JDN_19NL_July2020

JUNIOR DOCTORS
NETWORK
empowering young physicians to work together towards a healthier
world through advocacy, education, and international collaboration
Published by the Junior Doctors Network of the World Medical Association
The information, perspectives, and opinions expressed in this publication do not
necessarily reflect those of the World Medical Association or the Junior Doctors
Network. WMA and WMA-JDN do not assume any legal liability or responsibility
for the accuracy, completeness or usefulness of any information presented.
Junior Doctors Network Newsletter
Issue 19
July 2020
ISSN (print) 2415-1122
ISSN (online) 2312-220X
Junior Doctors Leadership 2019−2020
Junior Doctors Network Newsletter
Issue 19
July 2020
Page 2
Dr Yassen Tcholakov
Canada
Dr Christian Kraef
Germany
Dr Julie Bacqué
France
SOCIO-MEDICAL
AFFAIRS
OFFICER
SECRETARY
INTERIM
CHAIR
Dr Lyndah Kemunto
Kenya
Dr Uchechukwu Arum
Nigeria
Dr Lwando Maki
South Africa
EDUCATION
DIRECTOR
MEDICAL
ETHICS
OFFICER
MEMBERSHIP
DIRECTOR
Dr Maki Okamoto
Japan
Dr Helena Chapman
Dominican Republic
Dr Chukwuma
Oraegbunam
Nigeria
PUBLICATIONS
DIRECTOR
COMMUNICATIONS
DIRECTOR
IMMEDIATE
PAST
CHAIR
Dr Konstantinos
Roditis
Greece
Dr Jeazul Ponce H.
Mexico
Dr Mariam Parwaiz
New Zealand
Dr Vandrome Nakundi
Kakonga
Democratic Republic
of the Congo
Dr Suleiman A. Idris
Nigeria
Dr Ricardo Correa
United States
Dr Victor Animasahun
Nigeria
Junior Doctors Network Newsletter
Issue 19
July 2020
Editorial Team 2019−2020
Page 3
Dr Nneka Okafor
Nigeria
Table of Contents
TEAM OF OFFICIALS’ CONTRIBUTIONS
07 Words from the Management Team
By JDN Management Team
08 Words from the Communications Director
By Dr Maki OKAMOTO (Japan)
09 Words from the Publications Director
By Dr Helena CHAPMAN (Dominican Republic)
JUNIOR DOCTORS’ PERSPECTIVES
AFRICA
10 Reflections on the COVID-19 Pandemic from a Kenyan Junior Doctor
By Dr Lyndah KEMUNTO (Kenya)
13 Health Care Workers as Essential Frontline Agents during the COVID-
19 Pandemic
By Dr Judith JOLAYEMI (Nigeria), Dr Damilola AYOWOLE (Nigeria),
Dr Ganiyu Olanipekun AHMED (Nigeria), and Dr Oladimeji ADEBAYO
(Nigeria)
16 Is This What Medicine is All About?
By Dr Dabota Yvonne BUOWARI (Nigeria)
18 The Emergency Physician, the COVID-19 Hero
By Dr Dabota Yvonne BUOWARI (Nigeria)
AMERICAS
19 The Role of Youth Leadership in Online Education during the COVID-
19 Response
By Dr Pablo ESTRELLA PORTER (Ecuador)
22 One Health Research, Education, and Mentorship during the COVID-
19 Pandemic
By Dr Helena CHAPMAN (Dominican Republic)
26 Telemedicine and Artificial Intelligence: Redefining Medical Practice
during the COVID-19 Pandemic
By Dr Frank RODRÍGUEZ (Panama)
Junior Doctors Network Newsletter
Issue 19
July 2020
Page 4
Table of Contents
29 Obscurantism, Denialism, and COVID-19: A Brazilian Triple Challenge
By Dr Andrey OLIVEIRA DA CRUZ (Brazil) and Dr Michelle MEDEIROS
(Brazil)
32 The Political Role of the World Health Organization in Times of
COVID-19
By Dr Yassen TCHOLAKOV (Canada)
ASIA
35 Reflections on the COVID-19 Response: From a Taiwanese Junior
Doctor
By Dr Jen-Hsiang Roy SHEN (Taiwan)
38 Challenges Faced by Junior Doctors in Myanmar during COVID-19
Response Efforts
By Dr Wunna TUN (Myanmar)
41 Contribution to COVID-19 Response Efforts: Experiences of a Tertiary
Hospital in the Visayan Region of the Philippines
By Dr Maymona CHOUDRY (Philippines)
44 COVID-19 Prevention at the Community Level: Taiwan’s Measures
Against an Epidemic
By Dr Chiang Kuan YU (Taiwan)
47 Mental Health of Frontline Health Care Workers during the COVID-19
Pandemic
By Dr Rujvee PATEL (India)
49 Use of Information and Communication Technology for COVID-19
By Dr Jaehyeon JANG (Republic of Korea), Dr Keyhoon Kim (Republic of
Korea), Dr Sejin CHOI (Republic of Korea), and Dr Jihoo LEE (Republic of
Korea)
53 Education and Training of Junior Doctors in the Post-COVID-19 Era
By Dr Sejin CHOI (Republic of Korea), Dr Keyhoon KIM (Republic of Korea),
Dr Jaehyeon JANG (Republic of Korea), and Dr Jihoo LEE (Republic of
Korea)
Junior Doctors Network Newsletter
Issue 19
July 2020
Page 5
Table of Contents
56 Sharing Binational Experiences during the COVID-19 Response:
Collaboration between the Republic of Korea and Japan
By Dr Mineyoshi SATO (Japan), Dr Maki OKAMOTO (Japan), and Dr Sejin
CHOI (Republic of Korea)
EUROPE
59 The Importance of Primary Health Care during Health Emergencies
By Dr Flora KUEHNE (Germany)
62 Listening to the Hopes and Fears of Swedish Medical Students and
Junior Doctors
By Ms Lotta VELIN (Sweden) and Dr Hanna JERNDAL (Sweden)
65 Gender Gaps and the COVID-19 Pandemic
By Dr Jeazul PONCE HERNÁNDEZ (Spain)
WESTERN PACIFIC
68 Courage vs COVID-19: Australia’s Junior Doctors Leading by
Example
By Dr Naga ANNAPUREDDY (Australia) and Dr Simrun MODY (Australia)
MULTIPLE REGIONS
71 Challenges and Opportunities in Providing Primary Health Care
during the COVID-19 Pandemic in Six Countries
By Dr Wunna TUN (Myanmar), Dr Laura KALKMAN (The Netherlands), Dr
Flora KEUHNE (Germany), Dr Shiv JOSHI (India), Dr Andrey OLIVEIRA DA
CRUZ (Brazil), and Dr Chioma AMUGO (Nigeria)
76 Junior Doctors Network Leadership at the Post-World Health
Assembly 2020
By Dr Mike KALMUS ELIASZ (United Kingdom), Dr Caline MATTAR (United
States), and Dr Yassen TCHOLAKOV (Canada)
Junior Doctors Network Newsletter
Issue 19
July 2020
Page 6
Dear colleagues from around the world,
It is our pleasure to introduce this COVID-19 Special Edition of the Junior Doctors Network
(JDN) Newsletter. We hope that this resource allows junior doctors from all around the
world to share thoughts and experiences during these challenging times.
This decade has started with what is now being called a generation-defining event, and
healthcare workers all around the world are dedicated to serving their communities. As the
JDN, we are concerned about the well-being of all junior doctors, especially their capacity
to access personal protective equipment, their risk of experiencing violence, the
psychosocial stress related to extended work schedules, and the increased risk of
exposure to the disease.
As the JDN Management Team, we have laboured hard to ensure the continuity of
activities for our members. In April 2020, we coordinated two virtual conferences on topics
related to the coronavirus disease 2019 (COVID-19) pandemic, as the World Medical
Assembly (WMA) Council session in Porto was canceled. We transformed the pre-World
Health Assembly (WHA) into a virtual post-WHA and adapted the agenda to accommodate
participation across an array of time zones. Moving forward, we plan to launch a new
COVID-19 Working Group for JDN members. Notably, we are excited to welcome new JDN
members who can join our upcoming meeting and activities.
We hope that this JDN Newsletter will allow junior doctors to share personal stories of
clinical and community contributions during the COVID-19 response efforts. From these
unexpected challenges, we know that junior doctors will emerge stronger and more united
and look optimistically to the future.
Junior Doctors Network Newsletter
Issue 19
July 2020
Words from the Management Team
TEAM OF OFFICIALS’ CONTRIBUTIONS Page 7
Sincerely,
JDN Management Team
Credit: Dr Yassen Tcholakov.
It is my pleasure to welcome you to the COVID-19 Special Edition of the Junior Doctors
Network (JDN) Newsletter.
Since the beginning of this year, the world has changed in numerous ways – how people
interact, spend time, and work. As junior doctors, our contributions to the coronavirus
disease 2019 (COVID-19) response efforts are significant and recognized across the globe.
We must develop collaborations that allow shared learning and foster professional
networks across nations.
Supported by the World Medical Association (WMA), the JDN provides this international
platform, where JDN members can share their passion and enthusiasm to enhance
medical practices and support global health initiatives. This JDN network can expand the
scope of activities as we manage the direct and indirect impacts of the COVID-19
pandemic.
Thanks to our wonderful JDN Publications Team, led by Dr Helena Chapman, for preparing
this outstanding COVID-19 Special Edition of the JDN Newsletter. We hope that you enjoy
the articles – and despite social distancing – feel that your colleagues are close and
support your dedicated efforts on the frontline!
Take care and stay safe,
Maki
Junior Doctors Network Newsletter
Issue 19
July 2020
Words from the Communications Director
Maki Okamoto, MD
Communications Director (2019−2020)
Junior Doctors Network
World Medical Association
Dear colleagues,
TEAM OF OFFICIALS’ CONTRIBUTIONS Page 8
Figure 1. List of JDN media resources.
To learn more information about
JDN activities and updates,
please visit the new JDN media
accounts (Figure 1).
Media Resource
Website https://www.wma.net/junior-doctors/
Mailing List https://goo.gl/forms/jCP774K1fldLIoWj1
Twitter @WmaJdn
Facebook (Members) WMA-JDN
Facebook (Public) WMA JDN
Instagram wma_jdn
Junior Doctors Network Newsletter
Issue 19
July 2020
Words from the Publications Director
Dear JDN colleagues,
On behalf of the Publications Team (2019-2020) of the Junior Doctors Network (JDN), we
are excited to share the COVID-19 Special Edition of the JDN Newsletter with junior
doctors across the world.
Today, more than ever, we are united in health and community as the coronavirus disease
2019 (COVID-19) pandemic affects all nations. As junior doctors, we have prepared for
endemic and emergency scenarios and must contribute our expertise – clinical, community,
education, laboratory, policy, and research – in leading steps to scientific discovery.
This COVID-19 Special Edition of the JDN Newsletter includes articles from junior doctors
from Australia, Brazil, Canada, Dominican Republic, Ecuador, Germany, India, Japan,
Kenya, Myanmar, Netherlands, Nigeria, Panama, Philippines, Republic of Korea, Spain,
Sweden, Taiwan. United Kingdom, and the United States. These personal accounts
contribute essential perspectives to the significant role of junior doctor across their clinical
and community environments.
The JDN Newsletter offers an international platform for junior doctors across the globe to
share their activities and stress their key role in health care service delivery. Their national
and international leadership can strengthen communication between World Medical
Association (WMA) and JDN members. By sharing experiences across borders, junior
doctors can form collaborations that aim to expand and minimize health disparities.
We acknowledge the enthusiasm and leadership of all editors of the JDN Publications
Team 2019-2020 as we finalized this COVID-19 Special Edition. We appreciate the
continued support of the JDN Management Team and WMA leadership as we disseminate
this key junior doctors’ resource. We encourage you to read these personal accounts,
become inspired by their dedicated efforts, and reflect on your contributions to the global
pandemic!
Together in health,
Helena
Helena Chapman, MD MPH PhD
Publications Director (2019−2020)
Junior Doctors Network
World Medical Association
TEAM OF OFFICIALS’ CONTRIBUTIONS Page 9
The Republic of Kenya reported the first confirmed case of coronavirus disease 2019
(COVID-19) on Friday, March 13, 2020. Since this date, the numbers have steadily
increased, and as of July 1, 2020, Kenya had reported 6,673 confirmed cases, 2,089
recovered cases, and 149 fatalities (Figure 1) (1).
These measures included dusk to dawn curfews, closure of entertainment places (e.g.
pubs), closure of markets, and cessation of movement to and from areas with high COVID-
19 confirmed cases such as Nairobi and Mombasa counties. Beyond these restrictive
measures, the government introduced social distancing guidelines and mandatory use of
face masks for everyone in public spaces. People were encouraged to work from home,
where possible.
Junior Doctors Network Newsletter
Issue 19
July 2020
Reflections on the COVID-19 Pandemic from a
Kenyan Junior Doctor
JUNIOR DOCTORS’ PERSPECTIVES: AFRICA Page 10
As COVID-19 cases transitioned from imported cases to local
transmission, more restrictive measures were enforced.
Lyndah Kemunto, MBChB
Membership Director (2019−2020)
Junior Doctors Network
World Medical Association
Two days after the first confirmed COVID-19
case, the Kenyan president addressed the
nation and announced a raft of restrictive
measures. These measures included travel
suspension from countries with reported
COVID-19 cases, 14-day self-quarantine for all
travelers returning home, closure of all learning
institutions, and bans on large gatherings such
as church services, funeral, and political rallies.
Figure 1. COVID-19 statistics in the Republic
of Kenya, updated July 1, 2020. Credit:
Ministry of Health (Kenya) and Daily Nation.
From the onset, it was clear that the already deteriorating economy was set on a downward
spiral. Many employees in the informal and formal sectors were immediately rendered
jobless or suffered pay cuts. In particular, the hospitality industry was significantly affected.
In an attempt to cushion Kenyans from the harsh economic times, the government of
Kenya implemented tax reliefs and fee exceptions to individuals and businesses. In
addition, some vulnerable populations, such as the elderly and homeless, received some
financial aid. This national financial assistance, though, had minimal impact on the
population.
The COVID-19 pandemic may have presented a silver lining, as numerous institutions
embraced locally manufactured products including personal protective equipment (PPE),
medical technological innovations, and other products. With the need to adapt to this
unprecedented situation, institutions were forced to adopt digital solutions. The expectation
is that the new normal will persist beyond the pandemic for more efficient and effective
transactions.
Despite its limitations, the Kenyan health care system has managed the COVID-19
pandemic reasonably well. The Ministry of Health and devolved governments set aside
COVID-19 treatment centres, trained health care workers, provided guidelines for COVID-
19 prevention and management, and constantly kept the public informed and updated
(Photo 1).
Junior Doctors Network Newsletter
Issue 19
July 2020
JUNIOR DOCTORS’ PERSPECTIVES: AFRICA Page 11
It was about time to “Build Kenya and Buy Kenya.”
Photo 1. Health care workers in Kisii County participated
in hand hygiene technique demonstrations as part of the
COVID-19 training. Credit: Kisii County Government.
The COVID-19 crisis similarly accentuated challenges such as stigma, inadequate PPE
and other medical equipment, poor quality PPE, and misappropriation of COVID-19
resources. Furthermore, patients with other illnesses were disadvantaged, because at the
start of the pandemic, other health issues were overlooked. The Ministry of Health
cancelled all chronic illnesses’ clinics and elective surgeries, in order to divert limited
human resources for health towards COVID-19 preparedness. This undeniably resulted in
adverse outcomes, where cancer patients who could not receive timely care progressed to
more advanced disease or died.
Overall, there is a general perception that the government has handled the crisis better
than expected albeit challenges and high disease burden. The restrictive measures
certainly helped in curbing disease spread, so much so, that some Kenyans have indicated
doubt about the presence of COVID-19 in Kenya. Fortunately, the majority of reported
cases were asymptomatic, and thus recovered with minimal intervention and home-based
care. We cannot envisage the same, however, if COVID-19 incidence continues to
exponentially rise and a pharmacological cure or vaccine is not found.
The COVID-19 pandemic has demonstrated that nothing happens without good health. As
health practitioners and health advocates, we support and call upon all stakeholders –
including the political class – to offer leadership now and beyond the pandemic. After all,
health is a non-negotiable right.
Reference
1) Ministry of Health (Republic of Kenya). COVID-19 updates. 2020 [cited 2020 Jul 2].
Junior Doctors Network Newsletter
Issue 19
July 2020
JUNIOR DOCTORS’ PERSPECTIVES: AFRICA Page 12
There has never been a better time than now, to strengthen our
health system, using a societal approach to mitigate risk of
COVID-19 transmission.
While the global burden of the coronavirus disease 2019 (COVID-19) pandemic is
burgeoning, the exact number of COVID-19-affected health care workers (HCWs) remains
unknown. Similarly, specific data highlighting the burden among junior doctors or early
career doctors (ECDs) are limited. Hence, it is necessary to explore the effects of this
pandemic on HCWs, especially among ECDs.
COVID-19 and HCWs
Ongoing COVID-19 surveillance of infections among HCWs examines the burden in high-
and middle-income countries. In the United States, between February and early April 2020,
there were more than 9,000 new COVID-19 cases and 27 deaths among HCWs (1). In
Italy, by mid-March 2020, 2,026 infected HCWs constituted 10% of those diagnosed with
COVID-19 (1,2). In China, by March 2020, there were more than 3,300 new COVID-19
cases and 22 deaths among HCWs (3). In Nigeria, by early May 2020, there were 113 new
COVID-19 cases among HCWs, representing 6% of infections in the total infected
population (4). Researchers reported a seven-fold increase in COVID-19 cases among
HCWs during the past month, which has been attributed to the surge of infected patients at
health care institutions in Nigeria.
Junior Doctors Network Newsletter
Issue 19
July 2020
Health Care Workers as Essential Frontline Agents
during the COVID-19 Pandemic
JUNIOR DOCTORS’ PERSPECTIVES: AFRICA Page 13
Judith Jolayemi, BDS
Lagos University Teaching Hospital
Lagos, Nigeria
Damilola Ayowole, MB.ChB
Federal Medical Centre
Owo, Nigeria
Ganiyu Olanipekun Ahmed, MB.BS
Federal Medical Centre
Owo, Nigeria
Oladimeji Adebayo, MB.BS
University College Hospital
Ibadan, Nigeria
In the face of the COVID-19 pandemic, countries have observed that personal protective
equipment – such as surgical facemasks, N95 masks, other air-purifying respirators,
gloves, goggles, and face shields – has had insufficient supplies to ensure HCWs’
occupational protection (5). At a COVID-19 briefing in April 2020, the World Health
Organisation (WHO) estimated that in order to meet the global needs of HCWs’ personal
protective equipment, a total of over 89 million masks, 30 million gowns, 76 million gloves,
1.59 million goggles, and 2.9 million litres of hand sanitisers must be made available
monthly (5). This gross shortage is further worsened by the surge in the economic cost of
personal protective equipment.
This pandemic has forced global health care systems to operate higher than the maximum
capacity. This is in the milieu of inadequate resources, limited access to personal protective
equipment, continuous risk of exposure to patients and potentially infectious co-workers,
and increased occupational stress among frontline HCWs (1,6).
COVID-19 and ECDs
Although the differential effect on the psychosocial health status of ECDs is poorly
understood, it is expected that there would be a differential impact of the pandemic and
constraints on ECDs. Some considerations include their early career stage, strains related
to disrupted clinical training, differential impact of psychosocial stress, and limited material
and non-material resources and support systems, when compared to senior colleagues.
The protection of Nigerian HCWs, particularly ECDs, has been prioritized by the Nigerian
Association of Resident Doctors (NARD), with regular campaigns that advocate for the
health and safety of clinicians working on the frontline.
Conclusion
To address this global concern, health systems can expand research applications that
explore occupational risks associated with the health and well-being of HCWs, especially
ECDs. Global health leaders should ensure the increased cognisance of these challenges
and enhance efforts to prioritize HCWs’ safety. Junior doctors and ECDs globally should be
prepared to advocate for increased attention to HCWs’ physical and psychosocial health
and mitigate workplace risk of COVID-19 transmission.
Junior Doctors Network Newsletter
Issue 19
July 2020
JUNIOR DOCTORS’ PERSPECTIVES: AFRICA Page 14
The prevalence of COVID-19 is expected to increase globally as
more countries experience community widespread transmission
and surges of infected patients across all health care systems.
References
1. Burrer SL, de Perio MA, Hughes MM, et al. Characteristics of health care personnel with COVID-19 –
United States, February 12–April 9, 2020. MMWR Morb Mortal Wkly Rep. 2020;69:477-481.
2. Livingston E, Bucher K. Coronavirus disease 2019 (COVID-19) in Italy. JAMA. 2020;323:1335.
3. Lancet. COVID-19: protecting health-care workers. Lancet. 2020;395:922.
4. Adebayo O, Labiran A, Emerenini CF, Omoruyi L. Health workforce for 2016–2030: Will Nigeria have
enough? Journal of Innovative Health Research. 2016;4:9-16.
5. Lacina L. What’s needed now to protect health workers: WHO COVID-19 briefing. 2020 [cited 2020 May
22].
6. Greenberg N, Docherty M, Gnanapragasam S, Wessely S. Managing mental health challenges faced by
health-care workers during COVID-19 pandemic. BMJ. 2020;368.
Junior Doctors Network Newsletter
Issue 19
July 2020
JUNIOR DOCTORS’ PERSPECTIVES: AFRICA Page 15
Junior Doctors Network Newsletter
Issue 19
July 2020
Is This What Medicine is All About?
JUNIOR DOCTORS’ PERSPECTIVES: AFRICA Page 16
Dabota Yvonne Buowari, MD
Department of Accident and Emergency
University of Port Harcourt Teaching Hospital
Nigeria
Is this what medicine is all about?
Always helping humanity
Placing priority on the health needs of others
It has been joy
Being a doctor
Relieving the aches of my patients
Seeing my patients get well
I am always glad
When the groan on a patient’s face
Suddenly turns to a smile
Is this what medicine is all about?
The tide changed in a twinkle of an eye
The joy of waking up to attend to patients
Has suddenly tuned to fear
What is this fear?
Fear of contracting the deadly COVID-19 virus
Is this what medicine is all about?
Studying pandemics in the preventive and social medicine class
Least I never knew
That I shall experience it in my lifetime
As an anesthesiologist
I was never scared
Of contacting a respiratory infection
Even the Mycobacterium tuberculosis bacillus
That is common in the tropics
Looking down the larynx
Where respiratory infections sit
Gently inserting the endotracheal tube
Never scared of taking any infection home
Junior Doctors Network Newsletter
Issue 19
July 2020
JUNIOR DOCTORS’ PERSPECTIVES: AFRICA Page 17
Corona, Corona
Where did you come from?
March 2020, you were declared a pandemic
I thought it was a joke
It has come to reality
Coronavirus is in Nigeria
COVID-19 is here in Port Harcourt
Is this what medicine is all about?
COVID-19 pandemic
All universal precautions
Must be observed
I must wear a face shield
Face mask must be won
Throughout the shift
I must wear an apron
The shoe cover is not left out
Wearing the personal protective equipment
Fully kitted to fight the coronavirus
And the call of nature comes knocking
Is this what medicine is all about?
Oh Corona, Oh COVID-19, Oh pandemic
See how you have changed the world
The attitude of medical practitioners
Doctors no longer rush
To save a patient
Presenting with cough
A breathless patient
Raises red flags
And becomes a snare to health workers
Trusting in God
COVID-19
We shall beat you
COVID-19
You must be contained
Acknowledgments: The author acknowledges Prof Okolo Oko of the Department of
English at the University of Lagos (Lagos, Nigeria) for his editorial review of this poem.
Acknowledgments: The author acknowledges Prof Okolo Oko of the Department of English
at the University of Lagos (Lagos, Nigeria) for his editorial review of this poem.
Junior Doctors Network Newsletter
Issue 19
July 2020
The Emergency Physician, the COVID-19 Hero
JUNIOR DOCTORS’ PERSPECTIVES: AFRICA Page 18
Dabota Yvonne Buowari, MD
Department of Accident and Emergency
University of Port Harcourt Teaching Hospital
Nigeria
Oh emergency physician
You are the frontline physician
First attending to the COVID-19 patient
Before alerting the COVID-19 response team
Managing COVID-19
Oh emergency physician
You have the greatest risk
Of taking this unwanted free gift home
Oh emergency physician
You are a hero
In the fight against COVID-19
During the past months of the coronavirus disease 2019 (COVID-19) pandemic, youth
leadership of healthcare practitioners and students has taken a very important role in the
international setting. Youth associations and leaders have used their networks to educate,
coordinate online activities, and even mobilize students as part of the COVID-19 response
(1).
As a recent medical graduate from Ecuador, my passion has always been focused on
youth leadership and to create collaborative networks with students from different
backgrounds. During my medical career, I participated as a student representative at the
local, national, and regional levels. Moreover, in my last year of medical school, I served as
the global director of medical education of the International Federation of Medical Students’
Associations (IFMSA).
As healthcare professionals, our role in this COVID-19 pandemic is not limited to hospitals,
emergency departments or telemedicine consultations. That is why, in recent months, I
have centered my efforts on promoting COVID-19-related technical knowledge and soft
skills (e.g. career and communication skills) to medical students.
In terms of COVID-19 education, I have supported various online initiatives locally by
Ecuadorian student associations and internationally by Russian medical students (Figure
1). These COVID-19 webinars were conducted at the beginning of the pandemic, when
information was still limited and a general overview of the novel pathogen − severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2) − was needed for healthcare students.
Junior Doctors Network Newsletter
Issue 19
July 2020
The Role of Youth Leadership in Online Education
during the COVID-19 Response
JUNIOR DOCTORS’ PERSPECTIVES: AMERICAS Page 19
Pablo Estrella Porter, MD
General physician, Quito, Ecuador
Partnerships Manager for Latin America at AMBOSS
Berlin, Germany
Promoting and participating in youth leadership initiatives are
key elements that support global healthcare systems.
Even though we were saturated with new information on COVID-19 transmission, I
continued to collaborate with student leaders in other related areas. Humanity has
demonstrated that even with forced social distancing, we can stay closer and more
connected than ever. For example, I participated on an international virtual panel and
shared my reflections about how Latin American countries responded to the pandemic.
On a professional level, I am currently working for an international medical education
company. In my role, I have tried to redirect my actions into social accountability
opportunities for medical students and international medical graduates. I have worked with
different medical education experts to promote online lectures, webinars, and workshops
on technical knowledge and soft skills. Some topics have included techniques to improve
focus and productivity while studying at home, manage standardized exams, and utilize e-
learning tools for semester plans. Furthermore, I have been in contact with leaders from
different healthcare student associations to provide access to opportunities offered by my
company, including educational scholarships, open access to COVID-19 materials, and
collaborations to promote instructive webinars (Figure 2).
Junior Doctors Network Newsletter
Issue 19
July 2020
JUNIOR DOCTORS’ PERSPECTIVES: AMERICAS Page 20
Figure 1. International webinar on COVID-19, “World
Health Organization to Support Healthy Public Policy”.
Credit: Observatory of International Relations and
National Union of Medical Students (HCCM, Russia).
Figure 2. Webinar for Latin America, “How
to Study more Effectively at Home?”
Credit: AMBOSS GmbH.
Webinars have become a technological tool for sharing
knowledge and connecting experts and participants from
different parts of the world.
Finally, healthcare professionals together with youth associations have a key role in
empowering future generations of leaders.
Reference
1) Soled D, Goel S, Barry D, et al. Medical student mobilization during a crisis: lessons from a COVID-19
medical student response team. Acad Med. 2020.
Junior Doctors Network Newsletter
Issue 19
July 2020
JUNIOR DOCTORS’ PERSPECTIVES: AMERICAS Page 21
By using new technologies to unite voices and knowledge, we
can strengthen our international response for this pandemic and
ensure that healthcare systems are available for everyone.
The coronavirus disease 2019 (COVID-19) pandemic has highlighted the key contribution
of junior doctors across global health systems. As they apply their expertise in an array of
roles – such as clinical care, community health, education, policy, and research – junior
doctors are uniquely trained to share innovative analyses, offer medical and public health
expertise, and foster professional networks.
Emerging global health risks – ranging from air pollution to zoonotic disease spillover –
require transdisciplinary collaborations to develop novel approaches, implement
appropriate interventions, and minimize risk to affected communities. Effective mitigation of
this global burden hinges on the application of the One Health concept, which promotes a
holistic view of health, intrinsically connecting human, animal, and environmental health (1).
As junior doctors pursue their post-graduate training, they should evaluate how the direct
and indirect effects of global health risks affect population health and how they can offer
their leadership to advance the global dialogue. Hence, via virtual platforms, their
synergistic efforts have the potential to advance scientific knowledge through research
applications, educational outreach activities, and mentorship opportunities.
Junior Doctors Network Newsletter
Issue 19
July 2020
One Health Research, Education, and Mentorship
during the COVID-19 Pandemic
JUNIOR DOCTORS’ PERSPECTIVES: AMERICAS Page 22
Helena Chapman, MD MPH PhD
Publications Director (2019−2020)
Junior Doctors Network
World Medical Association
“Most of the fundamental ideas of science are essentially
simple, and may, as a rule, be expressed in a language
comprehensible to everyone”
− Albert Einstein
The era of physical distancing, as a result of the COVID-19
pandemic and increasing turnover of medical and public health
research, further justifies the need for making active remote
collaborations among junior doctors a top priority.
Strengthening One Health Research Applications
“To raise new questions, new possibilities, to regard old problems from a new angle,
requires creative imagination and marks real advance in science” (Albert Einstein). Junior
doctors can lead efforts that strengthen One Health research applications, noting innovative
data and technology sources at the forefront of scientific advancement. One such resource
includes Earth-observing satellite data, which offer real-time data that describe the natural
and anthropogenic changes of the aquatic, atmospheric, and terrestrial ecosystems over
time.
For example, the Group on Earth Observations (GEO) Health Community of Practice
serves as a global network of professionals who use Earth-observing satellite data to
enhance health decision-making at local, national, and international levels. With an
emphasis on environmental health applications, weekly community telecons were
coordinated to leverage global expertise, share data and resources, and discuss challenges
experienced across geographic regions. To date, junior doctors have contributed their
medical and public health expertise to community discussions on the latest clinical research
on the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and connections to
potential research that examine air and water quality, environmental determinants and
seasonality, and One Health and zoonotic diseases (Figure 1).
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July 2020
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Figure 1. GEO Health Community of Practice.
Credit: Dr Helena Chapman.
During the COVID-19 pandemic, junior doctors have participated
in global forums that offer collaborative learning across scientific
disciplines and enhance professional networking.
Contributing Expertise to Academic Seminars for the Global Community
“Education is the most powerful weapon which you can use to change the world” (Nelson
Mandela). In this virtual environment, junior doctors may be invited to participate on
national and international conference panels, supported by academic institutions and
professional medical societies. With this novel coronavirus, there is a significant need to
rapidly learn more about the clinical aspects of SARS-CoV-2 transmission, immune
response, and clinical management. At the same time, the secondary impacts due to the
lockdown measures – such as air quality monitoring due to reduced combustion processes,
economic limitations related to unemployment, and mental health challenges due to social
isolation – offer an insightful dialogue that can examine knowledge gaps, critical analyses
of current policies and programs, and recommendations for future actions. For this reason,
junior doctors have provided their expertise in multiple webinar presentations, which
support continued medical education for health professionals as well as dissemination of
accurate scientific information to the wider community (Photos 1-2).
Providing Essential Mentorship to Medical Students
“One of the greatest values of mentors is the ability to see ahead what others cannot see
and to help them navigate a course to their destination” (John C. Maxwell). Since junior
doctors are medical graduates who are completing their post-graduate training in diverse
scientific specialties, they understand the hardships faced with lengthy training, exhaustive
clinical and on-call schedules, comprehensive examinations, and work-life balance. Their
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Photos 1-2. Dr Helena Chapman presented the webinar presentation, “Using Earth Observations to
Strengthen One Health Collaborations”, to 60 medical students from the Universidad Central del Este School
of Medicine (San Pedro de Macorís, Dominican Republic), supported by Dr Goldny Mills, June 2020.
Photo credits: Dr Goldny Mills.
They have demonstrated their unique role to serve as indispensable global health leaders
at the frontline of clinical and community settings. Since junior doctors are trained in the
clinical and public health principles, basic research methods, and scientific writing, their
contributions can encourage their colleagues to seek novel opportunities where they can
advance their knowledge and skills. They are also strategically placed to offer a humanistic
touch to families and community members, emphasizing adherence to recommendations
that protect their health and well-being during the current pandemic. Moving forward,
national health systems should examine how health authorities can strengthen the
integration of junior doctors in the implementation of local and national initiatives to
minimize community risk of endemic and epidemic health threats.
References
1) Centers for Disease Control and Prevention. One health. 2020 [cited 2020 Jul 1].
2) Chapman HJ. Innovative workshop: developing critical inquiry in the Dominican Republic. JDN
Newsletter. 2019:0:24-26.
Junior Doctors Network Newsletter
Issue 19
July 2020
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This current global health crisis has demonstrated that
junior doctors are – and will continue to be – influential
leaders in One Health research applications, educational
outreach activities, and academic mentorship opportunities.
Figure 2. Flyer for the Publications
Workshop of ODEM-Dominican
Republic, June 2020. Credit: ODEM.
foresight can offer significant insight to medical students,
especially during the global lockdown measures and their
virtual academic lessons and clinical rotations. By
connecting with national medical organizations, they can
organize academic webinars, lectures, and personalized
practicum sessions that promote student learning in this
virtual environment. To date, their contributions have
guided and encouraged medical students to continue
their leadership through virtual community activities and
advance their creative and technical writing through the
preparation of brief perspectives or narrative papers (2)
(Figure 2).
According to the World Health Organization (WHO), the current coronavirus disease 2019
(COVID-19) has caused more than 10 million confirmed cases and 510,000 deaths
worldwide (1). This global pandemic has changed our daily lifestyles, including buying
groceries, visiting family and friends, and using public transportation for work commutes.
However, it has also stressed other complex sectors of society such as education, family
finances and national economies, and healthcare system capacity, and hence exposing
significant inequalities along the way.
In this context, mitigation strategies are essential to maintain our social systems. Global
innovations have been implemented, and the health sector is no exception. Hospitals have
reduced outpatient care services, reduced hospitalizations for conditions other than
COVID-19, and reorganized supply distributions.
First, telemedicine is the delivery of health services remotely using communication
technology platforms (2). Hospitals have implemented this technology worldwide, especially
for triaging patients with respiratory symptoms (3). Through telemedicine, physicians can
appropriately coordinate patient care based on their risks and previous contacts with
infected patients. This strategy has helped patients with mild symptoms obtain the
supportive care they need and reduce disease transmission to acutely ill patients in health
facilities (4). Second, artificial intelligence (AI) in bots can provide virtual screenings and
identify cases that, according to the WHO protocols, must obtain a COVID-19 diagnostic
test.
Junior Doctors Network Newsletter
Issue 19
July 2020
Telemedicine and Artificial Intelligence:
Redefining Medical Practice during the COVID-19 Pandemic
JUNIOR DOCTORS’ PERSPECTIVES: AMERICAS Page 26
Notably, novel technology can replace personal contact during
physical distancing measures, in order to avoid virus
transmission and protect population health.
Frank Rodríguez, MD
Temporal Consultant
Pan American Health Organization
Panama City, Panama
A new telephone line, managed by general physicians, is available for the population to
receive remote healthcare for diverse services including COVID-19 care. Services have
been relocated among hospitals and community health centers to prevent exposure of
chronically ill patients to other suspected or confirmed cases. Through AI and new
telephone lines, the general population can consult with healthcare professionals prior to
leaving home. Based on their symptoms, they can be referred to certain healthcare
facilities, learn general hygiene measures, receive psychological first aids, and obtain
coordinated health services and medications for pre-existing mental health conditions.
Another AI strategy is Dr. R.O.S.A. − Respuesta Operacional de Salud Automática
(Automatic Health Operational Response, in English) – a bot that uses Whatsapp® to
virtually screen individuals for COVID-19. Based on established protocols, patients who
require COVID-19 diagnostic testing will be connected to a physician and referred to the
closest testing center (5). Patients who do not require further evaluation will be requested
to stay home and take recommended precautions.
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July 2020
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Photo 1. Through telemedicine, physicians
can effectively coordinate patient care
based on their risks and previous contact
with COVID-19 patients. Credit: Pexels.
Nations may face challenges when utilizing
telemedicine or AI applications, such as the lack of
federal investment and legislation, untrained health
workforce, unequal access to internet, and hard-to-
reach communities. For example, providing
indigenous health services in marginalized areas of
low- and middle-income countries can be
challenging, but should be explored and prioritized
across health systems. Proper investment and
innovation to solve these challenges will remain in
our toolbox even after the pandemic (Photo 1).
In Panama, both telemedicine and AI applications have been
implemented by the Ministry of Health.
Technology can improve medical practice, especially during unprecedented times. Based
on the current COVID-19 pandemic, we can advance our knowledge on the implementation
of telemedicine and AI applications to medical practice, noting best practices and
populations to prioritize population health.
References
1) World Health Organization. WHO COVID-19 dashboard. 2020 [cited 2020 Jul 7].
2) Mahajan V, Singh T, Azad C. Using telemedicine during the COVID-19 pandemic. Indian Pediatrics. 2020.
3) Hollander JE, Carr BG. Virtually perfect? Telemedicine for COVID-19. N Engl J Med. 2020;382:1679-
1681.
4) Portnoy J, Waller M, Elliott T. Telemedicine in the era of COVID-19. J Allergy Clin Immunol Pract.
2020;8:1489-1491.
5) Pan American Health Organization. [Artificial intelligence, Panama’s tool to contain COVID-19]. 2020
[cited 2020 Jun 8]. Spanish.
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July 2020
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Since the pandemic of the coronavirus disease 2019 (COVID-19) emerged, the virus has
spread throughout 188 countries, causing more than 14 million cases and 600,000 deaths.
With the rise in the number of cases of COVID-19 worldwide, countries defined their own
strategies to manage the pandemic (1). Hampering efforts of scientists and frontline health
professionals fighting the pandemic, special groups linked to anti-science thinking (2,3) had
acquired an important space in discussions about this virus.
Many topics were related to vaccine safety, the shape of the earth, and climate change.
During the COVID-19 pandemic, however, the overabundance of information – some
accurate and some myths – rendered it difficult to find trustworthy sources of information
and reliable guidance. Subsequently, the World Health Organization (WHO) defined this
situation as an infodemic of planetary proportions (4).
This situation becomes more complicated when authorities – official institutions and federal
departments – fail to provide clear and reliable sources of information. The Merriam-
Webster (2020) defines obscurantism as a policy of withholding knowledge from the
general public (5). This action has more significance when implemented as a public policy.
As such, authoritarian governments can exhibit disturbing denialism about COVID-19,
depriving the general public of accurate information about the pandemic and actively
opposing the prosecution of journalists and others who may raise legitimate factual
concerns about COVID-19 (2).
Junior Doctors Network Newsletter
Issue 19
July 2020
Obscurantism, Denialism, and COVID-19:
A Brazilian Triple Challenge
Andrey Oliveira da Cruz, MD
Family Medicine Resident
State Secretariat of Health of Santa Catarina,
Florianópolis, Brazil
Michelle Medeiros, MD
Family Physician
Secretariat of Health of Florianópolis
Florianópolis, Brazil
JUNIOR DOCTORS’ PERSPECTIVES: AMERICAS Page 29
Recently, there has been a remarkable rise in the proliferation of
misinformation, disinformation, and fake news, plaguing the
scientific community and the public on a global scale.
In Brazil, this narrative is not unique. The ineffectual performance of the Brazilian federal
government in managing the COVID-19 pandemic was noticeable by the statistics.
With the scenario of high underreported rates, due to the extended national geography and
limited resources, Brazil became the second country with the highest number of COVID-19
cases, behind the United States.
Despite the increasing rates of COVID-19 infection and deaths in the country, the federal
government has expressed that scientists and scholars are pessimistic in their predictions,
and that their preferences remains with politicians to describe the real societal impacts. As
a result, new pandemic management measures have been taken. First, daily press
conferences from the Ministry of Health have been suspended. Second, data disclosure of
daily infection and death rates has been delayed for less coverage by journalists. Finally,
official websites with pandemic data have been removed and modified to emphasize the
number of infections, deaths, and cured individuals within the last 24 hours (3).
Notably, the Brazilian government fired two Ministers of Health in the middle of this
pandemic and appointed a new Minister of Health without any expertise or training in
medicine or public health. Leaders released official COVID-19 treatment protocols, based
on minimal scientific evidence and not recognized by the main medical societies.
Subsequently, the Brazilian government announced its desire to leave the WHO – the
same organization that Brazil had a direct influence on its foundation proposal at the United
Nations Conference on International Organization (San Francisco Conference) in 1945.
Notwithstanding the indignation of several health professionals and epidemiologists at the
new policies for covering up data, there is no national consensus that data censorship is
harmful, accentuating the polarization of political ideals (5). In this chaotic scenario, it is the
responsibility of the states and municipalities of the federation to choose their own
measures to combat the COVID-19 pandemic, as defined in a decision by the Brazilian
Supreme Court (3).
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July 2020
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By July 18, 2020, Brazil reported around 2 million cases and at
least 78,000 deaths due to COVID-19 (1).
On the other hand, health professionals from all over Brazil are working effortlessly to
contain the COVID-19 spread. However, they continue to struggle with inadequate working
conditions, poor remuneration, absence of personal protective equipment, and stress
related to the population demand for a vaccine. These challenges are shared across the
world, but with COVID-19 cases increasing across Brazil, the situation symbolizes boarding
a derailed train.
References
1) Johns Hopkins University & Medicine, Coronavirus Resource Center. COVID-19 dashboard by the
Center for Systems Science and Engineering. 2020 [cited 2020 Jul 18].
2) Mian A, Khan S. Coronavirus: the spread of misinformation. BMC Med. 2020;18:89.
3) Cunha BQ. Brazil’s COVID-19 response is caught between denialism and technocratic hubris. The
Regulatory Review. 2020 [cited 2020 Jun 7].
4) Camargo Jr KR. Trying to make sense out of chaos: science, politics and the COVID-19 pandemic.
Cad Saúde Pública. 2020;36:e00088120.
5) Merriam-Webster. Obscurantism. 2020 [cited 2020 Jun 7].
Junior Doctors Network Newsletter
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July 2020
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Although there are multiple approaches to curb COVID-19
transmission, obscurantism and negationism will most certainly
hinder efforts to mitigate disease risk across global populations.
At multiple moments in the coronavirus disease 2019 (COVID-19) pandemic, we have
witnessed political influences being exerted over the World Health Organization (WHO).
While many have been quick to critique these influences as being testimony to an erosion
of WHO’s independence, this article aims to emphasize the political role of the WHO as a
necessary condition for its leadership in global health and decision-making capabilities.
Decision-making and Functions of the WHO
Founded in 1948, the WHO is the specialized agency of the United Nations responsible for
global health. This multilateral organization, with 194 member states across six regions,
coordinates annual governing body meetings to decide the priorities of the programme of
work and provide programmatic and other activity updates (Figure 1).
The organization accomplishes its goals through the coordinated efforts by the Secretariat,
which is located at WHO Headquarters in Geneva, Switzerland, its six regional offices, and
its 150 country offices.
Junior Doctors Network Newsletter
Issue 19
July 2020
The Political Role of the World Health Organization
in Times of COVID-19
JUNIOR DOCTORS’ PERSPECTIVES: AMERICAS Page 32
Yassen Tcholakov, MD MScPH MIH
Interim Chair (2019-2020)
Junior Doctors Network
World Medical Association
❑ Provide leadership and engage in
partnerships where joint action is needed
❑ Shape the research agenda and stimulate
the dissemination of knowledge
❑ Set norms and standards and promote and
monitor their implementation
❑ Articulate ethical and evidence-based policy
options
❑ Provide technical support and build
sustainable institutional capacity
❑ Monitor the health situation and assess
health trends
Of these meetings, the World Health
Assembly is the most significant, where
thousands of global participants attend,
including high-level representation from the
Ministries of Health. Decisions there are taken
by simple majority of the members present
and voting (abstentions do not count) (e.g.
rule 71 of the WHO rules of procedure),
except certain procedural motions and
Decisions by the Health Assembly on
Important Questions, which are subject to a
two-third majority (e.g. rule 70 of the WHO
rules of procedure) (1).
Figure 1. Core functions of the WHO (2).
WHO Financing
Financing is a challenge for the implementation of global health work which is subject to
important resource constraints. Since its foundation, the WHO’s funding has gradually
evolved to rely more on voluntary contributions by members and funding by private actors
(3). Thus, in order to accomplish the goals set out by its members, the WHO must try to
appeal to those members in order to earn their voluntary contributions, and it must do the
same to philanthropies and private sector interest. While this may be perceived as
problematic, it is member states who have chosen over the years to freeze or to limit
increases to their contributions (Figure 2).
How it All Comes Together
Decisions at the WHO are made by 194 states, and each state holds one vote; however,
the implementation is dictated by a paucity of actors who mobilize a significant portion of
funds. The United States, the United Kingdom, and the Bill and Melinda Gates Foundation
together represent more than one-third of the WHO’s funding. Thus, for the WHO to be
able to accomplish its mission, it must play the fine balancing act of courting its financiers,
all while respecting the decisions by its governing bodies. This balance is hard to maintain,
and countries have threatened to reduce their contributions to the WHO in an effort to exert
pressure during certain negotiations.
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July 2020
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Figure 2. Top 20 contributors to the Programme Budget 2018 (4).
Currently, the United States has threatened to withdraw from the WHO and attributed that
decision to the management of the COVID-19 pandemic. This decision was made after
years of ideological differences on the role of global intuitions as well as on specific topics
such as climate change. Had the WHO not been the political actor that it is, we would now
be in a significantly worse situation with respect to COVID-19. The organization, like all
international institutions, is subject to political pressures by its members, yet those
pressures are intrinsic to the nature of the organization, and devoid of them, its normative
role would be meaningless. Nevertheless, the erosion of trust in multilateralism is
dangerous and exposes everyone in the world to greater risk.
While the world felt a scare in 2014 with the Ebola epidemic, and while the whole world was
expecting a novel flu pandemic, what happened in 2020 was predictable, yet unexpected,
and the challenges highlighted our global interconnectedness. Disease transmission
anywhere in the world is a hazard to all of us.
References
1) World Health Organization. Rules of procedure of the World Health Assembly. 2008 [cited 2020 Jun 2].
2) World Health Organization. The role of WHO in public health. 2020 [cited 2020 Jun 2].
3) Reddy SK, Mazhar S, Lencucha R. The financial sustainability of the World Health Organization and the
political economy of global health governance: a review of funding proposals. Global Health. 2018;14:119.
4) World Health Organization. WHO results report: programme budget 2018-2019: mid-term review.
Geneva: World Health Organization; 2019.
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July 2020
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Now is the time to stand behind prior commitments of solidarity and
further increase global aid in order to help low- and middle-income
countries obtain the capacities necessary to fight off this disease.
In Taiwan, this SARS outbreak highlighted the impact of healthcare-associated
transmission on community spread and the importance of personal protective equipment to
minimize occupational exposure (1). In response to this SARS outbreak, Taiwan’s health
authorities were dedicated to curb disease spread by leveraging medical expertise,
coordinating capacity building programs, and strengthening public health surveillance
including contact tracing (1). Through these rapid actions, the SARS outbreak was
controlled, and lessons were learned to strengthen public health infrastructure.
Early Awareness and Response during the COVID-19 Pandemic
From late December 2019, the Taiwanese community, including representatives of the
Centers of Disease Control, had reviewed leaked documents from the People’s Republic of
China and learned about a potential unknown infectious disease from Wuhan. The
government of Taiwan immediately quarantined passengers from Wuhan, Hubei Province,
and later applied this mandate to all provinces of China. Sanitization and social distancing
measures were implemented, and mask exportation was banned due to low national
supplies. Protective masks were required to be worn in all health facilities, and citizens
were requested to steam their masks for reuse. Also, the Taiwan’s Ministry of Health and
Welfare prohibited international travels for all medical professionals. By late January 2020,
the World Health Organization declared this coronavirus disease 2019 (COVID-19) a Public
Health Emergency of International Concern.
Junior Doctors Network Newsletter
Issue 19
July 2020
Reflections on the COVID-19 Response:
From a Taiwanese Junior Doctor
Jen-Hsiang Roy Shen, MD
Attending Staff, Department of Ophthalmology
Wanfan Hospital
Taipei, Taiwan
JUNIOR DOCTORS’ PERSPECTIVES: ASIA Page 35
Reflecting on the past, every Taiwanese citizen remembers the severe
acute respiratory syndrome (SARS) outbreak in 2002-2003.
Proactive Screening and Quarantine for all Incoming Visitors
In January and February 2020, all incoming visitors, who were in close contact with any
confirmed COVID-19 case, were quarantined and tested if they had any presenting
symptoms such as fever, malaise or headache. All incomings visitors without symptoms
were quarantined in a specialized hotel or at home and forbidden to be in physical contact
with family members or friends. All visitors received a protective mask, personal supplies,
and a 14-day food allowance. Every day, government staff called each quarantined person
to evaluate their health and identify any presenting symptoms.
Preventive Measures in Taiwan’s Hospitals
Several preventive measures were implemented across Taiwan’s hospitals to reduce
nosocomial and community transmission. These included: single building entrance and exit;
temperature screening by infrared scanner and forehead thermometer; use of 70% alcohol
spray when entering and leaving the hospital; mandatory use of protective masks except
when eating; social distancing when patients and hospital staff were eating; patients and
hospital staff with fever to be self-quarantined and tested for COVID-19.
Airport Screening Measures
As part of the community, many Taiwanese doctors volunteered their time for airport testing
shifts. This wood building was located behind the airport building, distant from the airport
terminal (Photos 1-2). With sufficient supplies of personal protective equipment, doctors
followed mandatory guidance to wear protective masks when in contact with suspected
COVID-19 cases.
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July 2020
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Photo 1. Author as volunteer at the
airport testing center in Taipei, Taiwan.
Credit: Dr J-H Shen.
Photo 2. Airport testing center in
Taipei, Taiwan. Credit: Dr J-H Shen.
Acknowledgments: I wish to thank all medical staff around the world for their dedicated
efforts during this global health crisis. Together, we collaborate on the global COVID-19
response efforts to reduce community transmission and maintain population health.
Reference
1) Centers for Disease Control and Prevention. Severe acute respiratory syndrome — Taiwan, 2003.
MMWR Morb Mortal Wkly Rep. 2003;52:461-466.
Junior Doctors Network Newsletter
Issue 19
July 2020
JUNIOR DOCTORS’ PERSPECTIVES: ASIA Page 37
In December 2019, the World Health Organization (WHO) office in China identified and
reported a cluster of pneumonia cases in Wuhan. The number of people diagnosed with the
novel coronavirus began to rise exponentially in Wuhan, China and then around the world.
This was followed by the declaration of the coronavirus disease 2019 (COVID-19) as a
global pandemic by the WHO on March 11, 2020. Up to July 15, 2020, COVID-19 had
affected 188 countries or regions with an estimated 13 million cases and 574,464 deaths,
with varying mortality and morbidity rates in different countries (1). Since the COVID-19
pandemic was growing rapidly, several nations took immediate action to curb disease
transmission. These measures included mandating stay-at-home orders, social distancing
measures, preventing massive crowds, halting academic classes for schools and
universities, limiting air travel, and raising community awareness about the virus.
Across nations, junior doctors have worked alongside fellow health professionals to
diagnose and manage COVID-19 cases (2). Many worked overtime shifts detailed to
primary care or emergency departments, serving as frontline health workers to address the
increased demand of health care services related to COVID-19. This article will describe
three specific challenges faced by junior doctors in Myanmar during the COVID-19
response efforts and offer potential solutions for clinical practice.
Junior Doctors Network Newsletter
Issue 19
July 2020
Challenges Faced by Junior Doctors in Myanmar
during COVID-19 Response Efforts
JUNIOR DOCTORS’ PERSPECTIVES: ASIA Page 38
Wunna Tun, MBBS MSc MD
Fellow in Medical Education
Founder, Myanmar Medical Association, Young Doctor Society
Yangon, Myanmar
Since junior doctors are often the first contact with
COVID-19 patients in the hospital and clinic, their
physical and psychosocial health are at risk.
Like other countries during the COVID-19 pandemic, junior doctors in Myanmar have
experienced a rapid shift into collective efforts that have certainly placed additional strain
on their physical and psychosocial health and well-being. First, junior doctors have faced an
insufficient supply of personal protective equipment (PPE) in the clinical workplace,
increasing their risk of pathogen exposure during intubation and clinical care. As the union
government had a limited budget, and medical mask prices were skyrocketing to 10- and
20-fold of the local market, PPE donations from Myanmar and former Myanmar citizens
residing abroad aided hospital supplies across the country. Second, junior doctors in
Myanmar have worked 24-hours shifts under sub-optimal working conditions and without
long breaks. In their efforts to increase public awareness, they have encouraged citizens to
adhere to stay-at-home restrictions and urged them to avoid unnecessary travels. Finally,
limited psychological support for junior doctors, especially from departments, was available
during this pandemic. Since many junior doctors have not returned home for fear of
transmitting the virus to their family members, their support system may be weakened and
directly affect their emotional health.
To address this global scenario, the World Medical Association and the World Heath
Professional Alliance encouraged governments to prioritize support for all frontline
healthcare staff including junior doctors in March 2020. The Junior Doctors Network and
the World Medical Association published a statement on physician well-being, which
highlighted that physicians have the right to working conditions that reduce risk of burnout.
They also emphasized that physicians should be empowered to care for their personal
health through healthy work-life balance of professional and personal responsibilities (3).
Certainly, frontline health workers are experiencing increased stressors and anxiety as well
as physical exhaustion due to the uncertainty of COVID-19 response efforts.
First, health authorities should strengthen the supply chain quickly to provide essential PPE
for frontline health workers (4). Continued training on the novel coronavirus, including
epidemiology and best clinical practices for management, is critical to mitigate nosocomial
transmission and enhance outcomes and safety for junior doctors and patients. Second,
since several studies have highlighted that physicians’ well-being is essential for the best
interest of patients, junior doctors should have adequate breaks during their shifts in order
Junior Doctors Network Newsletter
Issue 19
July 2020
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Future action steps should reduce physical and psychosocial
health risks for all frontline health workers, including junior doctors.
to reduce risk of burnout or exhaustion (3). Third, emotional support should be available
from departments to regularly connect with colleagues, debrief on clinical responsibilities,
and energize efforts and morale. Occupation health and safety guidelines should focus on
diagnostic testing for the novel coronavirus among frontline health workers.
This COVID-19 pandemic has provided an unprecedented opportunity for global health
workers to collaborate and mitigate risk of disease transmission. Junior doctors bravely
sacrifice their time to the provision of safe and quality care for their respective communities.
Every frontline worker – including junior doctors, nurses, and other health care workers –
are essential for preventing, diagnosing, and managing COVID-19 cases. Safe work
environments are essential to maintain a healthy workforce and community.
References
1) World Health Organization. Coronavirus disease 2019 (COVID-19): Situation Report – 177. 2020 [cited
2020 Jul 20].
2) World Medical Association. World health professionals calling governments to prioritise support for
healthcare workers in the front line against coronavirus. 2020 [cited 2020 Mar 17].
3) World Medical Association. WMA statement on physicians well-being. 2020 [cited 2020 Mar 19].
4) World Medical Association. WMA calls for international supply chain to fight coronavirus. 2020 [cited 2020
Mar 17].
Junior Doctors Network Newsletter
Issue 19
July 2020
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As a junior and frontline doctor in Myanmar, I would like to
express my support and best wishes to all junior doctors and
their families around the world who are actively involved in the
COVID-19 response efforts. Be strong and stay safe for your
family, patients, and communities!
When the first case of the coronavirus disease 2019 (COVID-19) broke out in the
Philippines, the government aimed to limit COVID-19 spread by implementing widespread
“lockdown” (“community quarantine”) measures. Although “lockdown” measures had
varying levels of strictness, the “enhanced community quarantine” (ECQ) was the strictest
measure. On March 16, 2020, the government of the Philippines, under President Rodrigo
Duterte, imposed an ECQ in Luzon (1), which placed restrictions on population mobility
except for necessity, work, and health circumstances. With over 600 kilometers between
Luzon and the Visayas region, I was certain that COVID-19 would be able to be contained
in Luzon. However, as the first case arrived in Cebu province (2), the Department Chair
directed immediate and mandatory schedule changes including skeletal duty.
Junior Doctors Network Newsletter
Issue 19
July 2020
Contribution to COVID-19 Response Efforts: Experiences from a
Tertiary Hospital in the Visayan Region of the Philippines
JUNIOR DOCTORS’ PERSPECTIVES: ASIA Page 41
Maymona Choudry, MD MPH
General Surgery Resident
Vicente Sotto Memorial Medical Center
Cebu City, Philippines
Photo 1. Donations of personal protective
equipment from fellows and consultants.
Credit: Dr Dancel.
As a second-year general surgery resident, I
completed several rotations in surgical
subspecialties, and I had recently started my
pediatric surgery rotations. Although our rotations
required alternating 24-hour duties, schedules
were revised to require daily duties as per the
skeletal workforce. As we learned about the
clinical presentations of confirmed COVID-19
cases, the hospital quickly developed a screening
protocol and classification system of patients
suspected of COVID-19 infection. During the first
few weeks, we received relief goods from
different organizations and companies, including
meals and personal protective equipment (PPE)
(Photo 1).
One day, as a post-operative patient was referred to the Department of Internal Medicine,
an oropharyngeal/nasopharyngeal swab was taken. When this test confirmed a severe
acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, I understood that the
virus was closer than previously thought. Knowing that triage and screening processes
have limitations, I felt that wearing a N95 mask was insufficient. The hospital administration
implemented drastic measures to ensure safety of medical residents, including schedules
changes where each group of residents would have clinical duties for seven consecutive
days, followed by 14 days of quarantine at home. Additionally, residents were required to
attend training sessions on best practices related to COVID-19 diagnosis and
management.
For this reason, during my off-duty periods on quarantine, I studied the latest research
updates on SARS-CoV-2 diagnosis and management. In particular, I continued to learn
about critical care management of patients admitted to the Intensive Care Unit, including
mechanical ventilation techniques and best clinical practices (Photo 3).
Junior Doctors Network Newsletter
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July 2020
JUNIOR DOCTORS’ PERSPECTIVES: ASIA Page 42
Photo 2. Residents conduct clinical rounds at
the emergency room with personal protective
equipment. Credit: Dr Maderazo.
As a doctor, it is my responsibility to remain up-to-date on
clinical knowledge, apply this knowledge to clinical
practice, and ultimately share this knowledge with
colleagues and patients.
All medical residents consistently used PPE in
the clinical environment, whether in the
emergency room or the operating rooms
(Photo 2). However, with PPE in limited
supplies, one resident organization requested
financial assistance from the wider community,
seeking additional PPE supplies for residents.
Personally, I requested donations from family
members living abroad to support our limited
institutional PPE supplies.
References
1) Presidential Communications Operations Office. Proclamation No. 929 s. 2020: Declaring a state of
calamity throughout the Philippines due to corona virus disease 2019. 2020 [2020 Jun 23].
2) Department of Health, Central Visayas Center for Health Development (Philippines). COVID-19 updates:
COVID-19 cases in Central Visayas. Report No. 43. Morbidity Week 28 (July 5 − July 11, 2020). 2020
[cited 2020 Jun 23].
Junior Doctors Network Newsletter
Issue 19
July 2020
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Although the future is uncertain, I believe that our global
society will overcome these challenges.
Photo 3. Preparedness for COVID-19
Infection Training on Rapid Sequence
Intubation. Credit: Dr Dollosa.
This COVID-19 pandemic has taken a
tremendous toll on global citizens, especially on
health care workers. Health care workers face
an array of risks and adversities each day to
protect their patients, families, and country. Their
collective efforts have contributed significantly to
response efforts, especially as we learn more
about this highly infectious and resilient
pathogen.
From the start of the coronavirus disease 2019 (COVID-19) pandemic until today,
Taiwanese health authorities acted promptly to allocate and distribute medical resources
and deploy health workers to aid in response efforts. These collective actions successfully
reduced disease transmission in Taiwan and protected population health.
Junior Doctors Network Newsletter
Issue 19
July 2020
COVID-19 Prevention at the Community Level:
Taiwan’s Measures Against an Epidemic
JUNIOR DOCTORS’ PERSPECTIVES: ASIA Page 44
Chiang Kuan Yu, MD
Hospitalist, Taipei City Hospital
Taipei, Taiwan
Figure 1. Taiwan’s response at community
facilities. (TOCC=Travel history, Occupation,
Contact history, Cluster; PCR=polymerase chain
reaction). Credit: Dr Chiang Kuan Yu; Referred and
modified from National Health Command Center
(NHCC) guideline, Taiwan.
Early during the epidemic, Taiwanese health
authorities implemented effective measures
taken to mitigate risk to the wider community,
including community-based surveillance, early
hospital referrals, preliminary triage measures,
and revised guidelines for clinical decision-
making in hospitals (Figure 1). In Taiwan’s
advanced response, COVID-19 cases were
managed in separate hospitals through a referral
system (island-hopping strategy). As the number
of COVID-19 cases increased, hospitals and
public health centers were integrated to enhance
community management of COVID-19 cases.
While suspected COVID-19 cases were awaiting
their two real-time polymerase chain reaction
(PCR) results, they were isolated in an
expanded screening ward. If both PCR results
were negative, then patients were transferred to
the general clinical ward or discharged,
depending on their presenting symptoms.
Taiwan’s national response efforts have highlighted key actions
implemented during the initial defense of the epidemic.
During the COVID-19 pandemic, several hospitals were designed for COVID-19 treatment,
enabling hospitals to share their available clinical capacity and medical resources. An
effective referral system was established to transfer patients among these designated
hospitals for optimal treatment. In order to minimize risks of cross-infection inside hospitals,
health authorities aimed to strengthen clinical management (3). The first triage station
outside the emergency room held isolated febrile patients, and patients with respiratory
symptoms were evaluated in separate wards. This strategy was also applicable for any
public health emergency where patients needed immediate clinical care (2). The prompt
response of preliminary triage measures helped reduce community transmission of COVID-
19, which outweighed the significance of COVID-19 transmission by international travel
(Figure 2). In contrast, the SARS outbreak in Taiwan in 2003 was impacted by SARS
transmission primarily by international travel (Figure 3).
Junior Doctors Network Newsletter
Issue 19
July 2020
JUNIOR DOCTORS’ PERSPECTIVES: ASIA Page 45
Figure 2. The number of confirmed coronavirus
disease 2019 (COVID-19) cases from international
travel and community transmission in Taiwan, as
reported by the weeks following the first diagnosed
COVID-19 case (January 21−May 9, 2020).
Credit: Dr Chiang Kuan Yu; Data from
https://data.gov.tw/.
Figure 3. The number of confirmed severe acute
respiratory syndrome (SARS) cases from international
travel and community transmission in Taiwan, as
reported by the weeks following the first diagnosed
SARS case in the world, 2003.
Credit: Dr Chiang Kuan Yu; Data from
https://data.gov.tw/.
Numerous lessons were learned following the SARS outbreak
in Taiwan in 2003, motivating the implementation of national
regulations to strengthen infection control measures (1).
Infection Control: Essential Component for All Medical Institutions
To continue to prevent continued COVID-19 transmission, securing airports and seaports,
protecting local communities through stay-at-home restrictions, and securing sufficient
capacity and resources among medical institutions were essential to curb disease spread
to local communities. With heightened awareness among political leaders, hospital
managers, and local citizens, infection control measures were effectively implemented
inside major hospitals. However, authorities faced challenges in other medical institutions,
including asylums, nursing homes, and other social welfare institutions, which have limited
infection control policies and funding for robust infection control measures. Additional
challenges included the comparison of severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2) to influenza virus among policymakers, leading to confusion of the general
public.
By distinguishing the COVID-19 pandemic from past disease outbreaks, health and policy
leaders can share lessons in effective infection control measures, especially with prompt
identification of at-risk populations. Taiwan’s leadership in implementing triaging and clinical
management strategies may serve as a reference point for hospital management. Moving
forward, all health institutions should integrate a holistic medical policy that identifies best
clinical and management practices and prepares health leaders to address future health
threats.
References
1) Centers for Disease Control and Prevention. Severe acute respiratory syndrome − Taiwan, 2003. MMWR
Morb Mortal Wkly Rep. 2003;52:461-466.
2) Lin C-H, Lin C-H, Tai C-Y, Lin Y-Y, Shih FF-Y. Challenges of burn mass casualty incidents in the
prehospital setting: lessons from the Formosa Fun Coast Park color party. Prehospital Emergency Care.
2019;23:44-48.
3) Ong SWX, Tan YK, Chia PY, et al. Air, surface environmental, and personal protective equipment
contamination by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from a symptomatic
patient. JAMA. 2020.
Junior Doctors Network Newsletter
Issue 19
July 2020
JUNIOR DOCTORS’ PERSPECTIVES: ASIA Page 46
As an unexpected pandemic of the 21st century,
COVID-19 has challenged all aspects of global health
preparedness and response efforts.
Globally, health care workers (HCWs) experience significant stress in the workplace, and
the current coronavirus disease 2019 (COVID-19) pandemic has emphasized this burden.
Since mental health significantly contributes to the holistic well-being of an individual, the
evaluation of workplace stressors needs special attention, especially for frontline HCWs in
humanity’s battle against the novel coronavirus.
Currently, HCWs’ clinical responsibilities are more physically and mentally exhausting,
attributed to the accompanying burden of controlling COVID-19 spread across public and
private sectors. Although preventing community spread is the collective responsibility of
humanity, substantial burden lies on the health care sector. The compelling need to rapidly
diagnose, treat, and manage patients invariably places significant stress on HCWs. All jobs
and positions in the health care system are challenged, including primary care services,
acute- and long-term care, community health promotion activities, monitoring and
evaluation tasks, and health administration.
As multiple factors affect the mental health of HCWs, the burden has increased significantly
since the beginning of the COVID-19 pandemic. Since new research advancements have
led to the development of new clinical protocols and guidelines, HCWs must keep up-to-
date on these evidence-based practices and new work patterns and environments.
These stressors can affect work-life balance and produce sleep deprivation, which
negatively affect the physical and psychosocial health of HCWs. As such, all potential risk
factors should be examined in depth, including the influence of personal life challenges and
preexisting mental health disorders.
Junior Doctors Network Newsletter
Issue 19
July 2020
Mental Health of Frontline Health Care Workers
during the COVID-19 Pandemic
JUNIOR DOCTORS’ PERSPECTIVES: ASIA Page 47
Rujvee P. Patel, M.B.B.S
Medical Officer, COVID-19
Surat Municipal Corporation
Surat, India
Extensive clinical responsibilities, increased need for
precision and alertness in the workplace, and few break
periods can increase anxiety and stress among HCWs.
Several studies have demonstrated this significant mental health burden on HCWs who are
managing COVID-19 patients in the clinical workplace across the world. In China, one
study concluded that of 1,257 HCW respondents, 634 (50.4%) reported symptoms of
depression, 560 (44.6%) described anxiety, 427 (34.0%) stated insomnia, and 899 (71.5%)
expressed distress (1). In Italy, another study confirmed that of 1,379 HCW respondents,
681 (49.4%) respondents reported post-traumatic stress disorder (PTSD), 341 (24.7%)
described symptoms of depression, 273 (19.8%) described anxiety, 114 (8.3%) stated
insomnia, and 302 (21.9%) perceived high levels of stress (2). In West Bengal, one study
reported that of 152 physician respondents, 34.9% expressed symptoms of depression,
39.5% described anxiety, and 32.9% perceived stress (3). In Singapore, another study
concluded that of the 470 HCW respondents, 68 (14.5%) were diagnosed with anxiety, 42
(8.9%) with depression, 36 (7.7%) were diagnosed with PTSD, and 31 (6.6%) perceived
stress (4). As such, all potential risk factors should be examined in depth, including the
influence of personal life challenges and preexisting mental health disorders.
In summary, mental health care of frontline HCWs requires special attention. We must
remember that individuals who provide health care services are human beings who equally
need rest and care. Their daily tasks require optimal health and well-being to be able to
provide high-quality health care services to patients. While real efforts are focusing on the
physical health of HCWs – such as proper sanitation and hygiene measures, balanced
nutrition, and drug prophylaxis – their mental health should not be overlooked.
References:
1) Lai J, Ma S, Wang Y, et al. Factors associated with mental health outcomes among health care workers
exposed to coronavirus disease 2019. JAMA Network Open. 2020;3:e203976.
2) Rossi R, Socci V, Pacitti F, et al. Mental health outcomes among frontline and second-line health care
workers during the coronavirus disease 2019 (COVID-19) pandemic in Italy. JAMA Network Open.
2020;3:e2010185.
3) Chatterjee SS, Bhattacharyya R, Bhattacharyya S, Gupta S, Das S, Banerjee BB. Attitude, practice,
behavior, and mental health impact of COVID-19 on doctors. Indian J Psychiatry. 2020;62:257-265.
4) Tan BYQ, Chew NWS, Lee GKH, et al. Psychological impact of the COVID-19 pandemic on health care
workers in Singapore. Ann Intern Med. 2020;M20-1083.
Junior Doctors Network Newsletter
Issue 19
July 2020
JUNIOR DOCTORS’ PERSPECTIVES: ASIA Page 48
Moving forward, as a society, we should prioritize the mental
health of HCWs as a call to action and a new focus area for
health systems.
In late January 2020, the Republic of Korea reported the first case of the coronavirus
disease 2019 (COVID-19). The national public health response was implemented, which
rapidly halted community spread of COVID-19. This described response ranged from
frontline health care workers in clinical management, contact tracing efforts to identify
potential infections, and the deployment of a diverse set of information and communication
technology (ICT) tools. This article will introduce some of the noteworthy devices that were
developed and used in the Republic of Korea.
Junior Doctors Network Newsletter
Issue 19
July 2020
Use of Information and Communication Technology for COVID-19
JUNIOR DOCTORS’ PERSPECTIVES: ASIA Page 49
Jaehyeon Jang, MD Msc
Public Health Physician, Anseong Public Health
Center
Director, Korean Intern and Resident Association
Anseong, Republic of Korea
Keyhoon Kim, MD
Public Health Doctor
Director of International Relations
Korean Association of Public Health Doctors
Seoul, Republic of Korea
Sejin Choi, MD
Public Health Doctor
Vice President, Korean Association of Public
Health Doctors
Seoul, Republic of Korea
Jihoo Lee, MD
Internal Medicine Resident, Seoul National
University
Director, Korean Intern Resident Association
Seoul, Republic of Korea
Notably, ICT tools have been adopted in various fields of
quarantine systems including integrating in epidemiological
research studies, disseminating information to the public,
and complementing screening processes.
Almost every country has utilized multiple strategies to control the COVID-19 pandemic,
focusing on the stay-at home restrictions and social distancing measures. Thus far, these
recommendations are considered best practices to curb COVID-19 spread. In the Republic
of Korea, the government developed the Cellular Broadcasting System (CBS) in order to
confirm compliance to social distancing measures (1). Previously, CBS had been widely
used as a means of communication reserved for informing the public about natural
disasters (e.g. earthquakes, flooding, forest fires). During this pandemic, the government
expanded its application to include public notification of COVID-19 related events. For
example, once an individual entered a metropolitan region, the local government
parastatals who were equipped with this system would immediately disseminate emergency
texts about the travel log of confirmed COVID-19 patients.
ICT also supported the COVID-19 screening process for healthcare workers. For example,
electronic medical records (EMR), which incorporated the Drug Utilization
Review/International Traveler Information System (DUR/ITIS), played an important role in
triage measures. This system alerted physicians on patients’ history of overseas travel as
well as self-diagnosis of symptoms (2). Instead of closing the national borders, the Republic
of Korean government implemented restrictions on the entry of certain visitors into the
country. Incoming visitors were required to download the app, where they would use the
questionnaire-based screening tool to update their health status on a daily basis (Figure 1).
If any anomaly in their health condition was detected, then they were mandated to visit a
health institution. Although this concept was initially developed for the visitors to the
Republic of Korea, it is now being used for university students (3).
Junior Doctors Network Newsletter
Issue 19
July 2020
JUNIOR DOCTORS’ PERSPECTIVES: ASIA Page 50
As citizens received these texts, they could quickly check if
their travels were proximal to the travel log of the confirmed
COVID-19 patients, prompting testing if applicable.
Figure 1. Diagram that demonstrates the process of the self-diagnosis application (3).
The COVID-19 Epidemiological Investigation Support System was developed to facilitate
the contact tracing efforts (4). As the number of COVID-19 cases in Daegu Province
skyrocketed, there was the need for breakthrough technology to manage the
epidemiological data. The new system operated with the spatiotemporal records of credit
card transaction and Global Positioning System (GPS) coordination of personal cellular
phones. This platform helped Epidemic Intelligence Service (EIS) officers to quickly identify
suspected COVID-19 cases by improving the reliability and shortening the investigation
time (3). While the original method of receiving information from telecommunication
companies via the district police station could take up to 24 hours of investigation, this
novel platform could collect data within 10 minutes, which prevented delays to missing the
golden time (Figure 2).
Despite the gargantuan leaps made with ICT, some pitfalls were encountered with the
aggressive and widespread use of ICT. First, as with any sort of internet technology that
utilizes citizens’ private information, ICT tools met some limitations regarding privacy
infringement, especially during contact tracing. Since contact tracing data was accessible to
the general population, people were discouraged from having social gatherings due to the
fear of their personal information in the public domain and any potential breach in privacy
With no social consensus on how much privacy that citizens should give up for the sake of
the greater good, it seems evident that new technologies should be adopted with more
caution and regulation. Second, healthcare workers were not comprehensively trained on
this novel technology due to time and resource limitations during the COVID-19 pandemic.
As a result, there were inconsistent applications of ICT in the clinical and community
settings. Hence, educating physicians on the mechanisms and implications of ICT tools will
be imperative in preparation for the post COVID-19 era.
Junior Doctors Network Newsletter
Issue 19
July 2020
JUNIOR DOCTORS’ PERSPECTIVES: ASIA Page 51
Figure 2. COVID-19 data collection procedure before and after the
COVID-19 epidemiological investigation support system (5).
References
1) Kim JM, Chung YS. Identification of coronavirus isolated from a patient in Korea with COVID-19. Osong
Public Health and Research Perspectives. 2020;11:3-7.
2) Junior Doctors (Republic of Korea). [Critical backup from Health Insurance Review and Assessment
Service for combating coronavirus]. 2020 [cited 2020 May 29]. Korean.
3) Ministry of Economy and Finance (Republic of Korea). Flattening the curve on COVID-19: how Korea
responded to a pandemic using ICT. Seoul: Government of the Republic of Korea; 2020.
4) COVID-19 national emergency response center. Early epidemiological and clinical characteristics of 28
cases of coronavirus disease in South Korea. Osong Public Health Res Perspect. 2020;11:8-14.
5) Park YJ, Cho SY, Lee J, et al. Development and utilization of a rapid and accurate epidemic investigation
support system for COVID-19. Osong Public Health Res Perspect. 2020;11:118-127.
Junior Doctors Network Newsletter
Issue 19
July 2020
JUNIOR DOCTORS’ PERSPECTIVES: ASIA Page 52
Like other countries, junior doctors of the Republic of Korea have dedicated their efforts in
the coronavirus disease 2019 (COVID-19) response efforts. To date, the Republic of Korea
has been recognized as one of the successful nations in managing the COVID-19
pandemic, touting relatively low infection and mortality rates.
In the Republic of Korea, junior doctors who have been mainly engaged in these COVID-19
response efforts were public health doctors (PHDs) – who work in medically underserved
areas including rural healthcare centers as a part of their military service – and medical
residents. As we all experienced in our clinical workplace, the public health crisis involved
many different sectors and stakeholders of society – including healthcare workers, central
Junior Doctors Network Newsletter
Issue 19
July 2020
Education and Training of Junior Doctors in the Post-COVID-19 Era
JUNIOR DOCTORS’ PERSPECTIVES: ASIA Page 53
Sejin Choi, MD
Public Health Doctor
Vice President, Korean Association of Public
Health Doctors
Seoul, Republic of Korea
Keyhoon Kim, MD
Public Health Doctor
Director of International Relations
Korean Association of Public Health Doctors
Seoul, Republic of Korea
Jaehyeon Jang, MD MSc
Public Health Doctor
Anseong Public Health Center
Director, Korean Intern Resident Association
Anseong, Republic of Korea
Jihoo Lee, MD
Internal Medicine Resident, Seoul National
University
Director, Korean Intern Resident Association
Seoul, Republic of Korea
From a junior doctors’ perspective, lessons learned during the
COVID-19 pandemic can pave the way to better prepare the
health system for the next pandemic.
and local governments, administrative workers, and business leaders. Since the primary
goal of these collective efforts was to protect the health and safety of community members
from this highly infectious pathogen, doctors voiced their concerns, made prompt and
appropriate clinical decisions, and led the healthcare teams in the clinical and community
response efforts.
In addition to these clinical roles, doctors of the Republic of Korea served in various non-
clinical roles. Many times, junior doctors served as technicians for laboratory samples (e.g.
nasopharyngeal swabs) and overall management of intensive care units. These
management decisions, completed by non-experts in the health system, overlooked clinical
expertise among healthcare workers and led to confusion and cracks in the national
quarantine efforts. For instance, the government started to loosen the social distancing
measures and schools reopened to provide classroom lessons, even though the country’s
Crisis Alert Level was still the highest level 4 (Photo 1). Healthcare workers have also been
inefficiently utilized, especially for the wide implementation of local infection prevention and
control strategies. The resulting approaches were unorganized, lacked scientific rigor, and
were less cost-effective.
Junior Doctors Network Newsletter
Issue 19
July 2020
JUNIOR DOCTORS’ PERSPECTIVES: ASIA Page 54
Notably, doctors – especially junior doctors – felt that they were
unable to assume the role of as “public health experts” to lead
these complex decision-making processes, due to their limited
training in public and population health.
Photo 1. Patrons without masks visit one
dance club in Seoul, Korea in May 2020.
Credit: Twitter (@supermassive101).
Current medical education and training in the Republic
of Korea are heavily focused on clinical medicine and
strengthening skill-based clinical competencies. This
training does not incorporate the health system as a
whole, public health as a continuum of medicine, or
knowledge of population health and field experiences
(1). Although the Korea Center of Disease Control and
Prevention (KCDC) has trained and employed some
doctors with public health expertise, their limited staff
cannot lead or manage every health emergency.
Ad hoc education and training are not enough. Structured and formal education and training
in public and population health should be integrated into current PHD and resident training
systems. KCDC may be able to offer some education and training courses for junior
doctors. When doctors are equipped with a priori knowledge and expertise on public and
population health, they will be able to lead different stakeholders of society to improve the
health and well-being of all citizens.
Evaluating the current scenario, there are few preventive medicine and public health
residents in the Republic of Korea. Second, the COVID-19 outbreak has demonstrated that
the public health training curricula required dramatic revision to train doctors to serve as
public health experts in the clinical and community settings. Unfortunately, they were not
given fieldwork opportunities as Epidemic Intelligence Service (EIS) positions for this
COVID-19 crisis. Instead, retired family medicine doctors and veterinarians were placed
into EIS positions, even without proper training. These collective actions have shown that
major revisions should be completed to strengthen medical education and training in the
Republic of Korea.
Through the COVID-19 response efforts in the Republic of Korea, health authorities have
identified limitations in the health workforce capacity and need for more public health
experts. Junior doctors, regardless of their selected specialty, also demand systematic
education and training to strengthen and support their clinical expertise to serve the health
and well-being of the national population (2). Unfortunately, simply increasing the number
of doctors will not meet the national demand for more public health experts. Now more than
ever, it is time to nurture experts – chief doctors – who can design and implement public
health action plans for the COVID-19 response efforts and future pandemics.
References
1) Koo D, Thacker SB. The education of physicians: a CDC perspective. Acad Med. 2008;83:399-407.
2) Choi S. A hidden key to COVID-19 management in Korea: public health doctors. J Prev Med Public
Health. 2020;53:175-177.
Junior Doctors Network Newsletter
Issue 19
July 2020
JUNIOR DOCTORS’ PERSPECTIVES: ASIA Page 55
“Population health encompasses the domains of critical thinking
and evidence-based practice, disease prevention and health
promotion, health systems, health policy, and community health,
including the broader community context for health or illness” (1).
In April, the World Medical Association (WMA) – Junior Doctors Network (JDN) coordinated
a general membership teleconference to discuss response efforts related to the
coronavirus disease 2019 (COVID-19) pandemic. After this event, junior doctors from the
Japan Medical Association (JMA) – JDN and the Republic of Korea organized a binational
virtual teleconference for junior doctors to share their clinical and community experiences
as well as discuss challenges related to COVID-19 response efforts across their countries.
Republic of Korea
The framework of the Korean strategy focused on mass testing. Dr Sejin Choi, from the
Korean Association Public Health Doctors (KAPHD), stated that young public health
doctors (PHDs) played a pivotal role in the implementation efforts of this strategy. PHDs
represent male doctors, between 20 and 30 years old, who have recently graduated from
medical school or have completed their medical residency. As an alternative to military
service, PHDs work for a period of three years in either rural areas with limited health
Junior Doctors Network Newsletter
Issue 19
July 2020
Sharing Binational Experiences during the COVID-19 Response:
Collaboration between the Republic of Korea and Japan
JUNIOR DOCTORS’ PERSPECTIVES: ASIA Page 56
Mineyoshi Sato, MD
Chair, Japan Medical Association – Junior Doctors
Network
Respiratory Physician, First Department of
Medicine
Hokkaido University Hospital
Sapporo, Japan
Maki Okamoto, MD
Communications Director (2019−2020)
Junior Doctors Network
World Medical Association
Sejin Choi, MD
Public Health Doctor
Vice President, Korean Association of Public
Health Doctors
Seoul, Republic of Korea
Notably, these neighboring countries implemented different
strategies to mitigate COVID-19 transmission, reporting low
infection and mortality rates, when compared to other countries.
resources or in public facilities such as public health centers, airport quarantines, and
correctional facilities (1).
When the first four COVID-19 cases in the Republic of Korea were confirmed on January
27, 2020, PHDs were deployed to the airport facilities to enforce quarantine measures. In
February 2020, following one regional outbreak in Daegu, 200 PHDs were sent to this
metropolitan city to lead and manage response efforts. To date, over 1,000 PHDs have
worked on the frontline – airports, screening centers, drive-thru testing sites for mass
testing, long-term care facilities – to mitigate COVID-19 spread. Moreover, they conducted
health inspections and provided consultations at temporary isolation facilities where
patients with mild symptoms were localized.
As of July 19, 2020, a total of 13,745 COVID-19 infections and 295 deaths were reported in
the Republic of Korea (2). Hence, this national response – including calling PHDs to the
frontline – was effective in curbing disease transmission. Since PHDs are replacements for
military personnel and serve under the direction of the national government, this existing
structure worked well to enhance a prompt and systematic national response.
Japan
Unlike the Republic of Korea, no national collective actions were coordinated by junior
doctors to reduce COVID-19 spread in Japan. Instead, local government authorities
focused on the key role of the local public health centers, to prioritize COVID-19 diagnosis
and management as well as continue medical care services for other infectious and chronic
diseases, maternal and child health, immunizations, and other health concerns. Health care
workers aimed to prevent COVID-19 transmission by tracking and identifying suspected
COVID-19 patients through contact tracing of clusters. With support by the government,
they held the authorization for an array of clinical decisions including designating laboratory
samples for PCR testing based on the guidelines set by the Ministry of Health, Labour and
Welfare. This responsibility aimed to prevent overloading hospital and laboratory capacity,
especially since Japanese citizens have free access to health care facilities. To date,
although this national approach raised public concerns about potential low or limited
diagnostic testing, a total of 24,642 infections and 985 deaths were reported in Japan (2).
Junior Doctors Network Newsletter
Issue 19
July 2020
JUNIOR DOCTORS’ PERSPECTIVES: ASIA Page 57
The role of PHDs in the COVID-19 response efforts are a significant
element to the effective national public health response.
By sharing these binational COVID-19 response efforts, junior doctors from the Republic of
Korea and Japan observed how various national approaches were successful in effective
control of COVID-19 transmission. They were able to learn from each other and observe
regional and national variation during this public health crisis. Although it may be difficult to
generalize the role of junior doctors across nations, their national leadership efforts are
inspiring and offer renewed insight into the significant role of junior doctors in the health
system.
References:
1) Choi S. A hidden key to COVID-19 management in Korea: public health doctors. J Prev Med Public Health.
2020;53:175-177.
2) World Health Organization. WHO coronavirus disease (COVID-19) dashboard. 2020 [cited 2020 Jul 19].
Junior Doctors Network Newsletter
Issue 19
July 2020
JUNIOR DOCTORS’ PERSPECTIVES: ASIA Page 58
Sharing these international experiences can strengthen the
network of junior doctors, provide valuable perspectives, and
inspire colleagues in preparing for future emerging health threats.
Through the Declaration of Alma-Ata of 1978, the concept of Primary Health Care (PHC)
was recognized as a key component achieving health for all and the foundation for health in
every health system. The main role of PHC within health systems was later reaffirmed in
the Declaration of Astana of 2018, and the comprehensive, horizontal approach to health
and well-being was emphasized. This commitment to PHC was motivated by the fact that
more than 80% of people´s health needs during their lifespan can be met by PHC. The
impact of PHC on the health and well-being of global citizens is fundamental, where strong
PHC can minimize risks of a future pandemic and pave the way to health for all (1). The
importance of PHC is recognized now more than ever with the coronavirus disease 2019
(COVID-19) outbreak, placing pressure on health systems and significantly affecting clinical
practice.
First, primary care practitioners take care of patients infected with severe acute respiratory
syndrome coronavirus 2 (SARS-CoV-2), with most patients managed in outpatient care
settings, presenting with mild symptoms. They are considered the most trusted source of
health information for patients, including advice on prevention measures to mitigate risk of
disease transmission. Second, primary care practitioners can help with monitoring disease
Junior Doctors Network Newsletter
Issue 19
July 2020
The Importance of Primary Health Care during
Health Emergencies
JUNIOR DOCTORS’ PERSPECTIVES: EUROPE Page 59
Flora Kuehne, MD
General Practice and Family Medicine Resident
Munich, Germany
PHC plays a crucial role in health emergencies, where primary
care teams are frontline agents of the COVID-19 response to
keep communities healthy and safe.
spread, such as serving as primary contacts for COVID-19 testing (1). As PHC represents
the first contact of patients with the health care system, it can function as a key stakeholder
in disease surveillance and health promotion through the adoption of best practices in
public health (2).
Furthermore, another critical aspect during this pandemic includes the provision and
maintenance of essential health services, including mental health, reproductive health,
chronic disease management, immunizations, rehabilitative and palliative care, and follow-
up or other referrals (4). Specific population groups – such as pregnant women and
patients living with cardiovascular or metabolic disorders – need regular medical
evaluations in the continuum of care. Some services, like immunization, HIV/AIDS
medications, and contraceptive methods, however, are expected to be delayed or declined
across many countries due to the pandemic (1).
For example, severe complications have been reported for patients who fail to seek early
care for acute coronary heart syndrome, stroke, and appendicitis (3). However, elective
diagnostic procedures, therapeutic measures, and preventive health evaluations must not
be neglected. The growing need for mental health services have increased in times of
social distancing, economic difficulties, and uncertainty. Within this scope, PHC can offer
effective strategies if a second peak is observed in the demand of health services,
pressuring already strained health systems (2).
Through multisectoral action, robust collaborations, and community engagement, PHC can
provide an approach for effective emergency responses and prepare for resilient health
systems (5). Decisions on health policy and resource allocation should therefore take into
account the opportunities that strengthened PHC systems can offer, shaping global health
for the future.
Junior Doctors Network Newsletter
Issue 19
July 2020
JUNIOR DOCTORS’ PERSPECTIVES: EUROPE Page 60
As the pandemic continues, delayed health care services –
whether due to limited clinic schedules and postponed elective
procedures or fear to visit health centers – may result in
disease complications.
References
1) Primary Health Care Performance Initiative. Key messages: COVID-19 and primary health care.
2020 [cited 2020 May 24].
2) World Health Organization. Technical series on primary healthcare: primary health care and health
emergencies. 2018 [cited 2020 Jun 10].
3) [Care for patients with acute treatment needs]. Deutsches Aerzteblatt. 2020 [cited 2020 Jun 9].
German.
4) World Health Organization, Regional Office for the Western Pacific. Role of primary care in the
COVID-19 response. 2020 [cited 2020 Jun 10].
5) Dunlop C, Howe A, Li D, Allen LN. The coronavirus outbreak: the central role of primary care in
emergency preparedness and response. BJGP Open. 2020;4.
Junior Doctors Network Newsletter
Issue 19
July 2020
JUNIOR DOCTORS’ PERSPECTIVES: EUROPE Page 61
Ensuring support for and taking time to listen to the worries, questions, hopes, and fears of
those at the center of this coronavirus disease 2019 (COVID-19) pandemic crisis will be
time well-spent if we are to conquer this battle. For medical students and junior doctors in
Sweden, a platform to discuss our role in the pandemic has been missing. Therefore, we
arranged a virtual panel discussion, A Student / Junior Doctor during the Pandemic − What
is my Role?, in early April 2020. More than 200 medical students and junior doctors
attended the event, and more than 500 additional individuals have watched the recording.
In this article, we would like to share three main take-away messages.
Medical students and junior doctors are essential members of the health workforce.
“Let us help” − has been a rallying cry from medical students in Sweden. Most of us have
entered this profession because we want to help our patients and, as voiced by one of our
panelists, Madeleine Liljegren, chair of the Swedish Junior Doctors’ Association: “This is
what we have been trained for”. In mid-March 2020, lists for medical students interested in
helping the Swedish health system were circulated, and thousands signed up. More than
just altruistic motivations, Niki Shams, panelist and chair of the Swedish Medical
Associations’ student branch, suggested that this is a unique opportunity: “There is so
much for us to learn”. This statement reflects that medical students are both learners and
clinicians in-training (1).
Junior Doctors Network Newsletter
Issue 19
July 2020
Listening to the Hopes and Fears of Swedish Medical Students
and Junior Doctors
JUNIOR DOCTORS’ PERSPECTIVES: EUROPE Page 62
Lotta Velin
Medical student, Lund University
Secretary, Junior Doctors Global Health Section
Swedish Society of Medicine
Lund, Sweden
Hanna Jerndal, MD
Secretary, Junior Doctors Public Health Section
Swedish Society of Medicine
Umeå, Sweden
Although academic learning may be jeopardised with cancelled
internships and virtual coursework, living and serving during a
pandemic can provide young doctors with unique clinical
experiences and competences that will be beneficial for their
career path as practitioners and leaders in health systems.
Since the start of medical school, medical interns and junior doctors look forward to their
first day of advanced clinical training with a mix of excitement and anxiety. Continued
support and mentorship are essential throughout these early career stages to reach
academic milestones. For those medical interns and junior doctors who are entering the
workforce during the COVID-19 pandemic, further academic support from senior leadership
are needed to offer the appropriate workplace conditions and training opportunities.
The flaws in our health system have been exposed.
Prior to the pandemic, there was evidence that the Swedish health system had major flaws
in governance and function (2). For example, the waiting time for recent medical graduates
to enter the mandatory two-year internship was approximately one year, and the lack of
transparency in the recruitment process raised questions about the selection process for
these coveted internship placements (3). As a scarcity of nurses has led hospital wards and
operating theatres to close, an ever-growing backlog of patients requiring surgical
interventions has become apparent.
For years, many physicians have expressed their burnout symptoms, linking significant
stress to managing extensive administrative paperwork and completing clinical
responsibilities. Additionally, increasing privatization of healthcare and undermining of our
universal health coverage system has caused further tensions in the fragile system. Since
our health system has continued to face significant challenges, this pandemic may offer
innovative solutions where health authorities can transform the health system at local and
national levels.
The Swedish system of medical education is about to be restructured in one of the largest
health transformations to be seen in decades (4). This process – prolonging the medical
program for one additional semester and resulting in a six-year academic program – has
been widely debated. The pandemic has delayed the implementation of these changes,
causing differing sentiments of relief and anxiety, among new medical graduates and final-
year medical students.
Junior Doctors Network Newsletter
Issue 19
July 2020
JUNIOR DOCTORS’ PERSPECTIVES: EUROPE Page 63
“Junior doctors are used to being quiet in order not to risk their
chances of getting an internship or a residency spot, but we have to
speak up if we feel uncertain”
Madeleine Liljegren, chair of the Swedish Junior Doctor’s Association
The lack of disaster preparedness was mentioned as another flaw in the Swedish health
system during the panel discussion. This has been observed during the surge in patients
receiving care at emergency rooms, primary care settings (e.g. elderly homes, rehabilitation
units), and intensive care units. In primary health care settings, already strained health care
workers have faced new challenges with supporting the delivery of acute health care
services for COVID-19 patients and will now be charged the enormous task of managing
long-term follow-up and rehabilitation services.
Medical students and junior doctors are privileged, and many are not.
Living in a privileged country like Sweden, we realize that the pandemic has left devastating
effects on society at large, with vulnerable groups in Sweden and around the world hit the
hardest. As medical students and junior doctors, we have been able to transit to virtual
education and continue our internships, albeit with significant modifications. In most health
facilities in Sweden, protective personal equipment is readily available. However, this is not
the case for colleagues across the global landscape.
Over the past few months, medical students and junior doctors have observed significant
changes to their professional and personal lives, and many have expressed physical
illness, psychosocial stressors, and burnout during their clinical rotations. We send our
thoughts to our colleagues around the world and hope that this response phase will be
followed by recovery efforts to rebuild the health system and strengthen medical education.
As we endure the pandemic and health systems under strain, we must remember to take a
moment to reflect, listen with empathy to one another, and offer our support.
References
1) Miller DG, Pierson L, Doernberg S. The role of medical students during the COVID-19 pandemic.
Ann Intern Med. 2020.
2) Swedish Medical Association. [Junior doctors protest against a diseased system]. 2019 [cited 2020
Jun 23]. Swedish.
3) Swedish Junior Doctors’ Association. [Report of waiting times 2019]. 2019 [cited 2020 Jun 23].
Swedish.
4) Swedish Board of Health and Welfare. [Proposal of new rules for physicians’ residency and
internship programs]. 2020 [cited 2020 Jun 23]. Swedish.
Junior Doctors Network Newsletter
Issue 19
July 2020
JUNIOR DOCTORS’ PERSPECTIVES: EUROPE Page 64
We can learn from this unprecedented global crisis and
prepare our health systems for all emerging health challenges.
For example, gender-related research studies on tuberculosis management have shown
that men and women report symptoms, seek health care services, experience barriers, and
interact with health professionals in distinct manners (1). In general, differences have been
observed as women have lower rates of reporting symptoms or visits to health centers,
report preferences for alternative care (e.g. traditional healers), and express general shame
or fear of stigma. These factors may be attributed to the limited number of health
professionals focusing on women’s health, This article aims to describe the gender
differences observed during the coronavirus disease 2019 (COVID-19) pandemic.
Globally, females represent a significant percentage of the health workforce, contributing to
efforts to strengthen clinical services and community health initiatives. For example, 54% of
health care workers are women in Wuhan, China (2), and 52% of registered doctors and
84.2% of nursing staff are women in Spain (3).
Some impacts may include neglected basic services for sexual and reproductive health
concerns. During the Zika virus outbreak, different gender norms influenced women’s
sexual and reproductive life, especially when seeking regular prenatal care. During the
Ebola virus outbreak, women experienced increased stress by serving as caregivers to
their families and working as frontline health care workers in health centers (2).
.
Junior Doctors Network Newsletter
Issue 19
July 2020
Gender Gaps and the COVID-19 Pandemic
Jeazul Ponce Hernández, MD MSc
Predoctoral Fellow
Complutense University of Madrid
Madrid, Spain
JUNIOR DOCTORS’ PERSPECTIVES: EUROPE Page 65
Gender is a social determinant of health that may influence
health-seeking behaviors and access to health care services.
Gender inequalities can be exacerbated during extreme situations
of societal stress, such as widespread disease outbreaks.
These discrepancies can be affected when supply chains are altered, as a result of the
pandemic response efforts (4). For example, during the COVID-19 lockdown restrictions,
society observed shortages of personal hygiene products (e.g. toilet paper, hand sanitizer,
soap) and sharp cost increases of family sanitary products (e.g. tampons). Also, many
young girls and women around the world had limited access to basic information and
services related to menstrual hygiene and family planning methods.
This domestic role may hinder their ability to seek employment and economic
independence outside the home. Notably, as women spend more time at home with their
families, gender violence or aggressions may become a significant threat to women’s
health. The incidence of gender violence is unknown, since acts of violence may not be re-
ported due to expressed distrust of police authorities and lack of awareness related to
proper legal reporting of incidents (5,6).
Currently, gender differences have been noted regarding the availability and access to
treatment for COVID-19 cases. However, there are few quantitative studies that have
closely examined data by age and sex. There are also limited qualitative studies that
explore these sensitive topics with women to better understand the gender perspective.
Women have found themselves in the first-line of action against COVID-19, but their
visibility in the development of public health policies, sanitary measures, and prevention
has been scarce. However, studies have reported that women are less likely to make
decisions during the COVID-19 outbreak (4).
Junior Doctors Network Newsletter
Issue 19
July 2020
JUNIOR DOCTORS’ PERSPECTIVES: EUROPE Page 66
Due to the COVID-19 pandemic, economic consequences
directly impact women, especially since they tend to provide
most of the informal care within families.
Women should have a more active role in planning and
response efforts related to the public health surveillance,
security measures, and prevention and control practices.
As a medical community, doctors should listen closely during medical evaluations with their
female patients. They can attempt to recognize the influence of these gender perspectives,
identify disparities, and explore their perceptions on disease risk and access to medical
care. Through these actions, they can advocate for further epidemiologic studies to
examine gender differences related to the provision of health care services as well as
prepare anti-violence campaigns. Since certain social measures (e.g. stay-at-home
restrictions) can influence gender violence, doctors can identify at-risk female patients and
provide essential health information and resources to seek additional medical or community
support.
References
1) Yang WT, Gounder CR, Akande T, et al. Barriers and delays in tuberculosis diagnosis and treatment
services: does gender matter? Tuberc Res Treat. 2014:461935.
2) Wenham C, Smith J, Morgan R. COVID-19: the gendered impacts of the out-break. Lancet.
2020;395:846-848.
3) Instituto Nacional de Estadística (Spain). [Press Notes: Health professionals statistics]. 2019 [cited 2020
Jul 20]. Spanish.
4) United Nations Population Fund. COVID-19: a gender lens. Protecting sexual and reproductive health and
rights, and promoting gender equality. 2020 [cited 2020 Jul 20].
5) Godin M. As cities around the world go on lockdown, victims of domestic violence look for a way out. Time
Magazine. 2020 [cited 2020 Jul 20].
6) Women’s Aid UK. The impact of COVID-19 on women and children experiencing domestic abuse, and the
life-saving services that support them. 2020 [cited 2020 Jul 20].
Junior Doctors Network Newsletter
Issue 19
July 2020
JUNIOR DOCTORS’ PERSPECTIVES: EUROPE Page 67
In summary, doctors are community leaders who can
promote women empowerment and the gender
perspective in health care service delivery.
In 2015, Menachery et al. published an article that described ‘a SARS-like cluster of
circulating bat coronaviruses [that] shows potential for human emergence’ (1). Less than
four years later, hypotheticals transpired into reality as a deadly coronavirus respiratory
disease became a household name. After one cross-species transmission, the coronavirus
disease 2019 (COVID-19) infected patient zero, and three months later, the virus
disseminated worldwide. Countries entered a collective lockdown. Our home, Australia,
was no exception.
As of June 5, 2020, the Australian Government Department of Health reported 7,251
confirmed cases and 102 deaths secondary to COVID-19 (2). According to the United
Nations, Australia ranked 65th in the number of confirmed cases and 72nd in the death toll,
compared to other countries (3). These findings confirmed that Australia was successful in
reducing the number of new COVID-19 cases. Australia’s geographical isolation and sparse
population density have contributed to the relatively low infection rate. Moreover, this
positive outcome is largely due to compliance with national government initiatives, including
the promotion of physical distancing, increased health system capacity, and strict
quarantine of infected patients.
Early on, Queensland Health recognised the impending surge of potential COVID-19 cases
and took immediate action. In February 2020, the Metro North Executive Director of
Medical Services stated that clinical staff were posted at Brisbane International Airport to
screen incoming travellers and assist thousands of people into self-quarantine. Hospitals
opened dedicated Fever Assessment Centres to review potential positive COVID-19 cases
in a contained environment. On March 6, 2020, Queensland’s premier announced an
Junior Doctors Network Newsletter
Issue 19
July 2020
Courage vs COVID-19: Australia’s Junior Doctors
Leading by Example
JUNIOR DOCTORS’ PERSPECTIVES: WESTERN PACIFIC Page 68
Naga Annapureddy, MD
Resident Medical Officer
The Prince Charles Hospital
Brisbane, Australia
Simrun Mody, MD
Resident Medical Officer
Logan Hospital
Brisbane, Australia
Individual hospitals and health care workforces have, therefore,
played a significant role in this national response.
increase in the Fever Assessment Centre, Emergency Department, and Intensive Care
capacities across all hospitals, purchasing additional ventilators, and bringing forward
AUD$25,000,000 of medications and personal protective equipment (4). Meanwhile, Public
Health Units provided health professionals with regular advice regarding COVID-19 testing
criteria, contact tracing, and management. They also performed outreach work with
community stakeholders, including Residential Aged Care Facilities. All workers in health-
related fields have had to adapt to these organisational changes in a limited timeframe.
Given government-initiated social restrictions, they also have had to adjust their
communication with patients.
COVID-19 has presented many challenges to clinical management, including the ability to
interact face-to-face with patients. Hence, the Australian Government introduced alternative
models of care to support patients recovering from the disease. One such initiative was the
virtual ward model, which capitalized on Hospital in the Home and Post-Acute Care
services via telehealth measures (6). Interestingly, the development of these alternative
approaches to patient care has streamlined hospital processes, including outpatient follow-
up, and has the potential to become the new standard practice.
Medical Interns in Fever Assessment Centres swabbed hundreds of patients as suspected
COVID-19 cases. Junior House Officers donned their personal protective equipment for
upwards of 10 hours each day in the Red Zones of the Emergency Departments. Senior
House Officers entered the negative pressure rooms of makeshift infectious diseases
wards to provide ongoing medical assessment for confirmed COVID-19 cases. Certainly,
junior medical staff had access to senior advice; however, the limited knowledge
surrounding this respiratory disease meant that there were many unknown factors. Despite
this, medical residents had voluntarily forgone their preferred electives and scheduled leave
in order to aid understaffed hospitals. Outside the hospital walls, junior doctors
strengthened the delivery of public health information in the media by correcting incorrect
facts and dispelling myths. In one MJA InSight+ article, junior doctors highlighted the racial
prejudices that have become macroscopic under the critical lens of COVID-19, both in the
hospital and at home, and encouraged society to acquit rather than accuse (7).
Junior Doctors Network Newsletter
Issue 19
July 2020
JUNIOR DOCTORS’ PERSPECTIVES: WESTERN PACIFIC Page 69
Amidst these new changes, junior doctors – who are advancing
their knowledge and skills in their appointed medical specialty
− have thrived under the pressure of this pandemic.
The Australian Medical Association’s Council of Doctors in Training supported the rights of
junior doctors during the COVID-19 response. The council’s four advocacy priorities
included: scope of practice, well-being, occupational rights, and career progression (8).
Employers were advised to provide appropriate induction to doctors transitioning beyond
their typical clinical duties, ensure accessible personal protective equipment, promote
physical and mental well-being services, and respect leave entitlements. Additionally,
medical colleges were encouraged to communicate clearly with their candidates regarding
examination cancellations and review selection criteria in light of the pandemic. As a result,
junior doctors were able to provide world-class care to their patients without fear of
personal compromise.
This was a direct consequence of the remarkable effort of all frontline workers, including
cleaners, nurses, pharmacists, and junior doctors. This unique experience has provided
junior doctors with expertise far beyond anything obtainable from didactic education. It is
clear that they are more than capable of forming a substantial and proactive part of the
healthcare system. Australia is in safe, sanitized hands.
References:
1) Menachery V, Yount B, Debbink K, et al. A SARS-like cluster of circulating bat coronaviruses shows
potential for human emergence. Nat Med. 2015;21:1508-1513.
2) Australian Government Department of Health. Coronavirus (COVID-19) current situation and case
numbers. 2020 [cited 2020 Jun 5].
3) Worldometer. Countries where COVID-19 has spread. 2020 [cited 2020 Jun 5].
4) Queensland Government. Media statements: Queensland boosts coronavirus measures. 2020 [cited
2020 Jun 5].
5) Australian Government Department of Health. Coronavirus (COVID-19) resources for health
professionals, including aged care providers, pathology providers and health care managers. 2020
[cited 2020 Jun 5].
6) Timms P, Clark D. Coronavirus is making our health sector and hospitals adapt to a virtual future.
Australian Broadcasting Corporation. 2020 [cited 2020 Jun 5].
7) Annapureddy N, Abeysekera N, Shao E. COVID-19: doctors on the frontline of a xenophobic
pandemic. Medical Journal of Australia InSight+. 2020. [cited 2020 Jun 5].
8) Australian Medical Association. AMA advocacy to support doctors in training during the COVID-19
response. 2020 [cited 2020 Jun 16].
Junior Doctors Network Newsletter
Issue 19
July 2020
JUNIOR DOCTORS’ PERSPECTIVES: WESTERN PACIFIC Page 70
The Australian Government Department of Health’s prompt
response to the pandemic resulted in low COVID-19 incidence
and case-fatality rates.
Primary Health Care (PHC) plays a crucial role in health emergencies like the coronavirus
disease 2019 (COVID-19) pandemic. Notably, this pandemic has highlighted gaps where
PHC can be strengthened and hence integrated across global health systems. In this
article, perspectives are provided by junior doctors from different countries – Myanmar, the
Netherlands, Germany, India, Brazil, and Nigeria – to illustrate the exemplarily role of PHC
during the COVID-19 pandemic as well as describe perceived challenges and opportunities
in health service delivery.
Junior Doctors Network Newsletter
Issue 19
July 2020
Challenges and Opportunities in Providing Primary Health Care
during the COVID-19 Pandemic in Six Countries
JUNIOR DOCTORS’ PERSPECTIVES: MULTIPLE REGIONS Page 71
Wunna Tun, MBBS MSc MD
Fellow in Medical Education
Founder, Myanmar Medical Association, Young
Doctor Society
Yangon, Myanmar
Laura Kalkman, MD
Geriatric and Internal Medicine Resident
Leeuwarden, The Netherlands
Flora Keuhne, MD
General Practice and Family Medicine Resident
Munich, Germany
Shiv Joshi, MD
Community Medicine Resident
Mahatma Gandhi Institute of Medical Sciences
Sevagram, India
Andrey Oliveira da Cruz, MD
Family Medicine Resident
State Secretariat of Health of Santa Catarina,
Florianópolis, Brazil
Chioma Amugo, MBChB
Medical Director, Queens Clinic and Maternity
MPH student, University of South Wales
Abuja, Nigeria
Myanmar
In Myanmar, fever clinics serve a frontline role, where clinicians provide COVID-19
diagnostic tests to febrile patients, and if necessary, refer them to the nearest public
hospital for further testing. These fever clinics, which are directed by primary care doctors,
relieve pressure on the under-staffed and under-resourced hospitals and health care
system, which would otherwise be unable to manage even a modest disease outbreak. As
a collaborative effort between primary care doctors and the Myanmar Medical Association,
doctors aim to raise general awareness and take action to reduce transmission of
nosocomial infections among primary care doctors and patients in hospitals. For this
reason, doctors in fever clinics are well equipped with personal protective equipment (PPE)
– both levels 2 and 3 – for screening of suspected respiratory pathogens of diverse
etiologies and for appropriate hospital referrals throughout the country (1).
The Netherlands
In the Netherlands, around half of the deaths attributable to COVID-19 occurred outside
hospitals, mainly in nursing homes (2). Excess mortality among the Dutch elderly, however,
is not solely attributed to the frailty of this vulnerable population. Since health authorities
have focused attention on upscaling capacities of in-patient and intensive care unit
services, health care workers employed in primary care and nursing homes have
experienced PPE shortages and lack of access to COVID-19 diagnostic testing. In their
clinical practice, health care workers faced an increased risk of occupational exposure to
severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and subsequent
transmission to other patients. Hence, many doctors and nurses in primary care and
nursing homes felt abandoned and forced to make impossible ethical choices without
proper guidance (3,4).
Germany
In Germany, the COVID-19 pandemic allowed us to recognize the importance of digital
health and challenges related to its national implementation. When compared to other
European countries, Germany has a conservative approach to digital health, where there
are no implemented electronic health records or routinely administered video consultations.
However, health care providers have been directed by law to connect to the virtual
telemedicine infrastructure until 2021, as a first step to nationwide digital health services.
Junior Doctors Network Newsletter
Issue 19
July 2020
JUNIOR DOCTORS’ PERSPECTIVES: MULTIPLE REGIONS Page 72
This example illustrates how equipping primary care providers,
especially those working with vulnerable populations, should be
prioritized in order to reduce mortality during an epidemic.
To date, a total of 85% of patients infected with SARS-CoV-2 in Germany were managed
by ambulatory care, mainly by general practitioners (5). To prevent infection and
transmission, doctors and patients have minimized physical contact through essential
telemedicine and video consultations including simplified requirements for invoicing
services (5). Many doctors, however, still lack the necessary infrastructure, skills, and
routine to conduct comprehensive video consultations.
India
India has continued to experience a national lockdown since March 25, 2020. Outpatient
medical services have been limited or suspended, and small hospitals and clinics were
expected to only provide emergency care by diligently maintaining proper hygiene,
sanitation, and PPE, albeit limited supplies. Private hospitals across India recorded a sharp
70%-80% drop in patient visits. This situation has caused significant financial stress among
general practitioners who are challenged to compensate their staff. Notably, government
hospitals are currently able to manage this situation, since the number of COVID-19 cases
has not exceeded their ability to provide health care services to patients. However, if this
threshold is breached, and there is a significant increase in the number of COVID-19
cases, government and private hospitals may collectively be unable to meet the patient
demand for COVID-19 diagnosis and management. In order to tackle this challenge, the
government should take adequate measures to strengthen health infrastructure, including
enhanced clinical training, appropriate compensation, increased protection, and private
sector involvement in providing COVID-related care.
Brazil
In Brazil, political issues have dominated the media, especially related to the national
management of the COVID-19 pandemic. Many national leaders have prioritized the need
to improve the economy and voiced disagreement with quarantine measures to control
COVID-19 spread.
Junior Doctors Network Newsletter
Issue 19
July 2020
JUNIOR DOCTORS’ PERSPECTIVES: MULTIPLE REGIONS Page 73
Despite these challenges, the COVID-19 pandemic has driven the
momentum to implement digital health as a remarkable
opportunity for Germany and PHC.
This pandemic has highlighted the need for strong PHC, which
provides essential health care services to the largest portion of the
population.
This effective PHC action was enabled by legislation, which identified the essential role of
PHC during the COVID-19 pandemic to strengthen health service delivery across federal,
states and municipalities (6). It was noted that PHC remains the gateway to the national
health system, offering clinicians the ability to directly monitor vulnerable families, provide
follow-up care for suspected and mild COVID-19 cases, continue chronic disease
management, and examine other related issues (e.g. mental health disorders, domestic
violence, alcoholism) that may arise from prolonged social distancing (7). To combat this
pandemic at the community level, PHC leaders must identify best practices for handling
suspected COVID-19 cases and managing care, ensuring options such as telehealth,
incorporating new care and service technologies, and strengthening links with local
communities through community health workers (7,8).
Nigeria
In Nigeria, although there are mixed perspectives on whether the COVID-19 pandemic has
crippled the economy or has exposed faults in the governance system, inadequacies in the
health sector were visibly exposed. Whether doctors are employed in the public or private
health sector or telemedicine system, discrepancies can be observed in medical care,
especially due to the lack of synergy between public and private health providers. Although
some private hospitals are designated as PHC centers, their efforts to refer patients to
tertiary-level health institutions are often overlooked due to inadequate infrastructure. As
hospitals are often ill-equipped to manage a surge in patient care, as observed during this
pandemic, they may not be able to access loans, finance these high interest rates, or fear
the inability to repay loans.
During this pandemic, the government has made no tangible effort to include private
hospitals in the national response. They have not been regarded as frontline institutions,
although many patients seek care at private hospitals and subsequently may be referred to
tertiary-level health institutions. In recent months, a health care sector loan of US$260
million (N100 billion) was approved, to provide credit support as part of the pro-active
measures to cushion the economic impact of the COVID-19 pandemic. It aims to improve
health care and ensure collaboration between primary, secondary, and tertiary health care
providers in Nigeria.
Junior Doctors Network Newsletter
Issue 19
July 2020
JUNIOR DOCTORS’ PERSPECTIVES: MULTIPLE REGIONS Page 74
Although it took a pandemic for the Nigerian government to
recognize the importance of the private health sector, it remains a
step in the right direction to prioritize population health.
The insights of health care workers involved in PHC across countries reflect how the
COVID-19 pandemic has posed diverse challenges in delivering quality health care for
suspected COVID-19 cases, ensuring the continuum of care for patients living with chronic
disease, and adapting to limited PPE supplies in the workplace.
References:
1) Lynn KY. Fever clinics: the first line of defence against COVID-19. Frontier Myanmar. 2020 [cited 7
Jun 2020].
2) Visser M. [Do many deaths mean that a country has failed?] Trouw. 2020 [cited 2020 May 26].
Dutch.
3) Specialists in Elderly Care Society (The Netherlands). [Delivery strategy for personal protective
equipment]. 2020 [cited 2020 May 26]. Dutch.
4) Royal Society of Doctors (The Netherlands). [Delivering care without proper personal protective
equipment]. 2020 [cited 2020 May 26]. Dutch.
5) Kassenaerztliche Bundesvereinigung. [85 percent of corona-patients get treatment in outpatient
care −− PPE still scarce]. 2020 [cited 2020 May 27]. German.
6) Brazilian Federal Supreme Court. [Precautionary measure in the Direct Action of Unconstitutionality
nº 6341 Federal District]. 2020. Portuguese.
7) Sarti TD, Lazarini WS, Fontenelle LF, Almeida APSC. What is the role of primary health care in the
COVID-19 pandemic? Epidemiol Serv Saude, Brasília. 2020;29:e2020166.
8) Brazilian Association of Family and Community Medicine. [Recommendations for the PHC during
the COVID-19 pandemic]. 2020 [cited 2020 Jun 10]. Portuguese.
Junior Doctors Network Newsletter
Issue 19
July 2020
JUNIOR DOCTORS’ PERSPECTIVES: MULTIPLE REGIONS Page 75
However, this public health crisis has enhanced international
recognition of the importance of the health sector and encouraged
the adoption of innovative technologies like digital health, in
efforts to strengthen PHC systems.
For the first time, the seventy-third World Health Assembly (WHA) was held in a virtual
format, due to the disruptions from the coronavirus disease 2019 (COVID-19). For these
same reasons, the Junior Doctors Network (JDN) held its traditional post-WHA workshop in
a similar virtual platform. This format change allowed for greater and more diverse
participation from over 40 JDN members around the world, while the technology provided
an opportunity for meaningful engagement.
The post-WHA workshop consisted of four one-hour sessions held over a period of two
days, in order to accommodate a maximum number of time zones for active participation by
JDN members. The event focused on COVID-19 response and recovery efforts and aimed
to engage JDN members in a wider discussion.
Junior Doctors Network Newsletter
Issue 19
July 2020
Junior Doctors Network Leadership at the Post-World Health
Assembly 2020
JUNIOR DOCTORS’ PERSPECTIVES: MULTIPLE REGIONS Page 76
Mike Kalmus Eliasz, MBBS DTM&H AKC
NIHR Academic Clinical Fellow in Global Child
Health
University of Liverpool
Liverpool, United Kingdom
Caline Mattar, MD
Past Chair, WMA-JDN
Assistant Professor of Medicine
Division of Infectious Diseases
Washington University in St. Louis
St. Louis, Missouri
Yassen Tcholakov, MD MScPH MIH
Interim Chair (2019-2020)
Junior Doctors Network
World Medical Association
The agenda focused on highlighting key discussions held at
the virtual WHA about national and international challenges
faced by delegates.
The JDN post-WHA sessions and speakers provided insight on a variety of global health
topics related to the COVID-19 pandemic.
We wish to thank all JDN members for their active participation in the post-WHA (Photos
1-2). We would like to extend an invitation to all JDN members to view the recorded
presentations on the WMA YouTube account and presentation slides.
Junior Doctors Network Newsletter
Issue 19
July 2020
JUNIOR DOCTORS’ PERSPECTIVES: MULTIPLE REGIONS Page 77
Saturday, May 23, 2020
(1400−1630 CEST)
Q&A with the World Medical Association (WMA)
Leadership on the WMA’s response to COVID-19 and
Engagement with the World Health Organization
(WHO)
o Dr Miguel Jorge (WMA President)
o Prof Dr Frank Ulrich Montgomery (Chairperson of
Council)
o Dr Otmar Kloiber (WMA Secretary General)
Moderated by Dr Yassen Tcholakov (JDN Deputy
Chairperson)
The Global Response to the COVID-19 Pandemic and
the Role of WHO
o Dr Paula Reges (Coordinator for the Solidarity Trial in
Brazil, Fiocruz − Rio de Janeiro)
o Dr Gina Samaan (COVID-19 Country Technical
Support Lead at WHO Headquarters)
Moderated by Dr Caline Mattar (Past JDN Chairperson)
Sunday, May 24, 2020
(1400−1630 CEST)
The Digital Health Transformation and How
the Pandemic will Shape it?
o Dr Priit Tohver (Ministry of Health, Estonia)
o Dr Lisa Murphy (Independent Digital Health
Consultant, former Digital Health Advisor to
Public Health England)
Moderated by Dr Mike Kalmus Eliasz (Past JDN
Socio-Medical Affairs Officer)
Critical Policy Analysis Skills for Global
Health (Interactive Workshop)
o Dr Mike Kalmus Eliasz (JDN Member and
Global Child Health Fellow at University of
Liverpool)
o Dr Yassen Tcholakov (Deputy Chairperson of
JDN and Public Health Resident at McGill
University)
Photo 1. Part of the JDN Delegation
attending the 73rd WHA virtually.
Credit: Dr Yassen Tcholakov.
Photo 2. JDN 2020 Post-WHA Session with WMA
Leadership. Credit: Dr Yassen Tcholakov.