, without any oversight. for example, she writes: "the south african government either lacks the political will or the resources to police and regulate the industry" of trophy hunting, and she notes that "[t]he truth is that trophy hunting promotes a culture of violence and guns. this is in direct opposition to the needs of south african society, which is desperately trying to free itself from its violent past" (48). she also describes how this instrumentalization of animals continues in an apartheid legacy: "wild animals were exploited to fund the apartheid war, the secret agencies, the special forces and the individuals connected to them. it is no secret that the nationalist government and its military machinery were involved in the illegal trade in ivory" (51). these obvious conflicts of interest in the form of a desire to extract a maximum profit from animal bodies and being charged with the task to protect them speaks to the many ways in which the law is compromised through its colonization by capitalist desire. as pickover's reporting on the exploitation of bodies during apartheid reveals, authorities often acknowledge or disavow the rights of others and choose to administer the law as it suits their agendas and financial interests. this problem-that the access to rights and to the protections of the law are made to depend on those administering it (perhaps best described in kafka's "before the law" with the countryman seeking access to the law from the doorkeeper)-was most obvious during the apartheid regime with the passing of laws denying the rights of black south africans. in the context of this discussion of the law being colonized by capitalist desire, perhaps the most pertinent of these laws limiting the rights of black south africans were those acts which prevented or hindered these communities from acquiring decent paying jobs, ensuring that the white community would benefit financially. in the reluctant passenger, the villainous judge conroy describes these financial benefits of apartheid to morris upon telling him of his former plan to hand over the fortune he collected from corrupt dealings as a lawyer: "you no doubt imagine yourself too morally fastidious to benefit by money derived from an evil regime. i need hardly point out that for decades every white south african to a greater or lesser degree benefited by the policies and practices of that regime" (404). heyns' and mda's novels shed light on many of these problems as they portray the corruption that informs environmental rulings: the heart of redness describes the conflict of interests of the government official deciding on the development project for qolorha by the sea; heyns' novel in particular describes the government's collusion in the abuse of baboons in vivisection. to return briefly to mda's the mother of all eating, discussed in chap. 4, it is the messenger's desire which takes off on a line of flight and threatens the power and privilege exercised by the man and his fellow government's officials, who are colonized by the reterritorialized desire of capitalism. the man's attempt to stop the messenger's revolutionary behavior, which i've referred to in chap. 2, acknowledges the way in which capitalism colonizes desire: the people don't have any leadership that will create a critical awareness in them, that will open their eyes. whenever new leadership emerges, even if it begins as honest leadership, it is swallowed by the culture of eating, and becomes one with it […] the people are doomed to … [an obvious kick, and a scream] okay, okay, i admit … it will take a very small thing to spark action in them, and to arouse them to an anger that has not been seen before. (35) the man tries to quell the messenger's revolutionary desire by attempting to convince him that his behavior and the position of the people is one of impotence, as is the case for humans in relation to the gods in oedipus. his descriptions of the people as "blind" recall the "blindspots" of plumwood's discussion of what happens as a result of the colonizing force of reason, and his observation that "honest" leadership may be colonized by the culture of eating confirms her argument about the colonization of political systems as well. after experiencing the violent kick from the messenger, however, the man acknowledges that the desire of the people is what he lives in fear of as it resists his easy management and control. indeed, it is what is threatening his life at this point in the play as the messenger refuses his bribes, and he fears that this desire has the potential to change the state of affairs, threatening to unseat and remove all the corrupt officials who "eat" the community. south african author michiel heyns, whose lost ground won him the sunday times fiction prize in 2012, has also received accolades for his translations of south african literary criticism and literature from afrikaans into english, such as marlene van niekerk's agaat. he also currently maintains a blog entitled books and dogs, where he writes often about his dog simon and dogs in literature ("michiel heyns"). heyns has written previously about the potential of affect to challenge and threaten the cool reason often exercised in the violent treatment of animals and others in his earlier novel, the children's day (2002) . his second novel, the reluctant passenger (2003), features a white south african middle-class environmental lawyer, nick morris, who takes on a case for luc tomlinson and a troop of baboons. the subjects of law, rights, and desire discussed earlier come into focus in the story as the protagonist becomes more involved in the case for the baboons. at the beginning of the novel, morris detests the unmasterable and disorderly aspects of himself and the environment. heyns' offers a critique of reason and mastery as morris is frustrated by any disorganization or things that don't adhere to the norms of human rationality or reason. for example, morris wishes he was an accountant as he originally planned, where the world is neatly divided and ordered into columns of debits and credits. he also resents his neighbor's dog, who shits on his lawn, and he chooses to live a celibate life with his girlfriend so he won't have to deal with the messiness of sex or love. in an early scene, the dog actually knocks him into a pile of shit as morris attempts to clean it up to restore cleanliness to his yard. in response, morris violently wipes the shit all over the dog's body, viewing animals in a pejorative sense as mere producers of dirt and filth. morris prefers order and is a perfect employee under capitalism, an ideal manageable subject of capitalist biopolitics, as he is never late, is apolitical, and maintains neatness and order above all else. he makes all attempts to master and control his animality through regimes of culture, and he seeks to avoid encounters with his own nonhuman life or zoe (including his desires), as well as encounters with nonhumans and the nonhuman world. in addition, his concerns for the neatness of his lawn and property cause him, rather comically, to forget to vote in the 1994 democratic elections. almost all of his life is ordered and he attempts to master or control it completely. as braidotti says of the dominant understanding of consciousness, he lives in fear of zoe: relentlessly vital, zoe is endowed with endurance and resilience … zoe carries on regardless: it is radically immanent. consciousness attempts to contain it, but actually lives in fear of it. such a life force is experienced as threatening by a mind that fears the loss of control. (nomadic subjects 110) he also lives a rather sedentary lifestyle alone in a large house in a gated community, and he seems to have little life or connection to the world outside of working, with the exception of meeting his one friend, gerhard, an openly homosexual fellow lawyer who embraces zoe by, for example, discussing his sexual encounters and desires openly, engaging in sexual acts in public, and often being late for meetings and work for love-related and other reasons. the novel centers on a case morris takes up when a kind of hippie wild-man character, who turns out to be the wealthy luc tomlinson, comes into his office asking him to take his case to protect the baboons and the private reserve where he lives with them. in animal rights in south africa, michelè pickover begins with a striking story about a baboon who worked for the railroad, and as a service animal for a disabled railway man, to counter the negative view of baboons and their limited protections in the law: in most provinces in south africa baboons are classified as vermin or 'problem animals'. taking advantage of this status, in 1999 several businessmen devised a plan to build a slaughterhouse in limpopo province to kill wild-caught baboons by electric shock and then process them into salami, polony, and tinned meat for consumption in central africa and eastern europe. baboon body parts, such as hands, teeth, and tails, would be exported to asia as aphrodisiacs. (2) the baboons in heyns' novel are classified in a similar violent, disposable status and therefore luc and nick's initial attempts to protect them through legal means are fruitless. luc's father threatens to build a resort at the reserve partly because it is a business venture and he is a capitalist, and partly because of a long family feud. where nick morris initially wants nothing to do with the case, his friend gerhard encourages him to be less reserved and to experience more of the uncertain, unpredictable, and non-normative aspects of life, like the dirty, unkempt luc and the baboons. as the novel unfolds, the protagonist learns about himself as he learns more about baboons, appraising them as a worthy case, suggesting the interconnectivity of a positive appraisal of the non-humanness of subjectivity and of the non-human world. as he embraces zoe as a positive passion, instead of a negative one which disrupts his orderly world of progress as he had before, he comes to value the complexities of the world in its open-ended becoming. he moves from being someone who fails to ever examine his own sexual feelings for the sake of order and not wanting to be inconvenienced by them, and who detests the disorder and dirt that animals bring into his life, like his neighbors' dog, to a person who finds himself having sex with his client, luc, in his home while the troop of baboons they've saved from a vivisection lab tear apart his furniture and cause havoc to the upstairs of his house. the novel's title and image on the cover, explained in the first pages, offers a suggestive description of zoe. morris describes: i once saw a man transporting his rottweiler in a shopping trolley through a no dogs allowed area: the beast was clearly well trained, and stayed put, but you could see that all it really wanted to do was chew the wheels off all the trolleys in the universe. (11) this image emphasizes the zoe of the animal and how it is maintained in consumerist culture or oedipalized for the benefits of human shoppersthe dog is thus a reluctant passenger. as braidotti writes, challenging the idea that dogs are only dirty, "[d]ogs are not only messy, but also openly sexual. they unleash a reservoir of images for sexual explicitness and even aggression, as well as unbridled freedom: they are a vehicle for zoe" (104). like the dog in morris' story, he himself is also reluctant as he somewhat hesitantly moves in the other direction from a bios-centred life to embrace zoe: at first, he is discomforted and bothered by the presence of luc and the thought of taking on the case for the baboons. as morris ends up exploring his sexual desires with luc tomlinson, he recognizes that the messiness of life which is part of his own subjectivity, or the zoe which flows through him, is connected to this non-human force of life in animals. he adopts a view of life and of the subject that correlates with ecofeminism "which asserts the fundamental interconnectedness of all life … [and which] offers an … ecological ethical theory for women and men who do not operate on the basis of a self-other disjunction" (2-3). he begins to care for the baboons, luc, and his neighbors' dog, which he formerly detested, when they plan to euthanize the dog because they are leaving for australia and no longer have a use for it, like the guard dogs in disgrace, to protect their property. the reluctant passenger reveals throughout the legal case for the baboons and through the behavior of various judges, lawyers, and government officials that the workings of the law are really the workings of desire. for example, we learn that luc desires protection of the baboons, and the protagonist, morris, begins to care for the case at first because he desires luc as the narrative later confirms. and it is gerhard's embracing of zoe and his encouraging of the protagonist to take pleasure in the world in its becoming that leads him to take on the legal case for the baboons. in other words, morris doesn't take on the case at first because he legally has to-the law doesn't require that he accept the case or that the baboons be protected, and indeed he appraises it as not much of a case at first. yet his desire, which is before thought, compels him to venture out to the preserve to meet luc and the baboons. further evidence of the law actually being desire is the revelation toward the novel's end that the authoritative figure judge conroy has been controlling most of the plot through underhanded deals, bribes, and so on-many of the same tactics that he and other judges used during the apartheid regime. having lost the woman he loved, joyce tomlinson, to the wealthy brick tomlinson, luc's father, while living a modest life to complete his law degree, conroy spends the rest of his life seeking revenge for the lack of consummation of his desire for joyce. we learn that he manipulates brick to propose the business development of the baboon's land, persuades luc to seek out legal recourse to protect the reserve, and controls many of the other events of the plot. as he tells the protagonist of his manipulations, nick queries: "so even in the capacity of puppet i was not indispensible?" (403). as conroy's actions reveal, he disposes of others consistently through his authority as judge for his own profit and to exact his private revenge. as these behaviors bear out, what appear to be the workings of the law are actually the workings of desire. another example of this occurs in the resignation of the director of nature conservation and development as he does so because he's blackmailed with the threat that his affair with his secretary will be revealed to his wife if he doesn't resign. thus the regulation of desire that pertains to the family is exploited here as capitalist desire attempts to reterritorialize the director's desire to protect the animals and environment. deleuze and guattari explain that [t] hese two coexistent states of desire are the two states of the law. on the one hand, there is the paranoiac transcendental law that never stops agitating a finite segment and making it into a completed object, crystallizing all over the place. on the other hand, there is the immanent schizo-law that functions like justice, an antilaw, a 'procedure' that will dismantle all the assemblages of the paranoiac law … to dismantle a machinic assemblage is to create and effectively take a line of escape that the becoming-animal could neither take nor create. thus the attempt to control or limit desires, to force people into dominant subjectivities and fit the world nicely into concepts or categories, becomes a paranoiac attempt to limit schizo-law. this desire to master the world is also something jane bennet challenges via adorno's critique in his "negative dialectics," where he theorizes that violent behavior results from the frustration that humans experience when the world does not fit their concepts (14). conroy's behavior and description of his motivations confirm his paranoid and narcissistic attempts to reterritorialize desire via his position as authority and arbiter of the law. especially interesting here also is that like her son luc, joyce tomlinson is closer to zoe in her embracing of desires as she often promotes luc's free-spiritedness. in contrast, conroy is colonized by oedipus, which defines his desire as lack in that his life is devoted to filling the lack created by joyce's marriage to brick, and to a lesser extent his desire to acquire wealth for the manipulation of others. conroy acquires wealth mostly for the purpose of attempting to separate joyce and brick. joyce, however, largely disregard's capitalism's lure as it seems she loves brick for himself, not for his finances. of course, brick's extreme adoption of capitalist logic leads him to view the baboons and their land as an opportunity for profit, and, anticipating this behavior, conroy manipulates him into the business venture. the novel thus points to the precarious biopolitical situation for those seeking protection from the law when its arbiters are colonized by capitalist desire. in other words, conroy's lack of joyce in his life and his use of his position to accumulate wealth jeopardizes the protection and futures of south african communities, making "disposable" those his position was created to protect. the desires of luc, morris, and the other characters who assemble to save the baboons, however, work to challenge these capitalist and narcissistic desires outside of the limitations of the law. as the novel reveals towards the end, conroy occupies a god-like position in his manipulation of the plot. his desire for mastery suggests an extreme form of the kind of control and disgust for vagueness and untidiness that the protagonist exhibited earlier in the novel. as the protagonist and conroy approach a relationship of mentor and mentee, heyns positions the development of the protagonist's character as dependent on his relationship to desire or zoe. at one end of the spectrum, the side of transcendental law, sits conroy, whereas nick's best friend and fellow lawyer, gerhard, embodies "immanent schizo-law" or desire and zoe as positive. conroy describes his frustration with the failure of his plan, that even after rendering brick to a state of poverty he still has not separated joyce from brick, blaming this on the incalculable nature of humans: "[a]gain i failed to take into account the inconsistency of human beings. joyce … was moved by his destitution to side with him" (404). joyce's exceeding the mastery of conroy's control suggests the ungovernability of foucault's homo oeconomicus from the birth of biopolitics, as cary wolfe describes: in opposition to what foucault calls homo juridicus (or homo legalis)the subject of law, rights, and sovereignty-we find in this new subject, homo oeconomicus, "an essentially and unconditionally irreducible element against any possible government," a "zone that is definitively inaccessible to any government action," "an atom of freedom in the face of all the conditions, undertakings, legislation, and prohibitions of a possible government." "the subject of interest," foucault writes, thus "constantly overflows the subject of right. he is therefore irreducible to the subject of right. he is not absorbed by him." (before the law 23) conroy thought he could control her, assuming that she loved her husband for his money, that she was colonized by capitalist desire, but she desires her husband for himself. even from his position of authority in the law, conroy cannot master joyce's desire or tame it to direct it toward himself. the protagonist, morris, also presents challenges to power and government that pertain to foucault's homo oeconomicus as he has broken numerous laws and no longer attempts to master his own desires. in addition, conroy offers in this scene his desire for an oedipal relation to the protagonist based on their similar orderliness and strict discipline: as you know, i had been taken with your dissertation some years ago … and now, i thought … you could take the place of the son i never had … you reminded me of myself at your age: ascetic, high-principled, civilised … for the first time my sterile obsession with avenging myself on the world for what i had missed yielded to a vision of what i might yet have. (404) here, conroy's knowledge of the protagonist's homosexual act with luc upsets his oedipal ambitions of fatherhood. more specifically, morris' acting on his sexual desires with luc caused him to miss his appointment with conroy-the first time the protagonist ever missed or was late for an appointment-frustrating conroy's ambitions of mastery. frida beckman's discussion of homosexuality in deleuze's thought acknowledges how in addition to non-human sexuality, "[a]nother way of exploding the anthropomorphic, heterosexual, familial, and oedipal organisations of sexuality is found in homosexuality" (16). she continues explaining that "[h]omosexuality, as verena andermatt conley notes, is seen here not as an identity, but as a becoming" (16). morris' now positive appraisal of desire, which also motivates his protection of the baboons (who express sexual desire themselves), therefore enables the freedom from conroy's complete mastery of most of the characters in the novel from his position as an authority of the law. morris embraces his homosexual desires, instead of repressing or avoiding desire as he does at the beginning of the novel, in a way that enables a becoming away from the fixed identity of the subject of rights or the subject of capitalism that conroy might have otherwise mastered. conroy's description of his ideal new society built on "wisdom of authority" also includes biopower in the form of "death squads" (404), biopower being that which foucault argues derives from a desire to govern and control homo oeconomicus. indeed, conroy describes his position of mastery here in a way that confirms his paranoid attempts to maintain and control desire. after suggesting that he wasn't trying to get joyce back, he comments: what i resolved to do was to achieve mastery over myself and others, partly through self-control, partly through control of them. and whereas control of the self is a matter of discipline, control of others is a matter of money. of this, as i have remarked, i soon had large sums, thanks to my contacts in countries officially hostile to south africa. (401) here, conroy confirms the manipulation of his position of authority to exact his revenge, and along the way treating others, the land, and indeed the country of south africa as disposable in service to exercising his personal grievances. in short, he adopts a relation to others of "eating," as discussed in chap. 4. while early on in the novel the protagonist, like conroy, attempts to live an exceedingly controlled and ordered lifestyle (and this is in large part why conroy views him as an ideal candidate for his mentorship), his embracing of zoe, perhaps especially his embracing of his homosexual desire, frustrates the mastery and control of conroy's plan. the protagonist's decision to embrace zoe as positive then becomes revolutionary as it creates a line of escape from the mastery and instrumentalization of the humans, animals, and environment of south africa exhibited in the apartheid regime's practices. baboons before the law at one point in heyns' novel, after the baboons have been stolen from their home, luc tomlinson appears at morris' office to discuss the legal case for saving the baboons and their land from his father's business plans to set up a luxury resort there at cape point. the conversation that the characters engage in about the legal status of the baboons reveals the problems that the law has in deciding on the status of animals, an issue fontenay discusses in her chapter entitled "between possessions and persons." luc expresses his desire to get a "court order" (259) for the baboon,s to which morris responds: "before i can get a court order i need to establish that somebody's rights are being infringed" (259). luc argues that it is obvious that the "chacs'" (chacma baboons') rights aren't being respected, noting how they've been taken away for medical testing and vivisection, an issue i'll return to later. the protagonist replies: "the rights of animals are a much debated area in law" (259). at this, luc replies angrily at morris: "i'm not interested in any fucking debate. anybody who isn't unbelievably stupid or dishonest knows what we're doing to the animals … it just suits us to come up with debates. the law is … ." morris attempts to finish luc's sentence, offering "an ass?", to which luc replies: "i was thinking of something more useless, like a … a eunuch" (259). their conversation about the law continues, describing how the law protects only certain people through their metaphor of eunuchs as morris remarks, "they guard the sultan's harem," and luc replies: "yeah. great if you're the sultan, not so great if you're not" (259). the discussion of the law in terms of eunuchs and harems continues to develop the theme of sexuality in the novel, and also points to the exclusionary nature of the law, as it only protects those who are considered as belonging to the community. the discussion of the harem and the sultan also perhaps highlights the discriminatory nature of the law's privileging some and excluding others. the protagonist attempts to end the conversation about the law and what can be done for the stolen baboons in a way that suggests he's exhausted all available avenues to help them. he remarks: "well … for better or for worse, the law, for all its shortcomings, is all we have to help us here" (259). such a position, that we can only work within legal discourse to improve the state of affairs for animals, greatly limits the political potential for addressing the problems facing them. as wendy brown and janet halley suggest, "rights cannot be fully saturated with the aims that animate their deployment … they retain a certain formality and emptiness which allow them to be deployed and redeployed by different political contestants" (9). in this sense, the affect and enthusiasm for protecting gets cut short when rights are viewed as the only avenue of intervention. brown and halley further explain the potential of critical theory for considering opportunities for politics and justice outside of legalistic frameworks, which the characters in reluctant passenger eventually take up in seeking extralegal, creative approaches: "[c]ritique [in contrast to legalism] hazards the opening of new modalities of thought and political possibility" (28). where the protagonist, who lives most of his life according to society's normative rules, who lives extremely discursively or "by the book" as it were, seems to be giving up on the case for the baboons when they reach a dead end legally, his friend gerhard intervenes, responding to morris' claim that the law is all we have: "not necessarily" (259). gerhard continues critiquing the lack of power that pertains to the law: "but where, as mr. tomlinson has pointed out, the law so manifestly lacks balls, we may have to rely on our own … devices for a remedy" (260). the characters' desires for one another-gerhard is sexually attracted to luc, flirting with him, and, as the consummation of luc and morris' relationship bears out later, they desire each other as well-and for the baboons, especially luc's, result in their hatching a plan to save the baboons, outside the parameters of the law. as a lawyer for luc and the baboons, morris employs some blackmailing of his own to win the case for the baboons and the preserved land, with the help of a fellow lawyer and her husband, and the rest of the group which have rallied round the cause, including gerhard, morris' former girlfriend, and others. as a result they are able also to reinstate mr. haartshorn, the original director of nature conservation and development, who testified in the case that he was blackmailed with evidence of his extramarital affair and bribed into resigning after writing a report denying brick tomlinson's business proposal for the land under question. morris and his team also use some compromising pictures of minister stanford from what are revealed to be sex parties for ministers during the apartheid regime, which involved their raping of young men in military uniforms at a building in rocklands, the preserve of the baboons (163). the photos were given to morris by joyce tomlinson, and later we learn, at the recommendation of judge conroy, to influence the minister's testimony so that he confesses that haartshorn gave him the report denying development prior to resigning. the trial results in haartshorn unseating the man who, in the old regime's pocket, replaced him and approved the proposal. for conroy, this is a victory because it caused a large financial loss for brick tomlinson by preventing the development of the land. however, the baboons are still rendered unprotected after the ruling as they are stolen and taken to the vivisection laboratory, and bulldozers appear at the nature preserve. thus even the legal ruling that uncovers the corruption and decides in favor of the baboons cannot protect them from the extralegal means of the capitalist desire to dispose of and turn a profit from them and their land. heyns portrays in morris a character who transforms his negative feelings about sexuality and animality into positive passions to work for the protection of the baboons, even outside the realm of the law. how do we think outside of dominant thought and beyond its closures? when faced with the limits of law, the characters' desires compel them to think differently. braidotti explains that deleuze and irigaray bank on the affective as a force capable of freeing us from hegemonic habits of thinking. affectivity in this scheme stands for the preconscious and the prediscursive: desire is not only unconscious but remains nonthought at the very heart of our thought because it is what sustains the very activity of thinking. our desires are that which evades us, in the very act of propelling us forth. (nomadic subjects 40) thus desire and affectivity enable gerhard, luc, and nick to think differently, outside the parameters of the law, to devise a plan to protect the baboons. woodward argues about luc's appeals for the rights of baboons throughout the narrative that "luc coaxes the reader to accept the concept of baboons as 'creature[s] … of moral standing' within modernity, to refer back to nussbaum's argument" (78). she further concludes her chapter on baboons by noting that "the moral agency of baboons … has not been acknowledged by the south african constitution, which does not incorporate the subjectivity or even sentience of nonhuman animals" (90). while heyns' novel certainly points to the lack of legal status for baboons, the reluctant passenger in my view more strongly argues that it is necessary to think beyond the law, and acknowledges the role that desire can play in this thinking differently. that is, by acting on their desires for the baboons' protection, and for nick morris by embracing zoe as positive instead of attempting to master it in a negative relation, these characters ensure the protection of the baboons that the law cannot always guarantee. as talal asad argues in "what do human rights do? an anthropological inquiry," rights do not always guarantee the protections they describe. he argues: human rights discourse may not … always be the best way (and it is certainly not the only way) to help remove oppression and relieve suffering among human animals, as well as non-human animals, or to preserve the world's natural and cultural inheritance. working in hospices, providing comfort for the traumatized, the sick, the destitute, helping to rejuvenate depressed neighborhoods, are among the activities that help to relieve human suffering. such commitments remain outside the imperative of the law. (51) in light of heyns' novel, we might add rescuing baboons from vivisection and hiding them in one's house to asad's list of the ways we can protect and prevent the suffering of non-human animals. although the reluctant passenger focuses on the life of an environmental lawyer, it emphasizes that we have creative options for responding to animals outside of legal means, options that exist "outside the imperative of the law" (asad) . as i've discussed in previous chapters, desire works across species boundaries, and again in the reluctant passenger an animal's desire and a human's desire for animals leads to the protection of the animals and their habitat. after nick and the adonis-like luc tomlinson walk naked with no deodorant on to meet the baboons (so as not to scare them off), petrus, the alpha male chacma baboon, takes a sexual interest in the protagonist: "'bloody amazing,' said luc, almost admiringly. 'you must have really potent pheromones.' he added with an unconvincing affectation of concern, 'i'm afraid he wants to fuck you.'" (84). as his attentions turn to another baboon, petrus does not consummate the sexual exchange in what would surely be his domination of morris, who fears petrus' great strength and doesn't want to engage in sex with a non-human animal, but the sexual arousal that the protagonist and his pheromones caused in petrus turns out to be the reason that luc, the self-proclaimed friend of the baboons, initially finds the protagonist attractive sexually as well. the passage in heyns' novel suggests the transversal nature of desire as it works across species and indicates the role that pheromones might play in sexual attraction. like the desires that involve lahnee o, minke, and corsicana in tanuki ichiban, and the whale caller and sharisha in the whale caller, here again animals' desire and humans' desire for animals ensures the protection of the animals. the desire that arises out of assemblages (and not transcendental law) enables justice: "transcendent and reified, seized by symbolical or allegorical exegeses, it [the abstract machine] opposes the real assemblages that are worth nothing except in themselves and that operate in an unlimited field of immanence-a field of justice as against the construction of the law" (deleuze and guattari 87) . thus the law is not the house of justice; instead, justice dwells in the potential of desire that results from the immanence of our bodies and relations to others in assemblage. of importance here is that this assemblage includes "black" south africans as well in the figure of nick's colleague and her husband mhlobo, who works at the mail & guardian and who supports the case for the baboons as he helps to discover the underhanded deals of the government officials. this environmentalism of the novel is therefore not a "white" or colonial conservationism but a postcolonial ecocriticism that benefits the larger community of south africa. heyns' novel portrays how the desires of an assemblage of human and non-human actors works against the mastery and control of dominant logics-a postcolonial desire that presents lines of flight out of the paranoid and narcissistic managements of the law and against the "eating" or instrumentalization of the community. gerhard's plan to retrieve the baboons from the vivisection ward demonstrates the creative potential of desire to work for the protection of others beyond the realm of the law. the group learns that the evil former apartheid government scientist now turned scientist for a corporate interest, colonel and doctor johanna van der merwe, performs vivisection on the baboons and also has a project of "rehabilitating" homosexuals to heterosexuality. pickover also highlights the horrifying fact that this testing on animals was done often to develop drugs and chemical weapons to dispose of and control those humans who opposed the apartheid government, and woodward notes this from pickover's work as well. pickover explains that this information came out in the trc hearings as she quotes dumisa ntsebesa who chaired them: when animals are being used by scientists for experiments to manufacture chemical and biological weapons, then society should condemn such experimentation in the strongest terms … even more alarming is the fact that the people who were using their research skills and knowledge to manufacture murder weapons, were people in white coats with stethoscopes hanging out of their pockets. these people are normally associated with preservation of life. that is the most repulsive feature of the evidence that has come before us. (133) ntsebeza's response to learning of the vivisection and the creation of weapons to destroy humans speaks to the biopolitics involved in this case as he notes that those who are supposed to aid in maintaining life end up being the administrators of death. in response to van der merwe's two projects, which render animals and non-dominant sexual desires (which upset her normative visions of the human and white nationalism) disposable to the control and mastery of science for the profit or benefit of the corporation and a particular vision of the nation-state, gerhard devises a plan to distract her by offering himself up as a victim for her experiments so that the other members of the assemblage might sneak into steal the baboons away. in offering his body, gerhard renders himself vulnerable and lets himself be "eaten" by the state, sacrificing his body in exchange for the protection of the baboons. gerhard explains that van der merwe "was a medical officer in the south african defence force" and during that time she "was in charge of some highly controversial experiments" (268). after mhlobo informs nick about van der merwe's horrifying science experiments, and creation of drugs and weapons to harm the black community, nick meets van der merwe, dubbed "the black widow," in a gay bar to set up the appointment where gerhard will be "rehabilitated." van der merwe expresses her views on sexuality here in a way that confirms her attempts to limit desire and to exercise biopolitical control over the south african population: "[i]n terms of all three of these paradigms [science, her womanhood, and christianity] the function of the human species is to procreate itself responsibly" (288). she continues offering here a speciesist perspective: "i believe, of course, that as the bible tells us, we have been instructed and empowered to rule over creation. the human being is the crown of creation, and as such is entitled to use the rest of creation for his benefit-within certain limits, of course" (289). such a view of animals confirms religion's role in attempting to separate humans and animals, something i've also discussed as it is portrayed in the whale caller. van der merwe continues to explain her convoluted arguments, at times insisting on the "naturality" of her positions while at other points explaining the need for science to correct nature after the fall of man. immediately prior to nick's meeting with the black widow, mhlobo informed him that one of the scientist's projects was to sneak birth control into foods that black south africans commonly eat as a way to control their populations. here van der merwe explains her position after nick queries: "isn't breeding natural?" (290). she replies: it's natural only in the sense that the procreation of rabbits and chickens is natural. nature in that sense is an accident, without plan or purpose. that is the creation over which the lord gave us dominion. the higher nature is guided by divine wisdom as manifested through science and technology, and informed by a sense of individual and national identity. here van der merwe clearly dehumanizes black south africans given that her eugenic project to control the population's sexual reproduction is discussed in terms of rabbits and chickens in this case, and she thereby establishes a hierarchy where whites are superior to black south africans. as the conversation turns to her project of making gay men straight, she explains that she takes it as her calling "to tell them what they should be, and to help them assume their rightful identities" (291). such a perspective demonstrates an attempt to control desire and subjectivity, limiting sexuality to only normative and procreative practices that might benefit the state in a fantasy of white nationalism. thus human and animal sexualities-these desires-threaten her biopolitical ambitions and ideal vision of the nation. as it turns out, van der merwe, in a sense, rapes gerhard "in the interests of science and the nation" by using a probe on him that was used to give baboons erections to extract their semen for use in experiments to develop birth control for the black population. gerhard's risking of his life, body, and perhaps sexual orientation for the baboons demonstrates a personal sacrifice that results from his desire for their protection. we learn later that the "reorientation" is unsuccessful as he admits having sex with his lover, clive, directly after the experiment, and perhaps gerhard is not as distressed from the experience with the black widow as one might assume as he seems to view it as a challenge. as the assemblage of people risk their lives and wellbeing for the baboons, it's clear that they've gone well beyond the law to ensure the animals' protection. in addition, nick's development of character emphasizes the novel's perspective that embracing zoe and desire as positive is a necessary intervention toward the protection of communities. no longer the solitary, sedentary, order-loving, manageable subject of complicit consumerism and model capitalist laborer, morris becomes political. he deals with the complexities and ungovernable aspects of life, including his sexuality, and multiplies his attachments around a common goal of a sustainable future, not just for the environment and baboons, but also toward social reforms of the legal system through removing those "eaters" of the country from their positions of authority in the government-sustainable futures for the social conditions of south africa. like morris and the assemblage of characters who work against the business proposal to "develop" the land and remove the baboons from their home in the reluctant passenger, camagu, the outsider to the village of qolorha-by-sea and protagonist of zakes mda's the heart of redness (2000), works to protect the community and environment of the village. mda also won the sunday times fiction prize for this novel, which describes how camagu and many of the other villagers, especially qukezwa, argue against the gambling city that is proposed to develop the small village he has recently made his home and come to love. offering a more sustainable alternative to the tourist town, camagu expresses his opinion, which he learns from qukezwa, that the town developed by outside businesses will offer little work or profit for the townspeople and be detrimental to their environment. as in the reluctant passenger, the association of big business with the law is revealed as the developers' attempt to intimidate the villagers' opposition with claims of their connections to the government: "how will you stop us? the government has already approved this project. i belong to the ruling party. many important people in the ruling party are directors of this company" (201). here we see another instance of the political systems that might check the instrumentalization of a community failing as a result of their compromised positions and colonization by a capitalist logic of desire. the audacity with which the developers assert their power demonstrates their impunity as they abuse their positions of authority and elite status in administrating the law: they do not seek to protect the people and animals of the village as the law might happen to prescribe. instead, the developers use their position of power to secure their personal wealth at the expense of the well-being of the community, continuing a practice of "eating" of the community in viewing it as disposable for their personal gains. somewhat similar to the reluctant passenger, where the character development of the protagonist is situated on a scale of zoe-between his embracing its uncertainties in the example of gerhard and controlling or mastering it in the example of conroy-camagu's character in the heart of redness also develops in relation to desire. in this case, how he apprehends it as oedipal, capitalist and as a lack or as positive, productive, and ethical is manifested through his thinking about his relationships with women and the environment: whether he sees the casino development's potential violence to the environment as totally beneficial to the community and views women as existing for his sexual pleasure, or by contrast, taking a more critical position, considers other more positive ways of relating to women and the environment. his interest in relationships with two women of the village indicate his growth as a character as he is at first interested in bhonco's daughter, xoliswa ximiya: a teacher who no longer lives in the village, fetishizes the us, deplores local traditions, such as the practice of dyeing the face with ochre ("the redness" of the novel's title), and sees the advancement of the community toward a greater likeness of western civilization as worth the sacrifice of the environment and animals of the village. as the novel progresses, camagu finds that he more strongly desires qukezwa, daughter of zim, who demonstrates an exceptional knowledge of and intimacy with the environment, the flora and fauna of the village, and local history and traditions. particularly important here as well is the believers' expanded notion of community beyond the "human" that is evidenced in particular characters' devotions to their horses, camagu's refusal to kill the snake of his totem that appears in his bedroom, and especially zim's love of and communication with weaverbirds. in contrast to the developers' plan, and based on the insight into "development" he learns from qukezwa, camagu proposes a smaller measure of a resort built with local materials by the villagers appealing to a different type of tourist who appreciates nature, but not for trophyhunting purposes. camagu's alternative proposal, importantly, does not disregard the fact that the villagers' lives would benefit from some increase in funds. that is, as i discussed in chap. 3 by quoting huggan and tiffin (20), he is not against "development" in and of itself. instead, he is against those forms of development that position the developers in a parasitic relation to the environments and communities they develop, where they can better control and manipulate the community through their inclusion into the global capital system. his proposal is certainly one of development as well. the important difference is that the proposal is developed so as to benefit the community as it values local flora and fauna, knowledge, and labor, rather than devastating it as the capitalist casino and theme park certainly would. the villagers of qolorha are largely divided into two groups: believers and unbelievers. the believers are descendants of the followers of the prophetess nongqawuse back in the times of the cattle-killing movement in the 1850s. 2 as the novel jumps back and forth from the colonial past to the present, at times seamlessly, colonial and neocolonial themes are developed in relation to the environment and sustainability. the believers are more traditional in their return to and appraisal of customs of the past and, as espoused by zim, a prominent believer, they are against the development of the tourist casino. however to be sure, mda does not portray these two groups as totally at odds or pure in their difference: the groups are more complex because some of the unbelievers value the traditions of others and have a mode of believing in unbelief, for example. these divisions along lines of belief, which were exploited by the british colonizers in a divideand-conquer strategy, offer a critique of the present political divisiveness that becomes a distraction and more about self-interest and pride than working toward a sustainable future and protections for the community. the heart of redness emphasizes the variety of temporalities and historical influences experienced in the present of south africa. as mbembe explains, "everything happening today is [not] simply a rerun of a scenario …. [t]oday's shift … is … toward the underground channels" (73). indeed, we've seen this underground market of animal trafficking in tanuki ichiban in chap. 4. in this sense, while i've gestured throughout the project to how the "new" south africa continues to be similar to the past violent organizations of society, mbembe makes clear that the new negative modes of relation and extraction are somewhat different in adopting this underground fashion. mbembe continues to explain how, [i] n this intermeshing of temporalities, several processes co-exist; there are processes tending to make peoples view the world in increasingly like ways, and at the same time, processes producing differences and diversities. in short, contradictory dynamics are at work …; it is too easy to reduce these dynamics to simple antagonism between internal and external forces. (73) this suggestion to avoid oversimplifying the more complex and nuanced interactions of the present organization of society is particularly useful for assessing the dynamics and influences at work in mda's novel: his observation that different, diverse perspectives are occurring, as well suggesting ways out of the culture of sameness and the status quo. as i've been describing how characters seek extralegal means to protect their communities, the heart of redness aligns with mbembe's conclusion about the dynamics of the current moment where the state is no longer viewed as "the best instrument "for ensuring the protection and safety of individuals, for creating the legal conditions for the extension of political rights" (73). the leading unbeliever, bhonco, and his daughter view all signs of "development" and "progress" imposed by corporations as beneficial for the future of the village. as evidence of this, bhonco discontinues some of the adornments of his traditional clothing and begins wearing business-style suits. as braidotti describes, late capitalism endangers not only biodiversity but also human and cultural diversity: [disregard for biodiversity] also threatens cultural diversity by depleting the capital of human knowledge through the devalorization of local knowledge systems and world-views. on top of legitimating theft, these practices also devalue indigenous forms of knowledge, cultural and legal systems. eurocentric models of scientific rationality and technological development damage human diversity. the plans to make the village of qolorha by the sea into a casino would not only render the environment unsustainable but also dominate the culture and non-dominant, indigenous knowledge, such as the ways of fishing and other environmental lessons that the american-educated camagu is continually learning from the villagers throughout the novel. alongside this are the high esteem that bhonco's daughter holds for the us, the country where camagu got a degree, only to return for the elections of 1994. camagu attempts to correct this view of the us as a land of progress by describing the prevalent racism and imperialist practices that he experienced in everyday american life and foreign policy. in his essay on the heart of redness, byron caminero-santangelo argues that the novel positions "cosmopolitan bioregionalism" as a mode of resistance to western development: if capitalism in its various phases has made space out of place, stripping away prior signification (deterritorializing) and reshaping in order to facilitate control and exploitation, then the process of imagining or reimagining a "place" entailed by bioregionalism can be one means of countering threats of exploitation, environmental degradation, and disempowerment. such a concept perhaps resonates with the idea of "smooth space" discussed earlier as a resistance to striated or mapped-out and managed space of the state. yet bioregionalism seems to offer a more specific, intimate knowledge of place and may therefore be a concept better suited to resisting the neocolonial power enacted against particular people, flora, and fauna. its cosmopolitanism challenges the isolationism or "ecoparochialism," to use nixon's term, of some bioregionalisms that adopt a view of place as separate from a broader world, or that ignore the historical and other conditions that are involved in the composition of place as a "process" (296). this cosmopolitanism is especially important in a south african context as it takes note of larger world processes, upsetting particular nationalist imaginaries and their rhetorics of purity that might attempt to deny or elide past violences, histories, occupations of land, and so forth, such as afrikaner white nationalism in south africa. as caminero-santangelo argues, "[n]otions of purity are debunked in the heart of redness not only in respect to identity and culture, but also in terms of the category of nature" (297). a cosmopolitan bioregionalist perspective makes clear how particular rhetorics of purity deployed to claim a place as home or to determine the limits of community are undermined by a broader view of international movements, material processes, relations, and so on. marisol de la cadena's concept of "indigenous cosmopolitics" presents perhaps an even more apt concept for considering the notions of politics at play in the heart of redness, given the emphasis on indigenous knowledge throughout the novel. much of her writing in her essay about differing worlds and worldviews concerning the prospect of a mining development and its potential devastation of a mountain called ausangate in the andes parallels the varied logics and arguments about development in qolorha in mda's novel. for example, bhonco shows disdain for many traditional practices and knowledges privileging western development, while qukezwa and her father zim have intimate relationships with non-human animals, and great respect for the environment and the indigenous knowledge of the xhosa. like caminero-santangelo's reading, which emphasizes the open-endedness of the novel, its privileging of continued dialogue and its refusal to uphold any one character's or group's-believers and unbelieversperspective as the truth or right view, de la cadena emphasizes plural perspectives on nature and politics rather than the one universalizing understanding that often elides other ways of knowing. she argues that despite indigenous knowledge that conceives of the "earth-being" (or mountain in non-indigenous parlance) called ausangate as significantly agentive, there are no guarantees that this knowledge will determine the decision people arrive at regarding the question of development: pluriversal politics add a dimension of conflict and they do not have guarantees-ideological or ethnic (cf. hall 1996) . people-indigenous or not, and perhaps ethnically unlabeled-could side with the mine, choosing jobs and money over ausangate, either because they doubt or even publicly deny its being a willful mountain, or because they are willing to risk its ire for a different living. ausangate's willfulness could be defeated in the political process-some would embrace it, others would not-but its being other than a mountain would not be silently denied anymore for a pluriversal politics would be able to recognize the conflict as emerging among partially connected worlds. and although i would not be able to translate myself into nazario's ontology, nor know with him that ausangate's ire is dangerous, i would side with him because i want what he wants, to be considered on a par with the rest, to denounce the abandonment the state has relegated people like him … to denounce the mining ventures that do not care about local life. (362) de la cadena, while situated outside of the world of indigenous knowledge, nonetheless promotes respect for it as she recognizes its potential-in the threat of agency from ausangate's ire-to challenge the instrumentalist views of nature offered by western biopolitics and development rhetoric. the heart of redness offers a similar perspective on "earth-being's" agency through indigenous knowledge that bhonco and other developers often elide or dismiss as backwards. for example, the qukezwa who married twin in the past explains that "we never kill the snake of the spring. if we did, the spring would dry out" (22). later, in the present of the novel, her namesake tells camagu about the agency of a specific snake, gqoloma, who lives in the prophet nongqawuse's pool: "when it pays a visit … moving from the pool at the gxarha river to another pool at the qolorha river … it causes havoc in its wake, like a tornado. it destroys houses. it uproots trees" (152). camagu also respects his people's customs when he prevents hotel workers from killing the snake that appears in his room because it is his totem. in contrast, xoliswa, who adopts western knowledge as universal, dismisses indigenous knowledge as nonsense: "what can we say about a man who believes in a snake?" (161). earlier her father bhonco and others too dismiss the believer's respect for indigenous trees and animals as "foolish" and "madness," and takes a homogenous view of nature in suggesting that native trees could easily be replaced with "civilized trees" (146-7) . the heart of redness's indigenous cosmopolitics positions indigenous knowledge as frustrating bhonco's attempt to deploy as a universal a western definition of politics as reserved exclusively for humans and his attempts to uphold a human/ nature binary. the "animist materialism," harry garuba's phrase, expressed in characters' spiritual views of these flora and fauna suggests a mode of resisting their instrumentalization. where bhonco reads them as lacking in use value-"these plants are of no use at all to the people. they are good neither as wood nor as food" (93)-qukezwa and other characters' animism values the animals and plants on their own accord. as garuba argues of animism, "objects thus acquire a social and spiritual meaning within the culture far in excess of their natural properties and their use value" (267). the reading of desire in the novel offered here aligns with cosmopolitan bioregionalism, animism, and indigenous cosmopolitics. where cosmopolitan bioregionalism offers a notion of place as process rather than defined space, this project focuses on challenging the defining or limiting views of subjectivity, desire, and other concepts that are also more processual. indigenous cosmopolitics emphasizes "non-representational affect" as key to its expanded notion of politics; theorizing desire, as one mode of affect, as a political potential to resist such exploitation coincides with these other concepts' emphasis on place and indigenous knowledge as modes of resistance. the ethics of sustainability that informs camagu's development of a cooperative calls into question the capitalist notions of western development. he discusses his cooperative with dalton, the trade store owner: i am talking of self-reliance where people do things for themselves. you are thinking like the businessman you are … you want a piece of the action. i do not want a piece of any action. this project will be fully owned by the villagers themselves and will be run by a committee elected by them in the true manner of cooperative societies. (248) his description confirms that his motive is "not for profit" but for creating more positive passions, more joyful lives for the villagers than the current work some of the villagers perform as workers in the mines, service workers at hotels, and the potential jobs that would come from the casino. the narrator describes these workers as receiving racist treatment at the hands of white tourists and also receiving poor wages. camagu makes his opinion of the casino proposal as an unsustainable option clear at one of the meetings the villagers have with the developers. "it is of national importance only to your company and shareholders, not to these people!" he yells. "jobs? bah! they will lose more than they will gain from jobs. i tell you, people of qolorha, these visitors are interested only in profits for their company. this sea will no longer belong to you. you will have to pay to use it" (200). part of the loss from these new jobs will include the devaluing of local customs, knowledge, and labor, and the inclusion of the work done by villagers into the economy of exchange in capitalism that translates into profit for the western developers. camagu's desire is clearly for the people, and this desire for the community stems from his initial desire for qukezwa and his knowledge of its importance to her. his anti-oedipal desire therefore counters the capitalist desire of the developers. as mentioned earlier, camagu arrives at his position on the proposal for the casino resort after his discussions with qukezwa. indeed, the arguments he voices at the village meeting with the developers are those she expressed to him earlier. having a ph.d. in "communication and economic development" (29) from the us, camagu at first finds the casino proposal unproblematic. in fact, early in the novel he adopts more of a capitalist logic of desire as lack and it is qukezwa's teachings that change his views about desire and his relation to others. at the novel's outset, camagu is about to leave south africa to return to the us for a job in economic development, and yet it is his desire that derails his trip, it is desire that brings him to qolorha. as in the whale caller, mda here distinguishes the protagonist's desire from narcissistic desire. after hearing the song of a funeral singer, a "makoti" (28), he cannot get her out of his mind: he becomes breathless when he thinks of her. he is ashamed that the pangs of his famous lust are attacking him on such a solemn occasion. but he quickly decides it is not lust. otherwise parts of his body would be running amok. no, he does not think of her in those terms. she is more like a spirit that can comfort him and heal his pain. a mothering spirit. and this alarms him, for he has never thought of any woman like that before. (28) while all of his relations to women previously are of a selfish nature and about accumulating sexual pleasure for himself, and he is ethically deficient in this regard as he pays his servant to have sex with him in a way that the narrator compares to the rape of a slave by her master (28), his desire for this woman is not of a self-serving kind; it is this desire for her that motivates him to seek her out again in qolorha. thus, while he is self-interested and narcissistic in his use of others for sexual pleasure at the novel's beginning, he comes to approach desire differently after this experience with the makoti and after learning from qukezwa. in contrast to the earlier one-sided affairs of camagu's lust and use of women, both he and qukezwa have sexual dreams about each other: "mutual dreams. messy dreams" (171). this transformation of his relation with women from a position of dominance to a mutual relationship brought about by qukezwa suggests that she is a feminist character. indeed, harry sewlall dubs her "the quintessential ecofeminist" (113), for her thorough knowledge of the plants and animals of her habitat, her challenges to the patriarchal traditions of the villagers, her dressing in traditional garb, and her educating others in the village about the environment and living in a sustainable way. yet, as caminero-santangelo convincingly argues, the novel's characterization of qukezwa is not an idealization of the indigenous as some critics hold, since she is more complex, transformed by history and cultural contact: "such characterizations [of qukezwa as the idealized ecofeminist] suggest that mda reinforces the notion of an unchanged indigenous ecosystem that existed before the impact of colonialism and advocates for a return to an indigenous, properly ecological relationship between human and nonhuman nature." in other words, qukezwa sees the similar logics of oppression at work that seek to disenfranchise animals, women, and others from a position of full standing and as deserving of the protections of the community. her ecofeminism becomes clear, especially in the scene where she seeks to defend her environmentalist practices of killing some foreign water-depleting trees before the council of elders, challenging the lower legal status afforded to women in traditional xhosa laws by gesturing to the laws of the "new" south africa that prevent gender discrimination. qukezwa's role as a mother to heitsi and her teaching him to swim in the sea at the novel's end demonstrate a particularly south african feminism that embraces motherhood as a political act, a mode of feminism in the country that as zoë wicomb explains differs greatly from the largely negative view of family roles in western feminisms. her teaching her child to swim in the sea, in relation to which she has played perhaps the most significant role in protecting it from being stolen from the community by the developers, confirms her feminism as a robust ecofeminism. qukezwa also plays a role in deterritorializing camagu's once capitalist desire as he no longer narcissistically spends his time seeking his own pleasures and profits at the expense of others. animals seem to play a role in this transformation of sexual desire as he, rather like the whale caller, achieves orgasm seemingly incidentally in the presence of an animal and in response to song, in this case while he and qukezwa both ride on the horse gxagxa: "[h]is pants are wet … . it is not from sweat" (152). at this point in the novel, camagu becomes enthralled with qukezwa, especially her singing rather than with her looks. in fact, the more "civilized" and western potential love interest xoliswa is known for her beauty which rivals that of models. after their ride on gxagxa, "[h]e remembers … when she sang him to an orgasm" (174). like nick morris in the reluctant passenger, at first he fears this different kind of non-human desire and seeks to maintain control over this zoë: "he must get away from these surroundings that are haunted by qukezwa's aura. he must fight the demons … he must try to be in control" (149). as he is "spellbound" and not in a dominant position of control as in his previous sexual experiences where he used women, the scene indicates a more positive experience of desire. this horseback ride, apparently, results in qukezwa's pregnancy-a strange, non-normative chance pregnancy that occurs incidentally during a fully clothed ride. conceived at this moment of non-human desire and intensity, without sexual intercourse, while atop a horse, their child heitsi figures as a future for the community where desire will continue to offer new ways of thought and creativity to resist neocolonial threats. while dominant culture might view such an act as dirty, weird, or something to be prevented, or even as a sort of violence to the horse, mda's novel indicates that the relationship between qukezwa and gxagxa is positive and ethical: "they love each other, gxagxa and qukezwa … . her father lives in this horse. she wouldn't dare do anything shameful in its presence … . she gives it the same kind of respect" (275). her sensual encounter with camagu while riding gxagxa in this regard is not "shameful" or pejorative but perhaps a moment of shared intensity and love between humans and animals. earlier, qukezwa draws attention to the colonization of camagu's thought that results from his american phd in economic development and highlights how this colonization informs his initial reaction to the proposal for the casino resort: vathiswa says they made you a doctor in the land of the white man after you finished all the knowledge in the world. but you are so dumb. white man's education has made you stupid. this whole sea will belong to tourists and their boats and their water sports. those women will no longer harvest the sea for their own food and to sell at the blue flamingo. water sports will take over our sea! (103) like nongqawuse, qukezwa desires to protect her community, a community which includes animals, plants, and the people of qolorha. after camagu argues that the village will be paid for this, and that the development will create jobs, she further challenges his thinking: what do villagers know about working in casinos? … . i heard one foolish unbeliever say men will get jobs working in the garden. how many men? and what do they know about keeping those kinds of gardens? what do women know about using machines that clean? well, maybe three or four women from the village will be taught to use them. three or four women will get jobs. as for the rest of the workers, the owners of the gambling city will come with their own people who are experienced in that kind of work. (103) thus it is qukezwa who is responsible for protecting the community, alongside the changed camagu, who decides to stay in qolorha instead of leaving for the us for his own financial gains, a decision to stay in south africa that nick morris makes as well in the reluctant passenger. therefore anthony vital's claim that "the united states is represented also as providing the central character with the economic understanding that protects the local from outside exploitation" (306) seems to fail to recognize qukezwa's knowledge and influence on camagu's thought and desire. qukezwa's assessment of the proposal is accurate, and the way in which the proposal is framed to benefit the community works just like traditional colonial logic of the civilizing mission, where the colonizer's behavior is presented as a benefit for the people, when really its goal is to further disenfranchise them so that the politicians and developers can "eat." mda points to this colonial history as well in portraying george gray's taking of the xhosa's land in return for "civilizing" them. this ethics of sustainability in the heart of redness is not one of moral universalism but instead one that acknowledges the importance of local or indigenous knowledge. harry sewlall describes the novel's representation of this knowledge by pointing to the importance of the local court's treatment of qukezwa for cutting down foreign trees: what emerges at the village trial of qukezwa is that the indigenous people of this land have always had their own laws to protect the environment. while qukezwa's actions are considered criminal because there are no laws proscribing wattle trees, there are traditional laws in place which allow the destruction of noxious weeds and plants, such as the mimosa. (114) the novel highlights multiplicities of perspectives, times, and values concurrently, as mentioned in the contrasting positions of the believers and unbelievers, but also in dalton and camagu's different plans for the village as either a cultural tourism site or a nature tourist site. the administration of the local laws of the amaxhosa reveals that the elders of the village who make rulings do not view the law as static or transcendental. for example, although the "old law" (213) regards any woman not married as a minor, they listen to the unwed twenty-year-old qukezwa's arguments against this law: "[i]n the new south africa where there is no discrimination, it does not work" (213). at this, the chief replies: "now she wants to teach us about the law" (213). while bhonco's daughter xoliswa ximiya is officially a teacher, it is qukezwa who becomes a more active teacher in the community. as mentioned earlier, bhonco and his daughter xoliswa eurocentrically denigrate most traditional customs and practices as "backward" and "uncivilized," embracing instead many western and american ideas about lifestyle, the natural world, and development. this extends to local flora and fauna, as bhonco asserts: "we want to get rid of this bush which is a sign of our uncivilized state" (92). zim and his daughter qukezwa, by contrast, follow traditional xhosa customs, practice indigenous environmental knowledge, and greatly value local biota, rejecting many of the western ideas introduced into their community. qukezwa and zim's embracing of tradition challenges bhonco and xoliswa's eurocentricism, yet it too is not without problems. in her chapter that focuses in part on heart of redness from her "wilderness into civilized shapes:" reading the postcolonial environment, laura wright reads some characters' engagement with traditions in mda's novel in terms of bhabha's notion of "colonial mimicry," arguing that they "rely on imagined identification with a now inaccessible and uninhabitable past, while simultaneously subverting and parodying that past in an attempt to monetarily benefit from its value as a marketable commodity" (21-2). she explains the problems of this exploitation of tradition in john dalton's obviously business-oriented and self-interested plans for a cultural village as she notes camagu's view of such a packaging of tradition as "inauthentic" and as "deny[ing] the value of contemporary xhosa culture" (50). wright also astutely observes how dalton's planned last-minute heroics by withholding the letter he secured declaring the village a protected heritage site is an example of a "colonial mentality that indigenous peoples were not capable of caring of themselves" (53). however, she also has problems with qukezwa's drawing from xhosa traditions. wright views qukezwa's focus on tradition and removal of invasive plants as taking part in a postcolonial tendency of "ineffective … attempts at establishing various prelapsarian-and imaginary-african edens, impossible landscapes that are somehow uncompromised by their postcolonial status" (23). while she argues that both the believers and unbelievers attempt to borrow and invent traditions in ways that are appropriative, qukezwa's attempts to "recreate" (51) tradition seem to occur without such appropriation. like bhonco, zim seems somewhat extreme, but in the other direction, in his embracing of past traditions, selectively deploying them at times in the imaginary fashion that wright identifies in order to emphasize his difference and purity from bhonco as when, for example, he shaves off his eyebrows. however, qukeswa's drawing from tradition and indigenous knowledge, and perhaps from nongqawuse's future-oriented biopolitics, is free from this edenic imaginary and approaches instead an attempt to serve the best interests of the community by exercising an ethics of sustainability. in this sense, qukezwa's breaking the traditional laws to cut down certain invasive and water-extracting trees might be seen as more in line with the extralegal efforts of the characters in heyns' reluctant passenger to protect their community and the baboons. perhaps the difference in readings comes here from wright's attempts to read the plants in mda's novel as metaphor: "plants function as metaphors for colonizers and colonized peoples, and the invasive species that characters seek to eradicate generate no hybrid entities" (14). the fact that there are no hybrid plants is surprising and supports wright's view nicely. however, there are issues with such a metaphorical reading. after acknowledging that the killing of invasive plants can be read in a literal sense as well, wright goes on to emphasize the plants as metaphor as she attempts to read qukezwa's killing of plants as a "shortsighted solution to white intrusion": "removing all invasive plant species not only would be impossible, but also such an action can only operate on a metaphoric level" (51). reading the invasive plants in a literal sense instead of as a metaphor for colonizers, we might appreciate qukezwa's environmental conservation efforts to preserve her community's water further. reading these scenes of the killing of flora and of community exclusions in terms of biopolitics enables more careful attention to the different kinds of life under consideration and the ethics of hospitality that pertain to them. wright's reading of qukezwa's biopolitical management of flora as metaphor also seems to ignore differences between kinds of life and the idea that qukezwa does not seek to remove all whites from the community in a xenophobic fashion. in fact, it is bhonco who seeks to remove dalton and other non-xhosa people by deploying a purist and prelapsarian rhetoric, as i discuss below, when he attempts to expel those from the community who disagree with his position on the casino development or who otherwise frustrate his ambitions. if bhonco is extreme in his disdain for local flora and fauna, and in his willingness to sacrifice indigenous plants, animals, and knowledges for english ones, zim is somewhat extreme in his love of all that is traditional and disdain for the foreign. yet quekezwa does not kill some of the foreign trees to restore an eden or out of a xenophobic impulse but out of concern for the community's water supply. bhonco's concerns seem more self-centered and short sighted. he becomes a kind of nationalist manager when he threatens camagu's membership of the community in response to camagu's anti-development arguments: "who are you to talk for the people of qolorha? … you talk of our rivers and our ocean. since when do you belong here? or do you think that just because you run after daughters of believers, that gives you the right to think you belong here?" while seeking to win the argument for the development, bhonco attempts to do so by excluding camagu from the community and from being a subject of rights in the community, enacting a biopolitics that threatens to remove those who are not pure enough, not xhosa enough. qukezwa doesn't seek to banish all the plants from the region, just those that greatly diminish the water supply and threaten the ability of other plants to survive. while she initially emphasizes that the trees she cut down are "foreign trees!" she explains that she did so because they are like the inkberry, which "destroys everything before it!" (215). bhonco attempts to discern and charge qukezwa with xenophobia by picking up on the "foreign" in her explanation: "are you going to cut down trees just because they are foreign trees?" asks bhonco indignantly (216). in her reply, qukezwa explains that she is not against trees just because they are foreign; instead, she kills the trees that harm the community. making biopolitical decisions about what must be sacrificed for the future of the community, qukezwa explains to the elders why she cuts certain trees and doesn't cut others: the [foreign] trees in nogqoloza don't harm anybody, as long as they stay there … . they are bluegum trees. the trees that i destroyed are harmful as the inkberry. they are the lantana and wattle trees. they come from other countries … from central america, from australia … to suffocate our trees. they are dangerous trees that need to be destroyed. (216) in reply, bhonco asserts that the traditional law doesn't allow for the killing of these foreign trees without permission, and qukezwa argues for the law to be changed because the wattle tree "uses all the water" (216). the law doesn't allow for the killing of the inkberry without permission either, yet everyone knows its harmful qualities and allows its cutting anyway, without the law's approval. qukezwa argues that this is the extralegal precedent for her actions, explaining: "[the wattle] is an enemy since we do not have enough water in this country" (216). in this scene, qukezwa decides to remove those plants that threaten the community's future, just as the earlier believers killed the cattle, effectively stopping the viral spread of the european lung sickness that was decimating their cattle and horses. the opening of the novel also confirms that the environmentalist efforts of the xhosa have been successful in securing a sustainable present: "indeed, qolorha-by-sea is a place rich in wonders. the rivers do not cease flowing, even when the rest of the country knells a drought. the cattle are round and fat" (7). described here as wonders, perhaps alluding to the magical realism of the novel and its prophets, the report on the state of the animals and environment suggests that environmentalist practices have created a sustainable relationship with the land where other parts of the country suffer water shortages. the comment about the healthy cattle follows the positive assessment of waters in qolorha, suggesting that the cattle-killing movement and the sustained interest in conserving water has in some measure helped to sustain the environment and the future of the community. bhonco, conversely, upholds the law at all costs in this case, further proving that it is desire which is actually in the place of law. although the ruling of the elders is interrupted by a fire that burns a few of the villagers' homes, the elders mostly disagree with bhonco as it's clear that he is just interested in punishing qukezwa because she is a believer, and zim's daughter at that. rather like judge conroy in the reluctant passenger, who seeks to use the law to abuse his rival brick tomlinson, bhonco appeals to the law in hopes of seeing zim punished for his daughter's crimes: "why doesn't he stand up like a man and take the rap?" (214). bhonco's desire is reterritorialized, seeing as he has no problem with the development of the casino city, which would break these laws, a project which the developers reveal involves the killing of many of the village's trees: "how can we call it a grove when we're going to cut down all these trees to make way for the rides?" in response, the other developer remarks: "[w]e'll plant other trees imported from england. we'll uproot a lot of these native shrubs and wild bushes and plant a beautiful english garden" . in contrast to the developers and bhonco, whose desire is self-interested, and who arbitrarily upholds the law when it suits him (and it is perhaps significant in this regard that bhonco's frustrations with his inability to secure his old-age pension from the government is a frequent sore spot for him throughout the novel), qukezwa's actions are motivated by a desire to protect her community; in this instance, specifically the local plants and water supply of qolorha. as the history of the amaxhosa wars with the british colonists and qukezwa's killing of colonizing plants make clear, the response to new things and deciding on their belonging to the community or not often involves a consideration of how these new people and things harm or "eat" the community, or if they further protect it. bhonco at times wants to expel dalton, descendent of a british colonial officer, and camagu, who at times he calls a foreigner. he decides that these "outsiders" do not belong to the village community in relation to how their presence or absence would personally benefit him, not the larger community. he has repeated arguments and later a violent encounter with dalton, for example. the racial inflections of dalton's status in the community highlight the various modes of biopolitical management at work in qolorha and demonstrate characters' anxieties about belonging and their relationship to the land as "home." these concerns about who belongs and who doesn't, how many, who belongs most, and the desire for a space that makes it feel homely according to a particular imaginary or fantasy recall the discussion of "nationalist managers" and homely space in disgrace in chap. 2. camagu has the most obviously ambiguous relationship with the community of qolorah as home and, indeed, with south africa. he doesn't feel at home in johannesburg, in part because he can't dance the toyi-toyi (the freedom dance of the struggle) because he was exiled for 30 years and never learned it (28), which results in his being excluded from a number of employment opportunities. in qolorha, he embraces his totem animal, a snake, in a way that impresses the villagers by showing them that he is like them and belongs. roman bartosch, through a citation of harry garuba's definition of "animist materialism," argues that camagu's respecting his totem animal is a "deliberate re-traditionalisation as described by garuba" and suggests that "he is calculating ('i have gained more respect […] since they saw i respect my customs')" (bartosch 170) . while this is an interesting reading, it neglects to consider that camagu respects the snake first, and only later understands the influence it has on others' perceptions of him. a calculating gesture would suggest more deliberate and perhaps insincere performing of respect. camagu, by contrast, seems genuinely joyful to have encountered his totem animal: "camagu is beside himself with excitement. he had never been visited by majola, the brown mole snake that is the totem of his clan … . he is the chosen one today" (98). where not knowing how to dance the toyi-toyi prevents camagu from belonging and imagining himself at home in the city, his ability to respect the customs of his people and his affective response enables a kind of assertion of belonging and imagining of a homeland in qolorha. the descendent of a colonial official, dalton too attempts a certain imagined relation to the community in denying this legacy. he replies "'it is not true! it is not true!' " to bhonco's point that "he is a descendant of headhunters" (168). while he is a "white man of english stock," he has an "umxhosa heart" (8), and zim argues that "dalton is not really white … it is just an aberration of his skin. he is more of an umxhosa than most of us" (147). dalton's particular imagined relationship and belonging to the community, through knowledge of the language and participation in its rituals such as circumcision, performs a rhetoric of belonging that attempts to ignore or elide the colonial past. yet he still benefits from his position of white privilege in south africa in belonging to the "white" community, and even continues some racist practices against the villagers, as when he makes bhonco ride in the back of his truck, a common mode of segregated, racist travel practiced by white men during apartheid: "the old man [bhonco] struggles to climb into the back of the bakkie. even though dalton is alone in the front seat, customs do not die easily. dalton can see a hint of anger on the elder's face" (141). in this sense, dalton imagines a relationship to both communities: the white nationalist community and the xhosa village. he also seeks to establish a connection to the land through his marriage to an afrikaner-the afrikaner "belongs to the soil. he is of africa"-and asserts to his friends who are leaving south africa: "this is my land. i belong here" (139). these imagined relationships to land and community through certain kinds of belonging and nationalism often demonstrate the kind of willful cognitive dissonance that characters take on in order to feel at "home" as they navigate their relationships to the past, to the land, and to the community. the imagined relationships also reveal the violence that results from certain rhetorics of "home" as characters often seek to exclude or treat poorly those they deem not "pure enough" or foreign. foucault observes this violence in the racism of biopolitics: [r]acism makes it possible to establish a relationship between my life and the death of the other that is … a biological-type relationship: 'the more inferior species die out, the more abnormal individuals are eliminated, … the more ias species rather than individual-can live, the stronger i will be, the more vigorous i will be. i will be able to proliferate. the fact that the other dies does not mean simply that i live in the sense that his death guarantees my safety; the death of the other, the death of the bad race, of the inferior race (or the degenerate, or the abnormal) is something that will make life in general healthier: healthier and purer. (255) foucault explains in this discussion that the death he's discussing is not just literal but also "indirect murder: the fact of exposing someone to death, increasing the risk of death for some people, or, quite simply, political death, expulsion, rejection, and so on" (256). bhonco's seeking to expel certain "impure" characters from the community that thwart his ambitions of wealth and social climbing to an elite status through westernizing himself, the environment, and the community exhibit this kind of racist bipolitics. his attempt to get zim and qukezwa punished legally, weakening their political standing, and indeed his risking of the community's water and the lives of the animals through attempting to stop the environmentalists, evidences a violent biopolitics that continues in a racist, colonial legacy. camagu's presence in the village is obviously not a problem initially when bhonco welcomes him energetically as a westernized south african and because he thinks camagu might marry his daughter. as it becomes clear that camagu's desire is for qukezwa instead, bhonco argues that he and dalton should be expelled from the community for their not being "pure" amaxhosa or their not being born in qolorha. however, this logic of exclusion based on categories only suits his desire for "development" and what he thinks will be his personal benefit and profit. indeed, he often disavows the importance of local knowledge, allowing western notions of "development" and civilization to inform his thinking about biopolitical decisions. in building his case against qukezwa for destroying the water-depleting trees, he argues that it is unjust to absolve her when "white tourists" were recently arrested for "smuggling cycads" and boys were also punished "for killing the redwinged starling, the isomi bird" (216). the elders reply to bhonco's argument by noting the difference of life under consideration here: "shall we now be required to teach revered elders like bhonco about our taboos? it is a sin to kill isomi. yes, boys love its delicious meat that tastes like chicken. but from the time we were young we were taught never to kill isomi … . we only desired them from a distance" (217, emphasis added). the traditional laws and words of the elders here express a desire for animals that respects their lives and membership in the community and results in the community protecting them from being eaten. the passage highlights the differing models of desire at work in qolorha as the indigenous notion of desire frustrates the view that capitalist desire is a universal or the only way to desire animals. this other way of desiring challenges the tourists and those who seek only a relation to the animals of eating, thereby showing capitalist desire to be but one way among other, different possibilities. the passage reveals that not only have the xhosa in the heart of redness long had their own environmental laws, as sewlall suggests, but also they've long had their own ways of desiring animals. in contrast to bhonco, qukezwa, evaluates newcomers to the community in relation to the harm they may cause or, alternatively, their ability to further protect and sustain the community. indeed, qukezwa works for the white dalton and begins a romantic relationship with the non-xhosa, camagu, that results in a hybrid child and future. bhonco's attempts to expel camagu and dalton from the community, as well as his approval of the sacrifice of the non-human life of qolorha for the casino city, suggests that his approach to the law relates to what derrida calls an autoimmunitary problem. wolfe writes about the need to deconstruct species and race as a way to prevent this problem: "[r]ace and species must, in turn, give way to their own deconstruction in favor of a more highly differentiated thinking of life in relation to biopower, if the immunitary is not to turn more or less automatically into the autoimmunitary" (56). in other words, bhonco's use of these categories at times as a way to challenge the membership of these others in the community risks the sustainability of the community in the expelling of its diversity, especially considering that it is dalton and camagu who, with the assemblage of other community members, ultimately successfully resist and prevent the development of the casino city. wolfe discusses the desire for sameness that pertains to the law, and how derrida's notion of "hospitality" can challenge this problem in its ethical response to the other: [t] he reason that this [the ideal of unconditional hospitality] is crucial to biopolitical thought is that it keeps that zone of immunological protection from automatically turning to, as derrida puts it, an autoimmune disorder. the idea is that once you start drawing lines between humans and animals, aryans and jews, muslims and christians, that is always going to lead to the runaway train process of an autoimmune disorder. so eventually, you know, how aryan is aryan enough? how christian is christian enough? how human is human enough? how "proper," to go back to heidegger, is proper enough? the horizon of unconditional hospitality as something to strive for is precisely calculated to remind you that whatever those lines are that you are drawing have to be always taken under erasure, even as, pragmatically those lines have to be drawn and are drawn all the time. ("after animality" 184) bhonco's desire to expel particular members out of the community then evidences this kind of autoimmune disorder as he accuses people of not being xhosa enough at times when it suits him and, at others, of not being civilized enough. in essence, bhonco seeks to improve himself, and to that end approves of the casino city, not recognizing its neocolonial nature, and thus advocating the sacrifice of the local land, animals, and other members of his community for the building of the casino. in contrast, the other characters consider sacrifice in terms of the protection of their community, including its human and non-human members. qukezwa responds differently to the biopolitical problems of protecting her community-with hospitality. wolfe quotes derrida's description of hospitality: "'pure and unconditional hospitality, hospitality itself, opens or is in advance open to someone who is neither expected nor invited, to whomever arrives as an absolutely foreign visitor, as a new arrival, nonidentifiable and unforeseeable, in short, wholly other'" (before the law 92). rather than write off or automatically exclude foreigners from the community, qukezwa responds ethically to camagu and the other new arrivals to qolorha, including flora and fauna. to be sure, she does not welcome everything in an unconditional hospitality because to do so, as wolfe observes, would be to become apolitical and unethical: "[d]iscrimination, selection, self-reference, and exclusion cannot be avoided, and it is also why the refusal to take seriously the differences between different forms of life-bonobos versus sunflowers, let's say-as subjects of immunitary protection is, as they used to say in the 1970s, a 'cop out'" (103-4). qukezwa clearly exercises discrimination in deciding which plants, animals, and people are welcome to be part of her community and which aren't, often on the basis of their colonizing or harming the life and futures of the other members of the community. toward the novel's end, the community stops the casino development when dalton gets a court order declaring qolorha a "national heritage site" (269), something camagu had suggested earlier in response to the developers' "how will you stop us?" the location's history of nongqawuse's prophecies that led to the cattle-killing movement renders it worthy as a potential site deserving protection. as dalton protects the community in a roundabout legal way, mda's novel provides another example of how desire exists where we think there is law to protect communities. camagu and dalton, in their desire to protect the community, think that this alternative way to ensure the casino development will not go through. thus, in addition to qukezwa's ethical response to protecting her community, nongqawuse's prophecies, her desire to protect the community in thinking toward the future that led to the cattle-killing movement in the 1850s in response to colonization that brought with it lung disease for the cattle, disease for the amaxhosa's crops, and the starvation of many of the amaxhosa, while tragic, continues to protect her people via the national heritage site enabling further sustainable futures. laura wright observes this as well: if there is any hope to be had, the polyphonic and temporally simultaneous structure of the text seems to suggest, it is in the cyclical and nonlinear nature of history wherein nongqawuse can be read at once as the cause of a people's destruction in the past and, through her cultural cachet as such a figure, their salvation in the present and as the girl whose failed prophecy in 1856 is fulfilled late in the twentieth century. (54) 3 although following the prophecy of nongqawuse was devastating for the amaxhosa, mda offers it as an ethical attempt to bolster the immunity of the community. j.b. peires explains the biological conditions that resulted from the colonial contact and led to the cattle killing: an important cause of the cattle-killing was the lungsickness epidemic which reached xhosaland in 1855. cattle mortality was as high as one half to two thirds in some places, and many xhosa lost all their cattle. the great believer chief phatho, for example, lost 96 percent of his 2500 cattle … the xhosa began to believe that their cattle were rotten and impure, and that they might as well kill them since they were probably going to die anyway. (312) in this light, part of the logic that informs the movement is the attempt to limit the spread of the disease, to prevent it from attacking all the cattle. another aspect of the logic of sacrificing the cattle involved the hope that it would remove the british colonists: cattle-killing was born partly out of xhosa frustration at colonial domination and partly out of the hope awakened by the news that the russians had beaten the english … . among the many predictions that circulated at the time was one to the effect that the english, like all other evil things, would be swept away in the great storm which would precede the resurrection of the dead. (peires 316) peires also explains that, alternatively, many also believed the sacrifice would amend the conflicts and bring peace between the british and the amaxhosa nation. perhaps the greatest reason for the british "success" in colonizing the amaxhosa, then, is this cattle disease that "was brought to south africa in september 1853 by a dutch ship carrying friesland bulls" (peires 70) as it functioned essentially as a kind of biological weapon in the war between the british and the amaxhosa. the slaughtering of the cattle in an attempt to prevent the spread of this disease is an exercise in biopolitics. as wolfe notes in critiquing affirmative biopolitics that fail to consider the difference of life-those approaches that view all life as equal-such an approach isn't practical (or perhaps desirable) given the destructive nature of some life forms: "[d]o we extend 'unconditional hospitality' to anthrax and ebola virus, to sars?" (before the law 93). in the heart of redness, environmentalist characters often perform a biopolitics and hospitality that is not always affirmative but discriminates and seeks to eliminate the lung sickness, water-depleting plants, and neocolonial developments that would decimate the community. in the face of such an attack on the immune system of the community, king sarhili's decision to follow the words of the prophetess exercises an ethical attempt to protect and sustain the community. of course, as history bears out, the situation and decision were devastating: one of the figures offered for the drop in the human population of the xhosa people from the cattle killing is an estimated loss of 40,000 over a twoyear period. also, 400,000 cattle were slaughtered and the xhosa lost 600,000 acres of land to the british (peires 319). these tragic figures highlight the vulnerability of bodies that humans and animals share. they also point to the great dependence of the community on these non-human others for survival. emphasizing our limited knowledge, and that to act at all we can only respond with a conditional hospitality, wolfe writes of biopolitics: we must choose, and by definition we cannot choose everyone and everything at once. but this is precisely what ensures that, in the future, we will have been wrong. our 'determinate' act of justice now will have been shown to be too determinate, revealed to have left someone or something out. (104) while the cattle killing may appear to have been "wrong" from the perspective of today as it can be seen as being responsible in part for the devastation of the amaxhosa community-peires notes that some view it as a mass suicide, although he clearly disagrees with this view-in light of the biopolitical decisions exercised by qukezwa in the present of the heart of redness, mda situates the movement as an attempt to act politically and ethically to protect the community. mda's novel emphasizes, as peires also argues, that the tragic deaths of the amaxhosa community were caused by the colonizing disease of lung sickness as well as the colonizing british, both of which established a relationship of "eating" these communities. just like the development project of the casino city, which attempts to colonize and devastate the community, the british colonization during the cattle-killing movement was geared towards ruining the amaxhosa nation: the cattle-killing cannot be divorced from the colonial situation which was imposed on the xhosa in 1847 by sir harry smith … it should be remembered that the essential objectives of grey [sir george grey] were identical to those of smith and of colonial rule generally: to destroy the political and economic independence of the xhosa, to bring them under british law and administration, to make their land and their labor available to white settlers, and to reshape their religious and cultural institutions on european and christian models. (peires 313) peires' passage describes an organization of labor and the community that would be replicated in a slightly new form by the international development company's proposal. yet by deterritorializing desire away from the narcissism of colonization and global capitalism toward a postcolonial desire, one for the benefit of the members of the community, qukezwa and the others of the assemblage, including camagu and dalton, work to fend off the disposal of the community by an international development corporation, exercising an ethical biopolitics that continues in the tradition of the prophetess, and, for the time being, she temporarily secures her community's protection and its potential for a future. in addition to the government officials who support the casino in the heart of redness, chief xikixa, who is charged with protecting the land where it "is illegal to build within a kilometer of the coast," also puts his own profits and pleasure ahead of the community. he gives the land away to wealthy white people and "some well-to-do blacks," some of whom build "right on the seashore," for bribes such as a "bottle of brandy" and later on "cellphones and satellite dishes" (68). these products of globalized capitalism bring the village of qolorha into the global economy, threatening the life and future of the community as it is rendered exchangeable for a cheap price, and for the pleasure and profit of a few. in both heyns and mda's novels, the commodification of the lands of local communities and the disposing or harming of the interests of their residents, human and non-human, are thwarted through what i'm describing as the postcolonial desire of an assemblage of characters, a desire for the community in a broad sense that disrupts and resists the colonizing ambitions of capitalism and its adherents. as braidotti argues, in the context of biotechnology, zoe exceeds capitalist control: "nature is more than the sum of its marketable appropriations: it is also an agent that remains beyond the reach of domestication and commodification" (transpositions 47). if capitalism seeks to commodify all of life and proliferate its logic of desire of lack through colonizing the unconscious, postcolonial desire describes a potential of desiring machines that escapes, resists, or undoes this colonization in a line of flight away from capitalism's reterritorialization of desire, reassembling communities around an ethics of sustainability instead of an accumulation of personal profit. where some global capitalists see an opportunity in the "under-developed" lands or villages to secure a profit at the expense of destroying and devastating its inhabitants, the resistances offered by these human and non-human assemblages disrupt the capitalist machine and, for the time being, protect the futures of their homes. in both the reluctant passenger and the heart of redness, the laws passed to protect these communities repeatedly fail to do so, often as a result of the compromised position of those tasked with upholding the law. while these authorities, judges, and politicians seek their own profit at the expense of the community, they reveal their colonization by capitalist logic. through weaving the history of the cattle-killing movement into the narrative about the present-day proposed casino city, zakes mda emphasizes the colonial legacy in which global capitalism operates and continues in the practices of capitalists and government officials from developed countries and their counterparts in "developing nations." heyns' novel focuses more specifically on protecting a troop of baboons instead of protecting a larger community of human and non-humans, as in mda's novel. nonetheless, the critique of the capitalist development of the baboon's home in the nature preserve also undermines the workings of the apartheid regime more broadly, in this case the animal testing and other exercises in biopower of the apartheid state on south african bodies. for both novelists, then, the explicit violence exerted on communities, on bodies, and on the land in the pasts of colonialism and apartheid reappears in a subtler and more nuanced fashion in the present of late capitalism through the weakened and compromised administration of the law which fails to fully protect communities from the threats of disposal and violence. mda and heyns represent desire as a resistance to this neocolonial threat that might better protect these communities and their futures from being consumed by the capitalist machine. notes 1. see jacques derrida, "before the law," in acts of literature, ed. derek attridge (new york, ny: routledge, 1992), 181-220. derrida also emphasizes this emptiness in noting the lack of an origin for the law in "before the law:" "what is deferred forever till death is entry into the law itself, which is nothing other than that which dictates the delay … what must not and cannot be approached is the origin of difference: it must not be presented or represented and above all not penetrated. that is the law of the law, the process of a law whose subject we can never say, 'there it is,' it is here or there" (205 peires. in the dead will arise, peires details how although extremely tragic for the amaxhosa, nongqawuse's prophecies and the decision to slaughter cattle resulted from extreme circumstances of british colonization and disease. the slaughter of most of the amaxhosa cattle, then, offers an example of a biopolitical issue. for example, peires writes "that the cattle-killing was a logical and rational response, perhaps even an inevitable response, by a nation driven to desperation by pressures that people today can barely imagine. i further believe, and i trust that the book will demonstrate this too, that the cattle-killing would not have been so fatal an error had it not been for the measures of governor grey, which first encouraged and then capitalized on the movement" (x). the unfortunate coincidence of increased pressure from british colonization and the lung the amaxhosa's decision to slaughter their cattle as a way to preserve their remaining community. as peires and mda's novel bears out, the decision to slaughter the cattle after the telling of nongqawuse's prophecies therefore figured as an attempt to secure the futurity of the amaxhosa people, even while it ultimately caused so many of them to die their alternative proposals prevent the immediate "development" of the casino, which would surely spell the ruin of the community, rendering it unsustainable. mda seems to acknowledge that this approach of ecotourism is not exactly the most radical approach either, as his later novel, the whale caller what do human rights do? an anthropological enquiry environmentality: ecocriticism and the event of postcolonial fiction what is sex? an introduction to the sexual philosophy of gilles deleuze nomadic subjects: embodiment and sexual difference in contemporary feminist theory after animality, before the law: interview with cary wolfe left legalism/left critique in place: tourism, cosmopolitan bioregionalism, and zakes mda's heart of redness indigenous cosmopolitics in the andes: conceptual reflections beyond 'politics kafka: toward a minor literature. translated by dana polan before the law without offending humans: a critique of animal rights 17 march 1976 lecture explorations in animist materialism: notes on reading/writing african literature, culture, and society the problem of ideology: marxism without guarantees the reluctant passenger. jeppestown: jonathan ball postcolonial ecocriticism: literature, animals, environment mda, zakes. fools, bells and the habit of eating: three satires mda, zakes. the whale caller in african literature: an anthology of criticism and theory the dead will arise: nongqawuse and the great xhosa cattle-killing movement of 1856-7 animal rights in south africa. cape town: double storey books ecofeminism in zakes mda's the heart of redness situating ecology in recent south african fiction: j.m. coetzee's 'the lives of animals' and zakes mda's 'the heart of redness to hear the variety of discourses before the law: humans and other animals in a biopolitical frame the animal gaze: animal subjectivities in southern african narratives wilderness into civilized shapes: reading the postcolonial environment the politics of necessity: community organizing and democracy in south africa 