Academic literature on the topic 'New Plymouth (N.Z.) City Council'

Problem setting. The problem lies in the development of a complex multifaceted interdisciplinary movement for the identification and acquisition of competencies by researchers in the innovation process. Analysis of recent researches and publications. Hamid Tohidi et al. considered various stages of the innovation process, highlighting the peculiarities of the methods. Sanabria-Z, J. et al. identified the personalities of the combination of open science and open innovation. Akimov N. et al. conducted a review of the components of education 4.0 within the framework of open innovation competences. S. V. Vojtko revealed the evolution of management theories in the context of Industry 4.0. Bhakta, D. and Boren, E. Determined the training needs of researchers at the beginning of their careers in science-intensive universities. Purpose of the research is to determinate of European requirements for the formation of the researcher’s competence framework and practical recommendations for determining their role in the innovation process. Article’s main body. The European researcher framework provides for four groups of competences. The framework describes four broad profiles with the following work. Descriptors apply to all researchers. The Research Comp European Competence Framework for Researchers is a tool for assessing and developing the skills of researchers and promoting career development. The European Council took a fundamental step to strengthen the European Research Area, adopting on 18 December 2023 the Council Recommendation on the framework for scientific careers, including a new Charter for researchers. To increase the role and importance of research activities, the European Association for the Development of Science and Technology EuroScience, in cooperation with the EC, declared Katowice the European City of Science 2024 (ECSK 2024). The European Competence Framework for Researchers includes several components: research management, influence, self-management, cognitive abilities, collaboration with others, management of research tools, conducting research. The new approach to researcher development is based on the Researcher Development Framework (RDF). An example of the role of the selected subdomain of domain B (RDF) in relation to personal effectiveness in the innovation process is given. The lists of research competences presented in the domains affect the success of ideas and strengthen the role of innovation. Conclusions and prospects for the development. The conducted studies of the European requirements for the formation of research competences showed their influence on the formation of the innovation process. A broad list of the structure of subdomains through the descriptors (63) of the European framework of researcher competences defines the description of research components from different angles in order to take into account the overall productivity of innovators. The modern strengthening of the European Research Area has a positive effect on the acceleration of the innovation process. The new European Charter for researchers promotes better working conditions, inclusiveness, new skills, enabling seamless mobility between sectors and more opportunities for innovation at all stages of their career.

Khanna A, Goyal RS, Bhawsar R. Menstrual practices and reproductive problems Study of adolescent girls in Rajasthan. J Health Manag. 2005;7(1):91–107. Ersoy B, et al. Effects of different socioeconomic conditions on Menarche in Female Turkish Students. Early Hum Dev. 2004;76(2):115–25. Dongre AR, Deshmukh PR, Garg BS. The effect of community-based health education interventions on menstrual hygiene management among rural Indian adolescent girls. World Health Popul. 2007;9(3):48–54. Tang CS, Yeung DY, Lee AM. Psychosocial correlates of emotional Responses to menarche among Chinese adolescent girls. J Adolescent Health. 2003;33(3):193–201. Adhikari P, et al. Knowledge and practice regarding menstrual hygiene in rural adolescent girls in Nepal. Kathmandu Univ Med J (KUMJ). 2007;5(3):382–6 Ali TS, Rizvi SN. Menstrual knowledge and practices of female adolescents in urban Karachi, Pakistan. J Adolescent. 2010;33(4):531–41. Bobhate P, Shrivastava S et al.. This was a cross-sectional study of knowledge and practices regarding reproductive health among female adolescents in an urbsluminf Mumbai. J Fam Reprod Health. 2011;5(4):117–24. Dasgupta A, Sarkar M. Menstrual hygiene: how hygienic is the adolescent girl? Indian J Community Med. 2008;33(2):77–80. Goel MK, Kundan M. Psycho-social behavior of urban Indian adolescent girls during menstruation. Australas Med J. 2011;4(1):49–52. Shanbhag D, Shilpa R, D’Souza N, Josephine P, Singh J, Goud BR. Perceptions regarding menstruation and Practices during menstrual cycles among high school going adolescent girls in resource-limited settings around Bangalore City, Karnataka, India. Int J Collab Res Inter Med Public Health. 2012;4(7):1353–62. Tiwari H, Oza UN, Tiwari R. Knowledge, attitudes and beliefs about Menarche of adolescent girls in Anand District, Gujarat. East Mediterr Health J. 2006;12(3-4):428–33. Thakre SB, Thakre SS, Reddy M, Rathi N, Pathak K, Ughade S. Menstrual hygiene: knowledge and practice among adolescent school girls of Saoner, Nagpur district. J Clin Diagn Res. 2011;5(5):1027–33. Yasmin S, Mallik S, Manna N, Ahmed A, Paria B. Menstrual hygiene among adolescent school students: an in-depth cross-sectional study in an urban community of West Bengal, India. Sudan J Public Health. 2013;8(2):60–4. Oche MO, Umar AS, Gana GJ et al.. Menstrual health: Unmet needs of adolescent girls in Sokoto, Nigeria. Sci Res Essays. 2012;7(3):410–8. Ray S, Dasgupta A. Determinants of menstrual hygiene among adolescent girls: a multivariate analysis. Natl J Commun Med. 2012;3(2):294–301. Boosey R, Prestwich G, Dave T. Menstrual hygiene management amongst Schoolgirls in the Rukungiri district of Uganda and their impact on their education: A cross-sectional study. Pan African Med J. 2014;19:253. Nemade D, Anjenaya S, Gujar R. Effect of health education on statistics and practices about menstruation among adolescent faculty girls of Kalamboli, Navi-Mumbai. fitness of Popul-Perspect issues. 2009;32(4):167–75 Narayan okay, Srinivasa D, Pelto P, Veerammal S. Puberty Rituals, Reproductive Understanding, and Health of Adolescent Girls in South India. Asia-percent Popul J. 2001;16(2):225–38. ARORA A, Mittal A, Pathania D, Mehta C, Bunger R. Impact of health education on understanding and practices about menstruation among adolescent college women in the rural part of the district Ambala, Haryana. Ind J Comm health. 2013;25(4):492–7. Lawan UM, Yusuf NW, Musa AB. Menstruation and menstrual hygiene among adolescent college women in Kano, Northwestern Nigeria. Afr J Reprod fitness. 2010;14(3):201–7. Zegeye DT, Megabiaw B, Mulu A. Age at menarche and the menstrual pattern in younger secondary college humans in Northwest Ethiopia. BMC Women’s Fitness. 2009;nine:29. Thakre SB, et al. Town-rural versions of menstrual troubles and practices of Female college students in Nagpur, India. Indian Pediatr. 2012;49(9):733–6. Udgiri R, Angadi MM, Patil S et al.. Expertise and practices concerning menstruation among adolescent women in a town slum in Bijapur. J Indian Med Assoc. 2010;108(8):514–6. Marvan ML, Molina-Abolnik M. Mexican youngsters’ revel in of menarche and attitudes toward menstruation: function of communique among moms and daughters. J Pediatr Adolesc Gynaecol. 2012;25(6):358–63. Sharma M, Gupta S. Menstrual sample and abnormalities in the immoderate college girls of Dharan: A cross-sectional test of the boarding faculty of Nepal Med Coll J.2003;5(1):34–6. Adinma ED, Adinma JI. Menstrual traits among south-eastern Nigerian adolescent faculty women West Afr J Med. 2009;28(2):110–3. Reis N, Kilic D, Engin R, Karabulutlu O. Sexual and reproductive health desires of adolescent girls from conservative and low-income households in Erzurum, Turkey. fitness of Popul Perspect trouble. 2011;3(6):370–7. Bosch AM, Hutter I, van Ginneken JK. Perceptions of teens and their months for reproductive and sexual development in MATLAB, Bangladesh. Int J Adolesc Med health. 2008;20(three):329–42 Dhingra R, Kumar A, Kour M. Understanding and Practices Associated with Menstruation Among Tribal (Gujjar) Adolescent Women. Ethno-remedy. 2009;3(1): 43–8 El-Gilany AH. Badawi. El-Fedawy S. Menstrual hygiene among adolescent schoolgirls in Mansoura, Egypt. Am. Reprod health subjects. 2005;13(26):147–52. Gumanga SK, Kwame-Aryee RA. Menstrual trends in a few adolescents women in Accra, Ghana. Ghana Med J. 2012;46(1):3–7. Dambhare DG, Wagh SV, Dudhe JY. Age at menarche and menstrual cycle the patterns among adolescent women in India. Glob J Health Sci. 2012;4(1): a hundred and 5–11. Kotecha PV, et al. Reproductive fitness focuses on rural college-going young people in the Vadodara district. Indian J sex Transm Dis. 2009;30(2): 94–9. Mudey A, Kesharwani N, Mudey GA et al.. Pass-sectional observed attention concerning secure and hygienic practices among faculty-going adolescent girls in a rural area of Wardha District, India. Glob J Health Sci. 2010;2(2):225–31 Ray S, et al. Knowledge and information on psychological, physiological, and gynecological problems among adolescent girls in eastern India. Ethiopia J Health Sci. 2011;21(3):183–9. Jarrah SS, Kamel AA. Attitudes and practices of school-aged girls towards menstruation. Int J Nurs Pract. 2012;18(3):308–15. Lee LK, et al. Menstruation among adolescent girls in Malaysia: A cross-sectional school survey. Singapore Med J. 2006;47(10):869–74. Wong LP. Attitudes toward menstruation, menstrual-related symptoms, and pre-menstrual syndrome among adolescent girls: A rural school-based survey. Women's Health. 2011;51(4):340–64. Wong LP. Premenstrual syndrome and dysmenorrhea: urban-rural and multipath differences in perception, impact, and treatment-seeking. J Pediatr Adolesc Gynaecol. 2011;24(5):272–7. Aniebue UU, Aniebue PN, Nwankwo TO. Impact of pre-menarcheal training on menstrual practices and hygiene in Nigerian schoolgirls. Pan Afr Med J. 2009;2:9. Iliyasu Z, et al. Sexual and reproductive health communication between mothers and adolescent daughters in Northern Nigeria. Health Care Women Int. 2012;33(2):138–52. Ajah LO, et al. Adolescent reproductive health challenges among schoolgirls in southeast Nigeria: Knowledge of menstrual patterns and contraceptive adherence. Patient Preference Adherence. 2015;9:1219–24. Chandraratne NK, Gunawardena NS. Premenstrual syndrome: The experience of a sample of Sri Lankan adolescents. J Pediatr Adolesc Gynecol. 2011;24(5):304–10. Abd El-Hameed NA, Mohamed MS, Ahmed NH, Ahmed ER. Assessment of dysmenorrhea and menstrual hygiene practices among adolescent girls in some nursing schools in LL-Minia governorate, Egypt. J Am Sci. 2011;7(9):216–23. Eswi A, Helal H, Elarousy W. Menstrual attitudes and knowledge of Egyptian female adolescents. J Am Sci. 2012;8(6):555–65. Omidvar S, Begum K. Factors influencing hygienic practices during menses among girls from South India: A cross-sectional study. Int J Collab Res Intern Med Public Health. 2010;2(12):411–23. Wong LP. Attitudes towards dysmenorrhea, impact, and treatment-seeking among adolescent girls: A rural school-based survey. Aust J Rural Health. 2011;19(4):218–23. Wong LP, Khoo EM. Menstrual-related attitudes and symptoms among Multiracial Asian adolescent females. Int J Behav Med. 2011;18(3):246–53. Sommer M. Ideologies of sexuality, menstruation, and risk: girls’ experiences of puberty and schooling in northern Tanzania. Cult Health Sex. 2009;11(4):383–98. Crichton J, et al. Emotional and psychosocial aspects of menstrual poverty in resource-poor settings: A qualitative study of the experiences of adolescent girls in an informal settlement in Nairobi. Health Care Women Int. 2013;34(10):891–916. Mason L, et al. ‘We keep it secret so no one should know’–a qualitative study to explore young schoolgirls’ attitudes and experiences with menstruation in rural western Kenya. PLoS One. 2013;8(11):e79132. Munthali AC, Zulu EM. The timing and position of initiation rites in preparing younger human beings for formative years and accountable reproductive behavior in Malawi. Afr J Reprod fitness. 2007;11(three): hundred and 50–67. fifty-three. McMahon SA, et al. ‘The girl together with her duration is the one to hang her head’ Reflections on menstrual management amongst schoolgirls in rural Kenya. BMC Int fitness haul rights. 2011;eleven:7. Sommer M. An early window of possibility for promoting girls’ health: Policy implications of the woman’s puberty e-book task in Tanzania. Int. Electron J Health Microbiol. 2011; 14:77–92 Dorgbetor G. Mainstreaming MHM in colleges through the play-primarily based approach: training discovered in Ghana. Waterlines. 2015;34(1): 41–50.56. Marvan ML, Vacio A, Espinosa-Hernandez G. Menstrual-associated changes expected with the aid of premenarcheal girls dwelling in rural and urban areas of Mexico. Soc Sci Med. 2003;56(4):863–8. Marvan ML, Vacio A, Espinosa-Hernandez G. A contrast of menstrual adjustments anticipated through pre-menarcheal kids and changes skilled with the aid of publish-menarcheal children in Mexico. J Sch health. 2001;71(9):458–61 Pitangui AC, et al. Menstruation disturbances: incidence, characteristics, and effects on the daily activities of adolescent girls residing in Brazil. J Pediatr Adolesc Gynecol. 2013;26(three):148–52 Santina T, Wehbe N, Ziade F. Exploring dysmenorrhea and menstrual reviews among Lebanese lady young people. East Mediterr Health J. 2012;18(8):857–63. Chaudhuri A, Singh A. How do school women cope with dysmenorrhea? J Indian Med Assoc. 2012; 10(5):287–91. Sommer M. Where the training machine and Girls’ bodies collide: The Social and fitness impact of ladies’ stories of menstruation and training in Tanzania. J Adolesc. 2010;33(4):521–9. Patil MS, Angadi MM. Menstrual patterns among adolescent girls in the rural regions of Bijapur. Al Ameen J Med Sci. 2013;6(1):17–20. Rana B, Prajapati A, Sonaliya KN, Shah V, Patel M, Solanki A. Assessment of menstrual hygiene practices among adolescent females in the Kheda district of Gujarat Kingdom, India. Healthline J. 2015;6(1):23–9. Sharma P, et al. Troubles associated with menstruation among adolescent girls. Indian J Pediatr. 2008; seventy-five (2): one hundred twenty-five–9, 65. Juyal R, Kandpal SD, Semwal J. Social elements of menstruation-associated practices in adolescent women in the district Dehradun. Indian J Network Fitness. 2013;25(three):213–6. Haque SE, et al. The impact of a school-based instructional intervention on menstrual health: An intervention examine among adolescent women in Bangladesh. BMJ Open. 2014;4(7):e004607. Bodat S, Ghate MM, Majumdar JR. School absenteeism during menstruation among rural adolescent girls in Pune. Natl J Community Med. 2013; four(2):212–6. Joshi D, Buit G, González-Botero D. Menstrual hygiene control: training and empowerment for women? Waterlines. 2015;34(1): 51–67. Sir Bernard Law et al. Sanitary pad interventions for girls’ schooling in Ghana: A pilot study. PLoS One. 2012;7(10):e48274 Oster E, Thornton R. Menstruation, sanitary products, and school attendance: Evidence from a randomized evaluation. Am Econ J. 2011;3(1):91–100. Mason L, Laserson K, Oruko K et al. Adolescent schoolgirls’ experiences of Menstrual cups and pads in rural western Kenya: A qualitative study. Waterlines. 2015;34(1):15–30. Kabir H, et al. Treatment-seeking for selected reproductive health problems: Behaviors of unmarried female adolescents in two low-performing areas of Bangladesh. Reprod Health. 2014;11:54. Nair MK, et al. Menstrual disorders and menstrual hygiene practices of girls in higher secondary schools. Indian J Pediatr. 2012;79 Suppl 1:S74–8. Baidya S, Debnath M, Das R. Reproductive health problems among rural adolescent girls of the Mohanpur Block of the West Tripura District. Al Ameen J Med Sci. 2014;7(1):78–82. Wong LP, Khoo EM. Dysmenorrhea in a multiethnic population of adolescent Asian girls. Int J Gynaecol Obstet. 2010;108(2):139–42. Poureslami M. Assessing knowledge, attitudes, and behavior of adolescent girls in suburban districts of Tehran about dysmenorrhea and menstrual hygiene. J Int Womens Stud. 2002;3(2):51–61. Eryilmaz G, Ozdemir F. Evaluation of menstrual pain management approaches by Northeastern Anatolian adolescents. Pain Manag Nurs. 2009;10(1):40–7. Wasnik VR, Dhumale D, Jawarkar AK. A study of the menstrual pattern and problems among rural school-going adolescent girls in the Amravati district of Maharashtra, India. Int J Res Med Sci. 2015;33(55):1252–6. Fakhri M, et al. Promoting menstrual health among Persian adolescent girls from a low socioeconomic background: A quasi-experimental study. BMC Public Health. 2012;12:193. Allah ESA, Elsabagh EEM. Impact of a Health education intervention on Knowledge and Practice about Menstruation among female secondary school students in Zagazig City. J Am Sci. 2011;7(9):737–47. Sumpter C, Torondel B. A systematic review of the health and social effects of menstrual hygiene management. PLoS One. 2013;8(4):e62004. Nanda PMA, Mukherjee S, Barua A Mehl GL, Venkatraman CM. A study To evaluate the effectiveness of WHO tools: an orientation program on adolescent health for healthcare providers and adolescent job aid in India. Geneva: International Center for Research on Women, 2012. Vandenhoudt H, et al. Evaluation of a U.S. evidence-based parenting intervention in rural Western Kenya: From parents’ matters! To families matter! AIDS Educ Prev. 2010;22(4):328–43. Sommer M, Ackatia-Armah N, Connolly S, Smiles D. A comparison of menstruation and education experiences of girls in Tanzania, Ghana, Cambodia, and Ethiopia. Compare. 2014;45(4):589–609. Children, S.t. Adolescent Sexual and Reproductive Health. 2015. Available from: http://www.savethechildren.org/site/c.8rKLIXMGIpI4E/b.9080949/k.F576/ Adolescent_Sexual_and_Reproductive_Health.htm Health, I.f.R. Meeting the Needs of Adolescents: Introducing CCycle-Smart2013. Available from: http://irh.org/blog/meeting-the-needs-of-adolescents introducing-the cycle smart-kit/ Health, I.f.R. A3 project. Available from: http://irh.org/projects/a3_project/. Accessed 15 Oct 2014. Kettaneh APS, Todesco M. Good policy and practice booklet no. 9: puberty education and menstrual hygiene management. Paris: United Nations Educational, Scientific, and Cultural Organization, 2014. Always. Tips and advice: “The talk.” Available from: http://always.com/en-us/ tips-and-advice/the-talk. Accessed 15 Oct 2014. George R. Celebrating womanhood: How is better menstrual hygiene management the path to better health, dignity, and business? Geneva: Water Supply and Sanitation Collaboration Council, 2013. Sommer M. V. E., Worthington, N., Sahin M. WASH in schools empowers girl’s education: proceedings of the menstrual hygiene management in schools virtual conference 2012. in Menstrual Hygiene Management in Schools Virtual Conference. New York, NY: United Nations Children’s Fund and Columbia University; 2012. Kanotra SK, Bangal VB, Bhavthankar DP. Menstrual Patterns and Problems among adolescent girls in rural areas. International Journal of Biomedical and Advance Research. 2013; 4(8):551–

Neural tube defects (NTDs), such as spinal cord and brain defects, are due to abnormal embryonic development of the neural tube and associated with increased fetal and infant mortality, morbidity, lifelong disability, and high economic costs. Globally, more than 260,000 pregnancies are estimated to be affected by NTDs, and 75% of the NTD live births result in under-5 deaths.1 Majority of NTDs are folic acid-sensitive; with much of the NTD burden preventable through consumption of folic acid before and during early pregnancy (periconception). An association between low folate status of women of reproductive age (WRA) and risk of NTD-affected pregnancy was first proposed in 1965 by Hibbard et al.2 and was subsequently substantiated in several randomized controlled trials which demonstrated the effectiveness of folic acid supplementation during periconception in preventing the first occurrence of NTDs.3 These findings resulted in a recommendation in 1992 by the U.S. Public Health Service that WTA consume 400 μg of folic acid daily to prevent occurrence of an NTD-affected pregnancy.4 This recommendation together with other large-scale, global intervention studies demonstrated the efficacy of a daily periconceptional supplement of 400 μg in preventing a large percentage of NTDs.5 Folic acid is a synthetic, oxidized form of folate that acts as a coenzyme in the biosynthesis of DNA and RNA. With 4 mg folic acid daily, it may take 20 weeks to reach red-blood-cell folate levels between 1050 and 1340 nmol/L, which is optimal for reduction of the neural tube defect risk. Therefore, folic acid supplementation should be started 5–6 months before conception. The residual risk with optimal red-blood-cell folate levels is reportedly 4.5 per 10,000 total births whereas the residual risk in pooled data from countries with mandatory folic acid fortification is 7.5 per 10,000 pregnancies, regardless of pre-fortification rates.6 In one study, the optimal RBC folate level was achieved in 80.4% of women who started FA 400 μg 4–8 weeks before their last menstrual period (LMP) compared to only 53.6% in women who started 4–8 weeks after their LMP (P < 0.001). 7 A worldwide survey of folic acid supplementation in WRA showed inadequate compliance to folic acid intake.8 A systematic review and meta-analysis of pooled prevalence estimates of folic acid compliance showed 32–51% in North America, 9–78% in Europe, 21–46% in Asia, 4–34% in the Middle East, 32–39% in Australia/New Zealand, and 0% in Africa. Poor compliance was secondary to many factors. In the United States, the recommendation of 400 μg supplemental intake of folic acid daily has limitations as many pregnancies, including up to 50% of all pregnancies are unplanned.9 In many countries, particularly among low- and middle-income countries, many barriers exist for the access of WRA to folic acid supplements, such as procurement of the micronutrients in a relatively costly prepackaged form and ineffective distribution system. An evaluation of NTD trends in multiple countries indicated that, regardless of form, timing, or intended target, issuing recommendations on folic acid use alone, in the absence of fortification, had no detectable impact on NTD incidence. Thus, food fortification with folic acid has been a component of national public health strategies; in particular, where folate status is insufficient and a fortifiable food vehicle, processed by a centralized industry is consumed regularly by WRA.10,11 Other factors associated with poor compliance in folic acid intake include low income, smoking during pregnancy, alcohol consumption, multiple pregnancy, geographic location, and religious beliefs. On the other hand, preconception counselling, previous infertility therapy, multivitamin intake before pregnancy, older age planned pregnancy, previous infertility therapy, and multivitamin intake before pregnancy increased compliance.12-16 Women who also believed that they had good general and obstetric health (e.g., no history of illness or miscarriage) had attitudes of not being susceptible to the health consequences of not taking folic acid supplements and were the low users of folic acid supplement.17 In the Philippines, although WRA are advised to consume 320 ug dietary folate equivalent per day,18 about 0.9 % (around 1 in 5) are folate-deficient based on red cell folate count, while 38.7% (around 2 in 5) are folate-deficient based on serum folate.19 Congenital malformations including NTDs remain in the top ten leading causes of infant mortality from 1960 to 2005.20 In the index paper of Bernardo21 a cross-sectional, cluster sampling survey of 184 healthy, pregnant women, of age 15–49 years was conducted in the Batangas province from May to July 2017 to assess the level of knowledge, attitude, and perceived practice among the subjects on the importance of folate periconceptionally. A pretested interview questionnaire was used. The mean scores were 77% (moderate level) for knowledge, 82% for positive attitude, and 71% for positive perceived practice. The scores in the survey were related to patient’s age, civil status and to some extent, education. The study suggested that while respondents knew about folate (70%), they had low knowledge of the effect of its deficiency especially as it can lead to infant death. Knowledge had significant and positive moderate correlation with attitude (r = 0.7) and perceived practice (r = 0.5), but there was a weak positive correlation between attitude and perceived practice (r = 0.4). This likely indicates failure to emphasize the translation of knowledge and awareness properly and sufficiently into actual practice. As recommended by the author, education is the principal means to achieve the desired outcome. However, it is not clear in the study whether some amount of educational intervention besides determination of prevalence was included. As in any prevalence study, the golden opportunity to improve health outcomes is to accompany the survey with educational intervention, which in many instances, is required by the institutional board review. Some regression analysis of the data may also have been useful to determine which factors contributed most to the outcome measures. Enrique M. Ostrea, Jr., MD Wayne State University Hutzel Women’s Hospital Children’s Hospital of Michigan Detroit, Michigan, United States of America; National Institutes of Health University of the Philippines, Manila REFERENCES Blencowe H, Kancherla V, Moorthie S, Darlison D, Modell B. Estimates of global and regional prevalence of neural tube defects for 2015: a systematic analysis. Ann NY Acad Sci. 2018; 1414:31-46. Hibbard B, Hibbard E, Jeffcoate J. Folic acid and reproduction. Acta Obstet Gynecol Scand. 1965; 44:375-400. MRC Vitamin Study Research Group. Prevention of neural tube defects: Results of the Medical Research Council Vitamin Study. Lancet 1991; 338:131-7. Centers for Disease Control and Prevention. Recommendations for the use of folic acid to reduce the number of cases of spina bifida and other neural tube defects. MMWR Recomm Rep. 1992; 11:1-7. Berry R, Li Z, Erickson J, Li S, Moore C, Wang H, et al. Prevention of neural-tube defects with folic acid in China. N Engl J Med. 1999; 341:1485-890. Cawley S, McCartney D, Woodside J, Sweeney M, McDonnell R, Molloy A, et al. Optimization of folic acid supplementation in the prevention of neural tube defects. J Public Health (Oxf ). 2018; 40:827-34. van Gool J, Hirche H, Lax H, De Schaepdrijver L. Folic acid and primary prevention of neural tube defects: A review. Reprod Toxicol. 2018; 80:73-84. Crider K, Bailey L, Berry R. Folic acid food fortification: Its history, effect, concerns and future directions. Nutrients. 2011; 3:370-84. Finer L, Henshaw S. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod. Health. 2006;38: 90-6. Botto L, Lisi A, Robert-Gnansia E, Erickson Stein J, Vollset E, Mastroiacovo P, et al. International retrospective cohort study of neural tube defects in relation to folic acid recommendations: are the recommendations working? BMJ 2005; 330: 571. Garrett G, Bailey L. A public health approach for preventing neural tube defects: Folic acid fortification and beyond. Ann N Y Acad Sci. 2018; 1414:47-58. Forster D, Wills G, Denning A, Bolger M. The use of folic acid and other vitamins before and during pregnancy in a group of women in Melbourne, Australia. Midwifery. 2009; 25:134-46. Tamirat K, Kebede F, Gonete T, Tessema G, Tessema Z. Geographical variations and determinants of iron and folic acid supplementation during pregnancy in Ethiopia: Analysis of 2019 mini demographic and health survey. BMC Pregnancy Childbirth. 2022; 22:127. De Santis M, Quattrocchi T, Mappa I, Spagnuolo T, Licameli A, Chiaradia G, De Luca C. Folic acid use in planned pregnancy: an Italian survey. Matern Child Health J. 2013; 17:661-6. Felipe-Dimog E, Yu C, Ho C, Liang F. Factors influencing the compliance of pregnant women with iron and folic acid supplementation in the Philippines. 2017 Philippine Demographic and Health Survey Analysis. Nutrients. 2021; 13: 3060.1-9. Toivonen K, Lacroix E, Flynn M, Ronksley P, Oinonen K, Metcalfe A, et al. Folic acid supplementation during the preconception period: A systematic review and meta-analysis. Prev Med. 2018; 114:1-17. Fulford B, Macklon N, Boivin J. Mental models of pregnancy may explain low adherence to folic acid supplementation guidelines: a cross-sectional international survey. Eur J Obstet Gynecol Reprod Biol. 2014 May; 176:99-103. Philippine Dietary and Reference Intakes. Food and Nutrition Research Institute - Department of Science and Technology (FNRIDOST). 2015. DOST Complex, FNRI Bldg., Bicutan, Taguig City, Metro Manila Philippines. Available from: https://www.fnri.dost.gov.ph/images/images/news/PDRI-2018.pdf. Desnacido JA, Cheong RL, Madriaga JR, Perlas IA & Marcos JM. Folate status of Filipino women of childbearing age: Philippines 2008. [Internet]. [cited 2019 May]. Available from: http://122.53.86.125/Seminar%20Series/38th/folate%20status_filipino%20women.pdf. David-Padilla C, Cutiongco-dela Paz E, Cavan BC, Abarquez C, Sur ALD, Sale RI, et al. Establishment of the Philippine Birth Defects Surveillance. Acta Med Philipp. 2011; 45 (4). [Internet]. [cited 2019 May]. Available from: https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source. Bernardo A. Assessment of knowledge, attitude, and perceived practices on the importance of folate among Filipino women of child-bearing age in the province of Batangas. Acta Med Philipp. May 2021, doi:10.47895/amp.vi0.1462.

This article reflects on part of a three-year battle over the redevelopment of an iconic Melbourne music venue, the Palace-Metro Nightclub (the Palace), involving the tactical use of Facebook Page data at trial. We were invited by the Save the Palace group, Melbourne City Council and the National Trust of Australia to provide Facebook Page data analysis as evidence of the social value of the venue at an appeals trial heard at the Victorian Civil Administration Tribunal (VCAT) in 2016. We take a reflexive ethnographic approach here to explore the data production, collection and analysis processes as these represent and constitute a “data public”.Although the developers won the appeal and were able to re-develop the site, the court accepted the validity of social media data as evidence of the building’s social value (Jinshan Investment Group Pty Ltd v Melbourne CC [2016] VCAT 626, 117; see also Victorian Planning Reports). Through the case, we elaborate on the concept of data publics by considering the “affordising” (Pollock) processes at play when extracting, analysing and visualising social media data. Affordising refers to the designed, deliberate and incidental effects of datafication and highlights the need to attend to the capacities for data collection and processing as they produce particular analytical outcomes. These processes foreground the compositional character of data publics, and the unevenness of data literacies (McCosker “Data Literacies”; Gray et al.) as a factor of the interpersonal and institutional capacity to read and mobilise data for social outcomes.We begin by reconsidering the often-assumed connection between social media data and their publics. Taking onboard theoretical accounts of publics as problem-oriented (Dewey) and dynamically constituted (Kelty), we conceptualise data publics through the key elements of a) consequentiality, b) sufficient connection over time, c) affective or emotional qualities of connection and interaction with the events. We note that while social data analytics may be a powerful tool for public protest, it equally affords use against public interests and introduces risks in relation to a lack of transparency, access or adequate data literacy.Urban Protest and Data Publics There are many examples globally of the use of social media to engage publics in battles over urban development or similar issues (e.g. Fredericks and Foth). Some have asked how social media might be better used by neighborhood organisations to mobilise protest and save historic buildings, cultural landmarks or urban sites (Johnson and Halegoua). And we can only note here the wealth of research literature on social movements, protest and social media. To emphasise Gerbaudo’s point, drawing on Mattoni, we “need to account for how exactly the use of these media reshapes the ‘repertoire of communication’ of contemporary movements and affects the experience of participants” (2). For us, this also means better understanding the role that social data plays in both aiding and reshaping urban protest or arming third sector groups with evidence useful in social institutions such as the courts.New modes of digital engagement enable forms of distributed digital citizenship, which Meikle sees as the creative political relationships that form through exercising rights and responsibilities. Associated with these practices is the transition from sanctioned, simple discursive forms of social protest in petitions, to new indicators of social engagement in more nuanced social media data and the more interactive forms of online petition platforms like change.org or GetUp (Halpin et al.). These technical forms code publics in specific ways that have implications for contemporary protest action. That is, they provide the operational systems and instructions that shape social actions and relationships for protest purposes (McCosker and Milne).All protest and social movements are underwritten by explicit or implicit concepts of participatory publics as these are shaped, enhanced, or threatened by communication technologies. But participatory protest publics are uneven, and as Kelty asks: “What about all the people who are neither protesters nor Twitter users? In the broadest possible sense this ‘General Public’ cannot be said to exist as an actual entity, but only as a kind of virtual entity” (27). Kelty is pointing to the porous boundary between a general public and an organised public, or formal enterprise, as a reminder that we cannot take for granted representations of a public, or the public as a given, in relation to Like or follower data for instance.If carefully gauged, the concept of data publics can be useful. To start with, the notions of publics and publicness are notoriously slippery. Baym and boyd explore the differences between these two terms, and the way social media reconfigures what “public” is. Does a Comment or a Like on a Facebook Page connect an individual sufficiently to an issues-public? As far back as the 1930s, John Dewey was seeking a pragmatic approach to similar questions regarding human association and the pluralistic space of “the public”. For Dewey, “the machine age has so enormously expanded, multiplied, intensified and complicated the scope of the indirect consequences [of human association] that the resultant public cannot identify itself” (157). To what extent, then, can we use data to constitute a public in relation to social protest in the age of data analytics?There are numerous well formulated approaches to studying publics in relation to social media and social networks. Social network analysis (SNA) determines publics, or communities, through links, ties and clustering, by measuring and mapping those connections and to an extent assuming that they constitute some form of sociality. Networked publics (Ito, 6) are understood as an outcome of social media platforms and practices in the use of new digital media authoring and distribution tools or platforms and the particular actions, relationships or modes of communication they afford, to use James Gibson’s sense of that term. “Publics can be reactors, (re)makers and (re)distributors, engaging in shared culture and knowledge through discourse and social exchange as well as through acts of media reception” (Ito 6). Hashtags, for example, facilitate connectivity and visibility and aid in the formation and “coordination of ad hoc issue publics” (Bruns and Burgess 3). Gray et al., following Ruppert, argue that “data publics are constituted by dynamic, heterogeneous arrangements of actors mobilised around data infrastructures, sometimes figuring as part of them, sometimes emerging as their effect”. The individuals of data publics are neither subjugated by the logics and metrics of digital platforms and data structures, nor simply sovereign agents empowered by the expressive potential of aggregated data (Gray et al.).Data publics are more than just aggregates of individual data points or connections. They are inherently unstable, dynamic (despite static analysis and visualisations), or vibrant, and ephemeral. We emphasise three key elements of active data publics. First, to be more than an aggregate of individual items, a data public needs to be consequential (in Dewey’s sense of issues or problem-oriented). Second, sufficient connection is visible over time. Third, affective or emotional activity is apparent in relation to events that lend coherence to the public and its prevailing sentiment. To these, we add critical attention to the affordising processes – or the deliberate and incidental effects of datafication and analysis, in the capacities for data collection and processing in order to produce particular analytical outcomes, and the data literacies these require. We return to the latter after elaborating on the Save the Palace case.Visualising Publics: Highlighting Engagement and IntensityThe Palace theatre was built in 1912 and served as a venue for theatre, cinema, live performance, musical acts and as a nightclub. In 2014 the Heritage Council decided not to include the Palace on Victoria’s heritage register and hence opened the door for developers, but Melbourne City Council and the National Trust of Australia opposed the redevelopment on the grounds of the building’s social significance as a music venue. Similarly, the Save the Palace group saw the proposed redevelopment as affecting the capacity of Melbourne CBD to host medium size live performances, and therefore impacting deeply on the social fabric of the local music scene. The Save the Palace group, chaired by Rebecca Leslie and Michael Raymond, maintained a 36,000+ strong Facebook Page and mobilised local members through regular public street protests, and participated in court proceedings in 2015 and February 2016 with Melbourne City Council and National Trust Australia. Joining the protesters in the lead up to the 2016 appeals trial, we aimed to use social media engagement data to measure, analyse and present evidence of the extent and intensity of a sustained protest public. The evidence we submitted had to satisfy VCAT’s need to establish the social value of the building and the significance of its redevelopment, and to explain: a) how social media works; b) the meaning of the number of Facebook Likes on the Save The Palace Page and the timing of those Likes, highlighting how the reach and Likes pick up at significant events; and c) whether or not a representative sample of Comments are supportive of the group and the Palace Theatre (McCosker “Statement”). As noted in the case (Jinshan, 117), where courts have traditionally relied on one simple measure for contemporary social value – the petition – our aim was to make use of the richer measures available through social media data, to better represent sustained engagement with the issues over time.Visualising a protest public in this way raises two significant problems for a workable concept of data publics. The first involves the “affordising” (Pollock) work of both the platform and our data analysis. This concerns the role played by data access and platform affordances for data capture, along with methodological choices made to best realise or draw out the affordances of the data for our purposes. The second concerns the issue of digital and data literacies in both the social acts that help to constitute a data public in the first place, and the capacity to read and write public data to represent those activities meaningfully. That is, Facebook and our analysis constitutes a data public in certain ways that includes potentially opaque decisions or processes. And citizens (protesters or casual Facebook commenters alike) along with social institutions (like the courts) have certain uneven capacity to effectively produce or read public protest-oriented data. The risk here, which we return to in the final section, lies in the potential for misrepresentation of publics through data, exclusions of access and ownership of data, and the uneven digital literacies at each stage of data production, analysis and sensemaking.Facebook captures data about individuals in intricate detail. Its data capture strategies are geared toward targeting for the purposes of marketing, although only a small subset of the data is publicly available through the Facebook Application Programming Interface (API), which is a kind of data “gateway”. The visible page data tells only part of the story. The total Page Likes in February 2016 was 36,828, representing a sizeable number of followers, mainly located in Melbourne but including 45 countries in total and 38 different languages. We extracted a data set of 268,211 engagements with the Page between February 2013 and August 2015. This included 45,393 post Likes and 9,139 Comments. Our strategy was to demarcate a structurally defined “community” (in the SNA sense of that term as delineating clusters of people, activities and links within a broader network), by visualising the interactions of Facebook users with Posts over time, and then examine elements of intensity of engagement. In other words, we “affordised” the network data using SNA techniques to most clearly convey the social value of the networked public.We used a combination of API access and Facebook’s native Insights data and analytics to extract use-data from that Page between June 2013 and December 2015. Analysis of a two-mode or bipartite network consisting of users and Posts was compiled using vosonSML, a package in the R programming language created at Australian National University (Graham and Ackland) and visualised with Gephi software. In this network, the nodes (or vertices) represent Facebook users and Facebook Posts submitted on the Page, and ties (or edges) between nodes represent whether a user has commented on and/or liked a post. For example, a user U might have liked Post A and commented on Post B. Additionally, a weight value is assigned for the Comments ties, indicating how many times a user commented on a particular post (note that users can only like Posts once). We took these actions as demonstrating sufficient connection over time in relation to an issue of common concern.Figure 1: Network visualisation of activity on the Save the Palace Facebook Page, June 2013 to December 2015. The colour of the nodes denotes which ‘community’ cluster they belong to (computed via the Infomap algorithm) and nodes are sized by out-degree (number of Likes/Comments made by users to Posts). The graph layout is computed via the Force Atlas 2 algorithm.Community detection was performed on the network using the Infomap algorithm (Rosvall and Bergstrom), which is suited to large-scale weighted and directed networks (Henman et al.). This analysis reveals two large and two smaller clusters or groups represented by colour differences (Fig. 1). Broadly, this suggests the presence of several clusters amongst a sustained network engaging with the page over the three years. Beyond this, a range of other colours denoting smaller clusters indicates a diversity of activity and actors co-participating in the network as part of a broader community.The positioning of nodes within the network is not random – the visualisation is generated by the Force Atlas 2 algorithm (Jacomy et al.) that spatially sorts the nodes through processes of attraction and repulsion according to the observed patterns of connectivity. As we would expect, the two-dimensional spatial arrangement of nodes conforms to the community clustering, helping us to visualise the network in the form of a networked public, and build a narrative interpretation of “what is going on” in this online social space.Social value for VCAT was loosely defined as a sense of connection, sentiment and attachment to the venue. While we could illustrate the extent of the active connections of those engaging with the Page, the network map does not in itself reveal much about the sentiment, or the emotional attachment to the Save the Palace cause. This kind of affect can be understood as “the energy that drives, neutralizes, or entraps networked publics” (Papacharissi 7), and its measure presents a particular challenge, but also interest, for understanding a data public. It is often measured through sentiment analysis of content, but we targeted reach and engagement events – particular moments that indicated intense interaction with the Page and associated events.Figure 2: Save the Palace Facebook Page: Organic post reach November—December 2014The affective connection and orientation could be demonstrated through two dimensions of post “reach”: average reach across the lifespan of the Page, and specific “reach-events”. Average reach illustrates the sustained engagement with the Page over time. Average un-paid reach for Posts with links (primarily news and legal updates), was 12,015 or 33% of the total follower base – a figure well above the standard for Community Page reach at that time. Reach-events indicated particular points of intensity and illustrates the Page’s ability to resonate publicly. Figure 2 points to one such event in November 2015, when news circulated that the developers were defying stop-work orders and demolishing parts of The Palace. The 100k reach indicated intense and widespread activity – Likes, Shares, Comments – in a short timeframe. We examined Comment activity in relation to specific reach events to qualify this reach event and illustrate the sense of outrage directed toward the developers, and expressions of solidarity toward those attempting to stop the redevelopment. Affordising Data Publics and the Transformative Work of AnalyticsEach stage of deriving evidence of social value through Page data, from building public visibility and online activity to analysis and presentation at VCAT, was affected by the affordising work of the protesters involved (particularly the Page Admins), civil society groups, platform features and data structures and our choices in analysis and presentation. The notion of affordising is useful here because, as Pollock defines the term, it draws attention to the transformative work of metrics, analytics, platform features and other devices that re-package social activity through modes of datafication and analysis. The Save the Palace group mobilised in a particular way so as to channel their activities, make them visible and archival, to capture the resonant effects of their public protest through a platform that would best make that public visible to itself. The growth of the interest in the Facebook Page feeds back on itself reflexively as more people encounter it and participate. Contrary to critiques of “clicktivism”, these acts combine digital-material events and activities that were to become consequential for the public protest – such as the engagement activities around the November 2015 event described in Figure 2.In addition, presenting the research in court introduced particular hurdles, in finding “the meaningful data” appropriate to the needs of the case, “visualizing social data for social purposes”, and the need to be “evocative as well as accurate” (Donath, 16). The visualisation and presentation of the data needed to afford a valid and meaningful expression of the social significance the Palace. Which layout algorithm to use? What scale do we want to use? Which community detection algorithm and colour scheme for nodes? These choices involve challenges regarding legibility of visualisations of public data (McCosker and Wilken; Kennedy et al.).The transformative actions at play in these tactics of public data analysis can inform other instances of data-driven protest or social participation, but also leave room for misuse. The interests of developers, for example, could equally be served by monitoring protesters’ actions through the same data, or by targeting disagreement or ambiguity in the data. Similarly, moves by Facebook to restrict access to Page data will disproportionately affect those without the means to pay for access. These tactics call for further work in ethical principles of open data, standardisation and data literacies for the courts and those who would benefit from use of their own public data in this way.ConclusionsWe have argued through the case of the Save the Palace protest that in order to make use of public social media data to define a data public, multiple levels of data literacy, access and affordising are required. Rather than assuming that public data simply constitutes a data public, we have emphasised: a) the consequentiality of the movement; b) sufficient connection over time; and c) affective or emotional qualities of connection and interaction with public events. This includes the activities of the core members of the Save the Palace protest group, and the tens of thousands who engaged in some way with the Page. It also involves Facebook’s data affordances as these allow for the extraction of public data, alongside our choices in analysis and visualisation, and the court’s capacity and openness to accept all of this as indicative of the social value (connections, sentiment, attachment) it sought for the case. The Senior Member and Member presiding over the case had little knowledge of Facebook or other social media platforms, did not use them, and hence themselves had limited capacity to recognise the social and cultural nuances of activities that took place through the Facebook Page. This does not exclude the use of the data but made it more difficult to present a picture of the relevance and consequence of the data for understanding the social value evident in the contested building. While the court’s acceptance of the analysis as evidence is a significant starting point, further work is required to ensure openness, standardisation and ethical treatment of public data within public institutions like the courts. ReferencesBruns, A., and J. Burgess. “The Use of Twitter Hashtags in the Formation of Ad Hoc Publics.” 6th European Consortium for Political Research General Conference, University of Iceland, Reykjavík, 25-27 August 2011. 1 Aug. 2018 <http://eprints.qut.edu.au/46515/>.Baym, N.K., and d. boyd. “Socially Mediated Publicness: An Introduction.” Journal of Broadcasting & Electronic Media 56.3 (2012): 320-329.Dewey, J. The Public and Its Problems: An Essay in Political Inquiry. Athens, Ohio: Swallow P, 2016 [1927].Donath, J. The Social Machine: Designs for Living Online. Cambridge: MIT P, 2014.Fredericks, J., and M. Foth. “Augmenting Public Participation: Enhancing Planning Outcomes through the Use of Social Media and Web 2.0.” Australian Planner 50.3 (2013): 244-256.Gerbaudo, P. Tweets and the Streets: Social Media and Contemporary Activism. New York: Pluto P, 2012.Gibson, J.J. The Ecological Approach to Visual Perception. Boston: Houghton Mifflin Harcourt, 1979.Graham, T., and R. Ackland. “SocialMediaLab: Tools for Collecting Social Media Data and Generating Networks for Analysis.” CRAN (The Comprehensive R Archive Network). 2018. 1 Aug. 2018 <https://cran.r- project.org/web/packages/SocialMediaLab/SocialMediaLab.pdf>.Gray J., C. Gerlitz, and L. Bounegru. “Data Infrastructure Literacy.” Big Data & Society 5.2 (2018). 1 Aug. 2018 <https://doi.org/10.1177/2053951718786316>.Halpin, T., A. Vromen, M. Vaughan, and M. Raissi. “Online Petitioning and Politics: The Development of Change.org in Australia.” Australian Journal of Political Science (2018). 1 Aug. 2018 <https://doi.org/10.1080/10361146.2018.1499010>.Henman, P., R. Ackland, and T. Graham. “Community Structure in e-Government Hyperlink Networks.” Proceedings of the 14th European Conference on e-Government (ECEG ’14), 12-13 June 2014, Brasov, Romania.Ito, M. “Introduction.” Networked Publics. Ed. K. Varnelis. Cambridge, MA.: MIT P, 2008. 1-14.Jacomy M., T. Venturini, S. Heymann, and M. Bastian. “ForceAtlas2, a Continuous Graph Layout Algorithm for Handy Network Visualization Designed for the Gephi Software.” PLoS ONE 9.6 (2014): e98679. 1 Aug. 2018 <https://doi.org/10.1371/journal.pone.0098679>.Jinshan Investment Group Pty Ltd v Melbourne CC [2016] VCAT 626, 117. 2016. 1 Aug. 2018 <https://bit.ly/2JGRnde>.Johnson, B., and G. 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Wilken. “Rethinking ‘Big Data’ as Visual Knowledge: The Sublime and the Diagrammatic in Data Visualisation.” Visual Studies 29.2 (2014): 155-164.Meikle, G. Social Media: Communication, Sharing and Visibility. New York: Routledge, 2016.Papacharissi, Z. Affective Publics: Sentiment, Technology, and Politics. Oxford: Oxford UP, 2015.Pollock, N. “Ranking Devices: The Socio-Materiality of Ratings.” Materiality and Organizing: Social Interaction in a Technological World. Eds. P.M. Leonardi, Bonnie A. Nardi, and J. Kallinikos. Oxford: Oxford UP, 2012. 91-114.Rosvall, M., and C.T. Bergstrom. “Maps of Random Walks on Complex Networks Reveal Community Structure.” Proceedings of the National Academy of Sciences of the United States of America 105.4 (2008): 1118-1123.Ruppert E. “Doing the Transparent State: Open Government Data as Performance Indicators.” A World of Indicators: The Making of Governmental Knowledge through Quantification. Eds. R. Rottenburg S.E. Merry, S.J. Park, et al. 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Photo by Ishan @seefromthesky on Unsplash ABSTRACT A strike to highlight the plight facing contract doctors which has been proposed has received mixed reactions from those within the profession and the public. This unprecedented nationwide proposal has the potential to cause real-world effects, posing an ethical dilemma. Although strikes are common, especially in high-income countries, these industrial actions by doctors in Malaysia are almost unheard of. Reviewing available evidence from various perspectives is therefore imperative to update the profession and the complexity of invoking this important human right. INTRODUCTION Contract doctors in Malaysia held a strike on July 26, 2021. COVID-19 cases are increasing in Malaysia. In June, daily cases ranged between 4,000 to 8,000 despite various public health measures. The R naught, which indicates the infectiousness of COVID-19, remains unchanged. During the pandemic, health care workers (HCWs) have been widely celebrated, resulting in a renewed appreciation of the risks that they face.[1] The pandemic has exposed flawed governance in the public healthcare system, particularly surrounding the employment of contract doctors. Contract doctors in Malaysia are doctors who have completed their medical training, as well as two years of internship, and have subsequently been appointed as medical officers for another two years. Contract doctors are not permanently appointed, and the system did not allow extensions after the two years nor does it offer any opportunity to specialize.[2] Last week, Parliament did decide to offer a two-year extension but that did not hold off the impending strike.[3] In 2016, the Ministry of Health introduced a contract system to place medical graduates in internship positions at government healthcare facilities across the country rather than placing them in permanent posts in the Public Service Department. Social media chronicles the issues that doctors in Malaysia faced. However, tensions culminated when and contract doctors called for a strike which ended up taking place in late July 2021. BACKGROUND Over the past decade, HCW strikes have arisen mostly over wages, work hours, and administrative and financial factors.[4] In 2012, the British Medical Association organized a single “day of action” by boycotting non-urgent care as a response to government pension reforms.[5] In Ireland, doctors went on strike for a day in 2013 to protest the austerity measures implemented by the EU in response to the global economic crisis. It involved a dispute over long working hours (100 hours per week) which violated EU employment laws and more importantly put patients’ lives at risk.[6] The strike resulted in the cancellation of 15,000 hospital appointments, but emergencies services were continued. Other major strikes have been organized in the UK to negotiate better pay for HCWs in general and junior doctors’ contracts specifically.[7] During the COVID-19 pandemic, various strikes have also been organized in Hong Kong, the US, and Bolivia due to various pitfalls in managing the pandemic.[8] A recent strike in August 2020 by South Korean junior doctors and medical students was organized to protest a proposed medical reform plan which did not address wage stagnation and unfair labor practices.[9] These demands are somewhat similar to the proposed strike by contract doctors in Malaysia. As each national health system operates within a different setting, these strikes should be examined in detail to understand the degree of self-interest involved versus concerns for patient’s welfare. l. The Malaysia Strike An anonymous group planned the current strike in Malaysia. The group used social media, garnering the attention of various key stakeholders including doctors, patients, government, and medical councils.[10] The organizers of the strike referred to their planned actions as a hartal. (Although historically a hartal involved a total shutdown of workplaces, offices, shops, and other establishments as a form of civil disobedience, the Malaysian contract doctors pledged no disturbance to healthcare working hours or services and intend a walk-out that is symbolic and reflective of a strike.)[11] The call to action mainly involved showing support for the contract doctors with pictures and placards. The doctors also planned the walk-out.[12] Despite earlier employment, contract medical doctors face many inequalities as opposed to their permanent colleagues. These include differences in basic salary, provisions of leave, and government loans despite doing the same job. The system disadvantages contract doctors offering little to no job security and limited career progression. Furthermore, reports in 2020 showed that close to 4,000 doctors’ contracts were expected to expire by May 2022, leaving their futures uncertain.[13] Some will likely be offered an additional two years as the government faces pressure from the workers. Between December 2016 and May 2021, a total of 23,077 contract doctors were reportedly appointed as medical officers, with only 789 receiving permanent positions.[14] It has been suggested that they are appointed into permanent positions based on merit but the criteria for the appointments remain unclear. Those who fail to acquire a permanent position inevitably seek employment elsewhere. During the COVID-19 pandemic, there have been numerous calls for the government to absorb contract doctors into the public service as permanent staff with normal benefits. This is important considering a Malaysian study that revealed that during the pandemic over 50 percent of medical personnel feel burned out while on duty.[15] This effort might be side-lined as the government prioritizes curbing the pandemic. As these issues remain neglected, the call for a strike should be viewed as a cry for help to reignite the discussions about these issues. ll. Right to strike The right to strike is recognized as a fundamental human right by the UN and the EU.[16] Most European countries also protect the right to strike in their national constitutions.[17] In the US, the Taft-Hartley Act in 1947 prohibited healthcare workers of non-profit hospitals to form unions and engage in collective bargaining. But this exclusion was repealed in 1947 and replaced with the requirement of a 10-day advanced written notice prior to any strike action.[18] Similarly, Malaysia also recognizes the right to dispute over labor matters, either on an individual or collective basis. The Industrial Relations Act (IRA) of 1967[19] describes a strike as: “the cessation of work by a body of workers acting in combination, or a concerted refusal or a refusal under a common understanding of a number of workers to continue to work or to accept employment, and includes any act or omission by a body of workers acting in combination or under a common understanding, which is intended to or does result in any limitation, restriction, reduction or cessation of or dilatoriness in the performance or execution of the whole or any part of the duties connected with their employment” According to the same act, only members of a registered trade union may legally participate in a strike with prior registration from the Director-General of Trade Unions.[20] Under Section 43 of the IRA, any strike by essential services (including healthcare) requires prior notice of 42 days to their employer.[21] Upon receiving the notice, the employer is responsible for reporting the particulars to the Director-General of Industrial Relations to allow a “cooling-off” period and appropriate action. Employees are also protected from termination if permitted by the Director-General and strike is legalized. The Malaysian contract healthcare workers’ strike was announced and transparent. Unfortunately, even after legalization, there is fear that the government may charge those participating in the legalized strike.[22] The police have announced they will pursue participants in the strike.[23] Even the Ministry of Health has issued a warning stating that those participating in the strike may face disciplinary actions from the ministry. However, applying these laws while ignoring the underlying issues may not bode well for the COVID-19 healthcare crisis. lll. Effects of a Strike on Health Care There is often an assumption that doctors’ strikes would unavoidably cause significant harm to patients. However, a systematic review examining several strikes involving physicians reported that patient mortality remained the same or fell during the industrial action.[24] A study after the 2012 British Medical Association strike has even shown that there were fewer in-hospital deaths on the day, both among elective and emergency populations, although neither difference was significant.[25] Similarly, a recent study in Kenya showed declines in facility-based mortality during strike months.[26] Other studies have shown no obvious changes in overall mortality during strikes by HCWs.[27] There is only one report of increased mortality associated with a strike in South Africa[28] in which all the doctors in the Limpopo province stopped providing any treatment to their patients for 20 consecutive days. During this time, only one hospital continued providing services to a population of 5.5 million people. Even though their data is incomplete, authors from this study found that the number of emergency room visits decreased during the strike, but the risks of mortality in the hospital for these patients increased by 67 percent.[29] However, the study compared the strike period to a randomly selected 20-day period in May rather than comparing an average of data taken from similar dates over previous years. This could greatly influence variations between expected annual hospital mortality possibly due to extremes in weather that may exacerbate pre-existing conditions such as heart failure during warmer months or selecting months with a higher incidence of viral illness such as influenza. Importantly, all strikes ensured that emergency services were continued, at least to the degree that is generally offered on weekends. Furthermore, many doctors still provide usual services to patients despite a proclaimed strike. For example, during the 2012 BMA strike, less than one-tenth of doctors were estimated to be participating in the strike.[30] Emergency care may even improve during strikes, especially those involving junior doctors who are replaced by more senior doctors.[31] The cancellation of elective surgeries may also increase the number of doctors available to treat emergency patients. Furthermore, the cancellation of elective surgery is likely to be responsible for transient decreases in mortality. Doctors also may get more rest during strike periods. Although doctor strikes do not seem to increase patient mortality, they can disrupt delivery of healthcare.[32] Disruptions in delivery of service from prolonged strikes can result in decline of in-patient admissions and outpatient service utilization, as suggested during strikes in the UK in 2016.[33] When emergency services were affected during the last strike in April, regular service was also significantly affected. Additionally, people might need to seek alternative sources of care from the private sector and face increased costs of care. HCWs themselves may feel guilty and demotivated because of the strikes. The public health system may also lose trust as a result of service disruption caused by high recurrence of strikes. During the COVID-19 pandemic, as the healthcare system remains stretched, the potential adverse effects resulting from doctor strikes remain uncertain and potentially disruptive. In the UK, it is an offence to “willfully and maliciously…endanger human life or cause serious bodily injury.”[34] Likewise, the General Medical Council (GMC) also requires doctors to ensure that patients are not harmed or put at risk by industrial action. In the US, the American Medical Association code of ethics prohibits strikes by physicians as a bargaining tactic, while allowing some other forms of collective bargaining.[35] However, the American College of Physicians prohibits all forms of work stoppages, even when undertaken for necessary changes to the healthcare system. Similarly, the Delhi Medical Council in India issued a statement that “under no circumstances doctors should resort to strike as the same puts patient care in serious jeopardy.”[36] On the other hand, the positions taken by the Malaysian Medical Council (MMC) and Malaysian Medical Association (MMA) on doctors’ strikes are less clear when compared to their Western counterparts. The MMC, in their recently updated Code of Professional Conduct 2019, states that “the public reputation of the medical profession requires that every member should observe proper standards of personal behavior, not only in his professional activities but at all times.” Strikes may lead to imprisonment and disciplinary actions by MMC for those involved. Similarly, the MMA Code of Medical Ethics published in 2002 states that doctors must “make sure that your personal beliefs do not prejudice your patients' care.”[37] The MMA which is traditionally meant to represent the voices of doctors in Malaysia, may hold a more moderate position on strikes. Although HCW strikes are not explicitly mentioned in either professional body’s code of conduct and ethics, the consensus is that doctors should not do anything that will harm patients and they must maintain the proper standard of behaviors. These statements seem too general and do not represent the complexity of why and how a strike could take place. Therefore, it has been suggested that doctors and medical organizations should develop a new consensus on issues pertaining to medical professional’s social contract with society while considering the need to uphold the integrity of the profession. Experts in law, ethics, and medicine have long debated whether and when HCW strikes can be justified. If a strike is not expected to result in patient harm it is perhaps acceptable.[38] Although these debates have centered on the potential risks that strikes carry for patients, these actions also pose risks for HCWs as they may damage morale and reputation.[39] Most fundamentally, strikes raise questions about what healthcare workers owe society and what society owes them. For strikes to be morally permissible and ethical, it is suggested that they must fulfil these three criteria:[40] a. Strikes should be proportionate, e., they ‘should not inflict disproportionate harm on patients’, and hospitals should as a minimum ‘continue to provide at least such critical services as emergency care.’ b. Strikes should have a reasonable hope of success, at least not totally futile however tough the political rhetoric is. c. Strikes should be treated as a last resort: ‘all less disruptive alternatives to a strike action must have been tried and failed’, including where appropriate ‘advocacy, dissent and even disobedience’. The current strike does not fulfil the criteria mentioned. As Malaysia is still burdened with a high number of COVID-19 cases, a considerable absence of doctors from work will disrupt health services across the country. Second, since the strike organizer is not unionized, it would be difficult to negotiate better terms of contract and career paths. Third, there are ongoing talks with MMA representing the fraternity and the current government, but the time is running out for the government to establish a proper long-term solution for these contract doctors. One may argue that since the doctors’ contracts will end in a few months with no proper pathways for specialization, now is the time to strike. However, the HCW right to strike should be invoked only legally and appropriately after all other options have failed. CONCLUSION The strike in Malaysia has begun since the drafting of this paper. Doctors involved assure that there will not be any risk to patients, arguing that the strike is “symbolic”.[41] Although an organized strike remains a legal form of industrial action, a strike by HCWs in Malaysia poses various unprecedented challenges and ethical dilemmas, especially during the pandemic. The anonymous and uncoordinated strike without support from the appropriate labor unions may only spark futile discussions without affirmative actions. It should not have taken a pandemic or a strike to force the government to confront the issues at hand. It is imperative that active measures be taken to urgently address the underlying issues relating to contract physicians. As COVID-19 continues to affect thousands of people, a prompt reassessment is warranted regarding the treatment of HCWs, and the value placed on health care. [1] Ministry of Health (MOH) Malaysia, “Current situation of COVID-19 in Malaysia.” http://covid-19.moh.gov.my/terkini (accessed Jul. 01, 2021). [2] “Future of 4,000 young doctors who are contract medical officers uncertain,” New Straits Times - November 26, 2020. https://www.nst.com.my/news/nation/2020/11/644563/future-4000-young-doctors-who-are-contract-medical-officers-uncertain [3] “Malaysia doctors strike, parliament meets as COVID strain shows,” Al Jazeera, July 26, 2021. https://www.aljazeera.com/news/2021/7/26/malaysia-doctors-strike-parliament-meets-as-covid-strains-grow [4] R. Essex and S. M. Weldon, “Health Care Worker Strikes and the Covid Pandemic,” N. Engl. J. Med., vol. 384, no. 24, p. e93, Jun. 2021, doi: 10.1056/NEJMp2103327; G. Russo et al., “Health workers’ strikes in low-income countries: the available evidence,” Bull. World Health Organ., vol. 97, no. 7, pp. 460-467H, Jul. 2019, doi: 10.2471/BLT.18.225755. [5] M. Ruiz, A. Bottle, and P. Aylin, “A retrospective study of the impact of the doctors’ strike in England on 21 June 2012,” J. R. Soc. Med., vol. 106, no. 9, pp. 362–369, 2013, doi: 10.1177/0141076813490685. [6] E. Quinn, “Irish Doctors Strike to Protest Work Hours Amid Austerity,” The Wall Street Journal, 2013. https://www.wsj.com/articles/no-headline-available-1381217911?tesla=y (accessed Jun. 29, 2021). [7] “NHS workers back strike action in pay row by 2-to-1 margin,” The Guardian, 2014. https://www.theguardian.com/society/2014/sep/18/nhs-workers-strike-pay-unison-england (accessed Jun. 29, 2021); M. Limb, “Thousands of junior doctors march against new contract,” BMJ, p. h5572, Oct. 2015, doi: 10.1136/bmj.h5572. [8] J. Parry, “China coronavirus: Hong Kong health staff strike to demand border closure as city records first death,” BMJ, vol. 368, no. February, p. m454, Feb. 2020, doi: 10.1136/bmj.m454; “MultiCare healthcare workers strike, urging need for more PPEs, staff support,” Q13 FOX, 2020. https://www.q13fox.com/news/health-care-workers-strike-urging-need-for-ppes-risks-on-patient-safety (accessed Jun. 29, 2021); “Bolivia healthcare workers launch strike in COVID-hit region,” Al Jazeera, 2021. https://www.aljazeera.com/news/2021/2/9/bolivia-healthcare-workers-strike-covid-hit-region (accessed Jun. 29, 2021). [9] K. Arin, “Why are Korean doctors striking?” The Korea Herald, 2020. http://www.koreaherald.com/view.php?ud=20200811000941 (accessed Jun. 29, 2021). [10] “Hartal Doktor Kontrak,” Facebook. https://www.facebook.com/hartaldoktorkontrak. [11] “Hartal,” Oxford Advanced Learner’s Dictionary. https://www.oxfordlearnersdictionaries.com/definition/english/hartal (accessed Jun. 29, 2021). [12] “Hartal Doktor Kontrak,” Facebook. https://www.facebook.com/hartaldoktorkontrak. [13] R. Anand, “Underpaid and overworked, Malaysia’s contract doctors’ revolt amid Covid-19 surge,” The Straits Times, 2021. [14] Anand. [15] N. S. Roslan, M. S. B. Yusoff, A. R. Asrenee, and K. Morgan, “Burnout prevalence and its associated factors among Malaysian healthcare workers during covid-19 pandemic: An embedded mixed-method study,” Healthc., vol. 9, no. 1, 2021, doi: 10.3390/healthcare9010090. [16] Maina Kiai, “Report by the Special Rapporteur on the Right to Freedom of Peaceful Assembly and Association,” 2016. [Online]. Available: http://freeassembly.net/wp-content/uploads/2016/10/A.71.385_E.pdf. [17] ETUI contributors, Strike rules in the EU27 and beyond. The European Trade Union Institute. ETUI, 2007. [18] National Labor Relations Board, National Labor Relations Act. 1935, pp. 151–169. [19] Ministry of Human Resources, Industrial Relations Act 1967 (Act 177), no. October. 2015, pp. 1–76. [20] Article 10 of the Federal Constitution states that all citizens have the right to form associations including registered trade or labor unions. A secret ballot with two-third majority will suffice to call for a strike required for submission to the DGTU within 7 days as stated in Section 25(A) of the Trade Union Act 1959. [21] Ministry of Human Resources Malaysia, Guidelines on Strikes, Pickets and Lockouts in Malaysia. Putrajaya, 2011. [22] Ordinance Emergency which was declared in Malaysia since 12 January 2021. Under the Ordinance Emergency, the king or authorized personnel may, as deemed necessary, demand any resources. [23] “Malaysia doctors strike, parliament meets as COVID strain shows,” Al Jazeera, July 26, 2021. https://www.aljazeera.com/news/2021/7/26/malaysia-doctors-strike-parliament-meets-as-covid-strains-grow [24] S. A. Cunningham, K. Mitchell, K. M. Venkat Narayan, and S. Yusuf, “Doctors’ strikes and mortality: A review,” Soc. Sci. Med., vol. 67, no. 11, pp. 1784–1788, Dec. 2008, doi: 10.1016/j.socscimed.2008.09.044. [25] M. Ruiz, A. Bottle, and P. Aylin, “A retrospective study of the impact of the doctors’ strike in England on 21 June 2012,” J. R. Soc. Med., vol. 106, no. 9, pp. 362–369, 2013, doi: 10.1177/0141076813490685. [26] G. K. Kaguthi, V. Nduba, and M. B. Adam, “The impact of the nurses’, doctors’ and clinical officer strikes on mortality in four health facilities in Kenya,” BMC Health Serv. Res., vol. 20, no. 1, p. 469, Dec. 2020, doi: 10.1186/s12913-020-05337-9. [27] G. Ong’ayo et al., “Effect of strikes by health workers on mortality between 2010 and 2016 in Kilifi, Kenya: a population-based cohort analysis,” Lancet Glob. Heal., vol. 7, no. 7, pp. e961–e967, Jul. 2019, doi: 10.1016/S2214-109X (19)30188-3. [28] M. M. Z. U. Bhuiyan and A. Machowski, “Impact of 20-day strike in Polokwane Hospital (18 August - 6 September 2010),” South African Med. J., vol. 102, no. 9, p. 755, Aug. 2012, doi: 10.7196/SAMJ.6045. [29] M. M. Z. U. Bhuiyan and A. Machowski, “Impact of 20-day strike in Polokwane Hospital (18 August - 6 September 2010),” South African Med. J., vol. 102, no. 9, p. 755, Aug. 2012, doi: 10.7196/SAMJ.6045. [30] M. Ruiz, A. Bottle, and P. Aylin, “A retrospective study of the impact of the doctors’ strike in England on 21 June 2012,” J. R. Soc. Med., vol. 106, no. 9, pp. 362–369, 2013, doi: 10.1177/0141076813490685. [31] D. Metcalfe, R. Chowdhury, and A. Salim, “What are the consequences when doctors strike?” BMJ, vol. 351, no. November, pp. 1–4, 2015, doi: 10.1136/bmj.h6231. [32] D. Waithaka et al., “Prolonged health worker strikes in Kenya- perspectives and experiences of frontline health managers and local communities in Kilifi County,” Int. J. Equity Health, vol. 19, no. 1, pp. 1–15, 2020, doi: 10.1186/s12939-020-1131-y. [33] The study has shown that there were 9.1% reduction in admissions and around 6% fewer emergency cases and outpatient appointments than expected. An additional 52% increase in expected outpatient appointments cancelations were made by hospitals during that period. D. Furnivall, A. Bottle, and P. Aylin, “Retrospective analysis of the national impact of industrial action by English junior doctors in 2016,” BMJ Open, vol. 8, no. 1, p. e019319, Jan. 2018, doi: 10.1136/bmjopen-2017-019319. [34] D. Metcalfe, R. Chowdhury, and A. Salim, “What are the consequences when doctors strike?” BMJ, vol. 351, no. November, pp. 1–4, 2015, doi: 10.1136/bmj.h6231. [35] R. Essex and S. M. Weldon, “Health Care Worker Strikes and the Covid Pandemic,” N. Engl. J. Med., vol. 384, no. 24, p. e93, Jun. 2021, doi: 10.1056/NEJMp2103327. [36] M. Selemogo, “Criteria for a just strike action by medical doctors,” Indian J. Med. Ethics, vol. 346, no. 21, pp. 1609–1615, Jan. 2014, doi: 10.20529/IJME.2014.010. [37] Malaysian Medical Association, “Malaysian Medical Association Official Website.” https://mma.org.my (accessed Jun. 29, 2021). [38] M. Toynbee, A. A. J. Al-Diwani, J. Clacey, and M. R. Broome, “Should junior doctors strike?” J. Med. Ethics, vol. 42, no. 3, pp. 167–170, Mar. 2016, doi: 10.1136/medethics-2015-103310. [39] R. Essex and S. M. Weldon, “Health Care Worker Strikes and the Covid Pandemic,” N. Engl. J. Med., vol. 384, no. 24, p. e93, Jun. 2021, doi: 10.1056/NEJMp2103327. [40] M. Selemogo, “Criteria for a just strike action by medical doctors,” Indian J. Med. Ethics, vol. 346, no. 21, pp. 1609–1615, Jan. 2014, doi: 10.20529/IJME.2014.010; A. J. Roberts, “A framework for assessing the ethics of doctors’ strikes,” J. Med. Ethics, vol. 42, no. 11, pp. 698–700, Nov. 2016, doi: 10.1136/medethics-2016-103395. [41] “Malaysia doctors strike, parliament meets as COVID strain shows,” Al Jazeera, July 26, 2021. https://www.aljazeera.com/news/2021/7/26/malaysia-doctors-strike-parliament-meets-as-covid-strains-grow

The World Health Organization (WHO) declared a COVID-19 pandemic last March 11, 2020.1,2 According to the WHO Director General, “In the past two weeks, the number of cases of COVID-19 outside China has increased 13-fold, and the number of affected countries has tripled. There are now more than 118,000 cases in 114 countries, and 4,291 people have lost their lives. Thousands more are fighting for their lives in hospitals.” Soon after, Metro Manila was placed on a complete lockdown which started on March 15, 2020 and continues up to the time of this writing.2 So, what exactly is this COVID-19 pandemic? Will it be changing how we live our lives as healthcare professionals? What will be our role in taking care of patients with COVID-19? These and many other related questions require immediate answers as we face the threat of COVID-19. The WHO was first informed of cases of pneumonia of unknown cause in Wuhan City, China near the end of 2019. A novel coronavirus was identified as the cause by Chinese authorities and was initially named 2019-nCoV.3,4 This was later revised to COVID-19 (coronavirus disease of 2019) and the virus that causes it called SARS-CoV-2 (severe acute respiratory syndrome-coronavirus 2). In the first global epidemic caused by the “first” SARS coronavirus in 2003, the Philippines had a total of only eight confirmed patients. All the cases had contact with a nurse aide who had returned from Toronto, Canada where she got it. The index case and her father eventually died from SARS while the rest recovered.5 But, with COVID-19, at the time of writing this editorial, there were approximately 1,611 weekly cases with 112 weekly deaths in the Philippines and appears to be an increasing trend.6,7 By mid-March 2020, the WHO European Region had become the epicenter of the epidemic, reporting over 40% of globally confirmed cases. As of 28 April 2020, 63% of global mortality from the virus was from the Region, according to the WHO.3 There is much that we need to know about SARS-CoV-2, the virus that causes COVID-19. It belongs to the same family of coronavirus that causes SARS, MERS (Middle East Respiratory Syndrome), and even the common cold.3 Early studies report that SARS-CoV-2 was most often detected in respiratory samples from patients in China. However, live virus was also found in feces.8 It is thought that transmission mainly occurs through the respiratory route, probably as droplets, but extra respiratory sources may also be important. Risk factors for severe illness remain uncertain but old age and comorbidities such as cardiovascular disease, liver disease, kidney disease or malignant tumors, have emerged as likely important factors. There are no proven effective specific treatment strategies, and the risk-benefit ratio for commonly used treatments such as corticosteroids is not clear.7,8 COVID-19 may also cause damage to other organs such as the heart, the liver, and the kidneys, as well as to organ systems such as the blood and the immune system. Patients die of multiple organ failure, shock, acute respiratory distress syndrome, heart failure, arrhythmias, and renal failure.9,10 Among the WHO’s current recommendations, people with mild respiratory symptoms should be encouraged to isolate themselves, and social distancing is emphasized, and these recommendations apply even to countries with no reported cases.3,11 However, such measures could drastically affect the economy with impact on work practices as well as commercial establishments which depend on people’s patronage.12,13 Moreover, the psychological and mental burden that isolation and quarantine can bring about should also be considered. 14,15 For those in the academe, adjustments and quick transition to online learning strategies will need to be made.16 This will also affect how scientific research is done, particularly as we try to learn more about COVID-19.17 The longer the pandemic lasts, and the longer these measures need to be implemented, the more significant will the effects be on the economic and mental well-being of the people. There has certainly been a rush to get more information about COVID-19.18 Although well-intended in most cases, this has resulted into an “infodemic” with some erroneous or unscientific information about COVID-19. 19-21 Even mainstream scientific publications have not been spared by such faulty information. 22,23 Health professionals, therefore, who will be using the information found in these publications will need to be more vigilant in making sure that the data are properly collected and interpreted. We need to constantly update ourselves as new information becomes available.24-26 As in many viral diseases, the best way to combat COVID-19 could be vaccination. Based on the experience with developing vaccines for the other coronaviruses such as the ones causing SARS, MERS and even the common colds, the development of an effective vaccine against COVID-19 may be challenging.27-30 Even if one were to be quickly developed, having the resources needed to make enough vaccines for potentially all inhabitants of our planet are also staggering. And then of course, once a vaccine is available, each country would have to device its own vaccination strategy and all of its accompanying logistic considerations. And then there is the cost of such a vaccine. As a third world country, would the Philippines be able to afford enough vaccines for its citizens? Pending availability of an effective vaccine, one would need to look at actual treatment of COVID-19 patients. In the short-term, it may be possible to repurpose some of the currently available drugs we use for treating other viruses.31-33 In order to help address these, some wide-ranging initiatives have been set up. In March 2020, the UK Research and Innovation (UKRI) Medical Research Council and the UK National Institute of Health Research (NIHR) started the RECOVERY (Randomised Evaluation of COVID-19 Therapy) trial.34,35 It is the world’s largest clinical trial into treatments for COVID-19, with more than 40,000 participants across 185 trials sites in the UK. It is led by the University of Oxford. At about the same time, the WHO also announced the start of an international randomized and adaptive clinical trial SOLIDARITY which will also be looking at potential treatments for COVID-19. 36,37 The Philippines is set to participate in the SOLIDARITY trial.38 Use of personal protective equipment (PPEs) similar to how we have used them against Ebola and other viruses could also be beneficial.39 But similar to developing capacity for making enough vaccines, the ability to make enough PPEs, especially the disposable ones and bring these to where they are needed could also be additional challenges. In the Philippines, as in many other parts of the world, many healthcare workers report insufficient availability of PPEs which puts them at risk of getting COVID-19 from their patients.40,41 There are many more questions needing answers that we will need to deal with as we confront COVID-19. And, most likely, there will also be new challenges that can arise as the pandemic evolves. The combined efforts of the scientific and political communities will need to be engaged if we hope to successfully deal with this emergency. Joven Jeremius Q. Tanchuco, MD, MHA Professor, Department of Biochemistry and Molecular Biology, College of Medicine, University of the Philippines Manila Clinical Professor, Division of Pulmonary Medicine, Department of Medicine, College of Medicine and Philippine General Hospital, University of the Philippines Manila REFERENCES WHO Director-General's opening remarks at the media briefing on COVID-19 [Internet]. 11 March 2020 [cited 2020 Apr 15]. Available from: https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020. Metro Manila to be placed on 'lockdown' due to COVID-19 [Internet]. [cited 2020 Apr 15]. Available from: https://cnnphilippines.com/news/2020/3/12/COVID-19-Metro-Manila-restrictions-Philippines.html Cucinotta D, Vanelli M. 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New Microbes New Infect. 2020;35:100679. doi:10.1016/j.nmni.2020.100679 The RECOVERY trial [Internet]. [cited 2020 Apr 15]. Available from: https://www.ukri.org/our-work/tackling-the-impact-of-covid-19/vaccines-and-treatments/recovery-trial-identifies-covid-19-treatments/ RECOVERY [Internet]. [cited 2020 Apr 15]. Available from: https://www.recoverytrial.net/ UN health chief announces global ‘solidarity trial’ to jumpstart search for COVID-19 treatment [Internet]. [cited 2020 Apr 15]. Available ftom: https://news.un.org/en/story/2020/03/1059722 WHO COVID-19 Solidarity Therapeutics Trial [Internet]. [cited 2020 Apr 15]. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/global-research-on-novel-coronavirus-2019-ncov/solidarity-clinical-trial-for-covid-19-treatments PH Solidarity trial for COVID-19 treatments receives green light from ethics review body [Internet]. [cited 2020 Apr 22]. Available from: https://www.who.int/philippines/news/detail/22-04-2020-ph-solidarity-trial-for-covid-19-treatments-receives-green-light-from-ethics-review-body Balachandar V, Mahalaxmi I, Kaavya J, Vivekanandhan G, Ajithkumar S, Arul N, et al.COVID-19: emerging protective measures. Eur Rev Med Pharmacol Sci. 2020;24(6):3422-3425. doi:10.26355/eurrev_202003_20713 Philippines: Country faces health and human rights crisis one year into the COVID-19 pandemic [Internet]. [cited 2020 Apr 28]. Available from: https://www.amnesty.org/en/latest/press-release/2021/04/philippines-faces-health-human-rights-crisis-covid/. Shortage of personal protective equipment endangering health workers worldwide [Internet].[cited 2020 Apr 15]. Available from: https://www.who.int/news/item/03-03-2020-shortage-of-personal-protective-equipment-endangering-health-workers-worldwide.