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Gavin: Welcome to a new episode of The Lancet Voice. It's August 5th, 2020. I'm Gavin Cleaver. 

Jessamy: And I'm Jessamy Baganal. And coming up on this episode, we talk with The Lancet Psychiatry Editor in Chief, Dr. Niall Boyce, about the development and recovery of children in institutions off the back of a wide ranging new piece of research summarizing what we know about the effects of orphanages.

on childhood development. 

Gavin: First, though, I spoke with Professor Kenji Shibuya about mask wearing in Japan, the pandemic response in Japan and the West, and what the world can learn from the pandemic response. So I'm joined by Professor Kenji Shibuya. He's the director of the Institute of Population Health at King's College, London, as the former chief of health policy at WHO.

Professor Shibuya, thank you so much for joining me today. 

Kenji: Sure, my pleasure. Always happy to work with Lancet. 

Gavin: Professor, a lot of Western countries have been rapidly introduced to good hygiene practice over the last few months. But the situation is quite different in Japan, isn't that right? 

Kenji: Yeah as Japanese people wear masks when they were sick to protect others from getting their germs.

In general, Japanese people have a tendency to feel that it's a sort of civic duty. 

Gavin: So what's some of the history of mask wearing in Japan? How has it become so commonplace? 

Kenji: I'm not quite sure about the origin of it, but it has been there for quite a long time. So when people commute at the time of, in the winter, They always wear masks in the crowded commuter rails.

I live at at schools, hospitals. People tend to wear masks. It's a kind of general practice there. 

Gavin: Japan's quite a densely populated country, but it's had a relatively good COVID rate of infection so far, it's been relatively low rate of infection. Do you think some of this good hygiene practice underlies this low rate of infection?

What do you think's behind it? 

Kenji: I think Japan did manage very well the first wave first of all. They implemented a cluster based approach at the early phase of infection, but by mid March, Japan entered the exponential growth phase, and Japan was lucky because they avoided the explosion as observed in the U.

S. or in the U. K. because they acted. Promptly, even though they didn't impose strict lockdown, but the people behaved very well. And also government implement a state of emergency declaration, which did work. But after lifting the lockdown state of emergency measure in May, we now see a resurgence, big one.

So we are in the middle of the big wave now. 

Gavin: So what do you think the future holds for COVID 19 in Japan? 

Kenji: Japan has been implementing social distancing measure, new way of life, avoiding closed contact, but a fundamental problem with Japanese approach to taku COVID is lack of testing. Japan Could have expanded at the time when lifting the state of emergency measures, but they didn't.

I think they have to rapidly expand the testing capacity and implement test trace. I said as quickly as possible, otherwise it is becoming difficult. to control COVID infection while maintaining the economic activities. 

Gavin: As someone from Japan who now lives over in London, what have you made of the kind of West's response to COVID so far?

Kenji: I think it depends on the country and also leadership. But in general, The more promptly you act, the more successfully you can tackle COVID. And when I was in London, and when I started wearing mask, people started looking at me as if I were infected. But surprisingly, everybody on the tube right now is wearing mask.

It's big change in terms of culture. But I think, um, previously, I don't know why, but people here in London think might think that they may associate wearing mask with being ill or weak, or that's the kind of a bizarre Asian manner. But surprisingly, people are now wearing mask on the tube in the public space which is a good thing for COVID response.

Gavin: Do you think, or at least hope, that these kind of hygiene practices will actually become more commonplace in the West as a result of this? 

Kenji: I think so because COVID will not go away for a while, and I think one of the best strategies, non pharmaceutical inflammation, would be mask wearing, and I think this practice will be sustained for a while.

Gavin: Is there anything else you'd like to mention or talk about in relation to mask wearing or Japan? 

Kenji: Yeah, so not only in Japan, but again, I'd like to stress the fact that Japanese people wear a mask, as I said, when they were sick to protect others from getting the germs. And I think we tend to feel that it's a sort of civic duty to protect others.

But as a medical personnel, there was no scientific basis for this, but COVID was exceptional. And it did work. Yeah, I think it's quite unique for the Japanese custom to be. consider to be one of the most effective strategies to tackle COVID. But can I go back to the current Japanese response, which you asked earlier, because I'd like to rephrase a little bit.

So I think Japan did manage the first wave well. And Japanese approach to COVID on the basis of cluster control approach worked very well at the beginning to buy time. But mid March, Japan entered the exponential growth phase. And right after that, because we are facing the decision about the Tokyo Olympics, so The decision to implement a state of emergency delayed, but right after the Olympic decision was made, the Tokyo governor and the government and also Japan Medical Association worked very well to tell the people to stay at home.

Even though it was not the strict lockdown as in the UK, people behaved very well and comply the kind of social distancing measures and also stay at home measures. But this time it's a, I think this is a resurgence after lifting the state of emergency in May. And it's becoming a big wave because Japanese government is right now, is trying to boost the economy by enhancing the domestic travels.

And on the other hand, they have to control the infection. So the government is facing a huge dilemma. And the government is reluctant to implement again the state of emergency measures. Right now, Japan is in a big problem. 

Gavin: It's a dilemma being seen across a lot of countries, isn't it? This kind of desire to balance out the economy but also controlling the virus at the same time.

Where do you stand on the response to that? 

Kenji: My hunch is, unless you contain the virus quickly, Decominu will not be recovered. 

Gavin: How do you feel the WHO's response have gone? Do you think there are things that have gone really well? Do you think there are things that could have gone better? 

Kenji: I think WHO has been consistent that the government should act very promptly, and they have to stick with the basic strategies, such as testing, tracing, and isolation from the beginning.

But unfortunately, I think the situation is highly politicized, and the government approach has been fragmented. But I think the COVID is very difficult to contain unless We seek for concerted efforts. So I think it's time for the politics to be used to enhance the concerted efforts more than ever. 

Gavin: Why do you think, in your opinion, the virus has become so highly politicized around the world?

Kenji: That's a very good question. But I think it reflects the politics, not in global health, but also politics in general global trend. And each country has facing each country is facing its own domestic problem. For example, the Japan and the support to the government. And also in March we are facing the Battle Olympics, whether it should be postponed or not on the us.

They have a pre action and many countries facing domestic issues as well as international relations. And it's easy to scapegoat some institution, but that doesn't help. 

Gavin: Thank you very much for speaking with us today. My pleasure, as always. 

Jessamy: Such a great interview, Gavin, and such a topical issue that is really divisive at the moment.

Gavin: Yes, I think what came out from my chat with Kenji is a lot of How this is a completely natural thing in Japan and other Asian countries that mask wearing is a sign of respect that it's expected once you're outside your house, particularly in times as they are now, but that it's something that the West is going to come to terms with.

I think there's an interesting concept in a article I read recently about how Society required this kind of joint societal memory, Of going through a pandemic and wearing masks during the pandemic and obviously Japan and Asia being far more affected and being far closer to the SARS and MERS outbreaks recently mean that they have this kind of societal memory, this kind of need to wear masks.

Not that mask wearing wasn't already a major thing in those countries, but they never really affected the West massively. I think while it seems like there is a lot of turbulence in relation to mask wearing at the moment in Western countries, I do hope that we will progress towards it becoming something more normal and completely acceptable and, something that people are completely fine with and is an expected part of society.

Jessamy: Yeah, I think this collective memory issue is interesting because, obviously it's the history of mask wearing is that, that We have been wearing them historically. They were first worn during the plague when they had these kind of beak like masks. They look terrifying actually, the plague doctors, because they had these sort of huge beaks that were filled with different smells because of this concept of miasma or bad air.

But, after that, then we didn't use them much, and the play kind of went from memory. We didn't actually start wearing masks in surgery until the turn of the 20th century, and that was largely due to the Lister with their sort of concept of microscopics. And they were actually first worn by a Polish surgeon in 1897, and there was a female physician at the turn of the century that wrote in JAMA and said, do you not think that spitting into the abdomen of one of your patients is probably not the best way to, to make sure that they don't get an infection.

And so gradually, within surgery, it became the norm by about the 1920s. And I think there's a one survey that showed that by the 1920s, in terms of photographs, That about a third of surgeons were wearing them. And then you've also got, the, during the Manchurian flu of 1910 in China, there was a Chinese physician who said, we really need to be wearing masks for health professionals and generally in the public.

And he came up against a lot of criticism. But that was implemented. And then in 1918, during the Spanish flu, mask wearing was really widely adopted with many cities in the US requiring them in public, San Francisco, Seattle, all of these types of city, you had to wear them when you are on public transport.

And I think that, so far the evidence that we have does suggest that mask wearing is protective both for you and for other people. But obviously, like so many other, very small sort of pieces of kit that aren't necessarily Worth lots of money that the evidence base that we have the research base that we have is poor there aren't really any randomized control trials There aren't studies that look into how a mask is worn, you know So if you're wearing a mask, but actually, your nose is in the mask or you keep on moving it around, does that kind of convey some sort of false sense of security for those people?

And is it then potentially more harmful? There are all of these issues that mean that our actual ability to estimate the really effectiveness of a mask and what type of mask is very limited. 

Gavin: Yeah, undoubtedly more evidence is required. We've been operating, I think as Kenji mentioned in that interview, we've been operating on the basis since this pandemic started that mask wearing has worked in tackling outbreaks.

But as you say, there's not actually a huge amount of evidence and certainly the detailed evidence that we need in relation to kinds of masks and how they're worn and how often they're worn and in what circumstances they're worn, all that kind of detailed information. There's not really any in depth reliable research out there which makes the argument for them.

a very difficult one, I think, in terms of saying to someone, no, this will protect you or this will protect other people in this particular way. Here's the research. It's actually quite difficult to do that. 

Jessamy: And that's what we found recently with some of the modeling studies that we've been viewing for submissions from the Lancet is that, a major criticism of them is that the assumptions that they're based on are not strong enough.

To give really clear estimates, it comes back to that conversation that we had last time about, if you're putting kind of rubbish in, then you get rubbish out and that's a real difficulty because the message, I think. is fairly clear. There is a growing body of evidence, albeit not the strongest, that mask wearing is beneficial.

But then when you try and apply them to these large modeling studies to say, okay if we wore masks, in March, could we have prevented X amount of deaths? That's a really difficult leap then to make.

A major new commission in two of our journals, the Lancet Child and Adolescent Health and the Lancet Psychiatry, advocates wide ranging reform of the care of separated children by replacing institutional care like orphanages with safe family based care. We spoke with the editor in chief of the Lancet Psychiatry, Dr.

Niall Boyce, about how this reform might work and why it's needed. Niall, thanks so much for talking to us about your recent commission with the Lancet Child and Adolescent Health about institutionalization of children. It's quite a sort of strange topic for a medical journal to choose only because it's so broad and covers so many different aspects of sort of society and physical health, neurobiological health.

How did the commission come about? 

Niall: This came about, it's the product of several years work, but it's also, the end product of about 30 years. 30 years ago, those of us who have memories of 1989 and 1990 will remember the terrible pictures which we saw on the news of children in orphanages in Romania who had been neglected and who were in terrible states of physical and emotional distress.

And those of us who saw those pictures will have followed the story up over the past 30 years. It occurred to me that what we'd seen were lots of news stories and pieces of evidence about the ongoing consequences of that, but that no one had really tackled how we avoid more children in future ending up in that situation.

Now this also coincided with more attention in the press to this issue of volunteerism, which is where you have Orphanages and young people, often from high income countries, go to visit and volunteer. And from the psychiatry point of view, that struck me as being a bit of a recipe for disaster in terms of attachment.

And then, as various journalists have shown, there are all sorts of other medical, emotional, physical health and indeed very strong ethical issues there. But as you say, it's a huge topic, far too much for one Lancer journal to take on. And so I got talking with Jane Godsland, who's the editor of the Lancer Child and Adolescent Health, and we decided it was something which our journals could tackle together.

Jessamy: And it's a fantastic commission, and it's just, a moving read, but also, forward looking and interesting. And I just wanted to take one step back, and our listeners won't know, but you are a bit of a polymath in that you have a very wide range of interests and know everything. So I have complete confidence in asking you this question in your answer.

Can you briefly just tell us a little bit about the history of institutionalisation? Where does it come from? And why do we do it? 

Niall: If you Look back in history. There have been institutions for Children for a very long time. If you look back, for instance, into early modern London, so I'll be talking about the Renaissance period here.

There were specific hospitals as they were called, which was set up. for children who were abandoned, whose parents had died, who had no relatives to look after them. We then have the development slightly later of the Foundling Hospital in London, this is for children who were abandoned at a very young age, which eventually became the Coram Foundation, which now helps to place children with adoptive families.

There's a very long history of these institutions all around the world, but of course, just because something's been established for a very long time, it doesn't mean that it's the best thing for today, and it doesn't mean that things have to continue that way, and I think that rather as with mental health, we've moved from thinking that the best thing is for people to stay in institutions with that sort of very rigid care.

We now have a model of care which is based much more around the community and autonomy and freedom and allowing people to flourish. And I think It's really time worldwide for a comparative mental and practical shift in terms of the care of orphan children. 

Jessamy: And I suppose that's what this commission does, is it just is a call to action for that.

What's the evidence that we have so far of some of the consequences of institutionalization on children's physical health and neurobiological health and mental health? And where are the gaps and what needs to happen? 

Niall: Okay, the first thing is that the numbers might surprise some people.

I've been to lots of mental health meetings, lots of global mental health meetings. I don't think I've ever heard anyone talk about institutionalized children. But what this commission estimates is that Around 5. 4 million children worldwide are housed in institutions. And this has consequences. It is associated with what doctors, what medics would refer to as developmental delays.

And this seems to be in a dose response manner. So that is, the longer that a child stays in an institution, the larger the delays are. And these are most prominent in areas such as physical growth, brain growth, that obviously then has an effect on cognition and attention. And also this thing which interested me, which is the idea of attachment.

Now, attachment is something psychiatrists are very fond of talking about. Winnicott, Donald Winnicott, who was one of the great figures in child mental health, child psychiatry, said that there's no such thing as a baby. And by that, what Winnicott meant was the moment you think of a small child, a baby or an infant you can think of that child independently of also thinking about the caregiver.

And if you think about that a bit that's true. That's the way that your mind goes. And the thought that there are children who don't have that permanent figure, and the implications for that in terms of the attachments which they form, and the importance of attachment really in the immediate health of the child, the immediate physical and mental health, and then the longer term consequences of mental health would clearly be profound.

Those are what we know about the effects. But we also know that once the child goes into family care, recovery of a lot of these domains is actually possible, particularly in physical and brain growth. Although, of course there are some cases in which the more substantial impairment can persist, but that doesn't mean it's not worth doing everything we can to safely move children from institutional care to family care.

Jessamy: I guess I suppose that's what I took so much hope from, was that the, that, that recovery can happen and children, sometimes seem so flexible in that sense, that they're, you can change their environment and have such a positive impact on their health and their sort of mental development.

But what are the kind of barriers at the moment to keeping children in a family? situation. Obviously it varies globally but what are the major barriers that we have? 

Niall: There are financial barriers, clearly, because it costs a bit to invest in systems of social work, of social care, of A successful family placement, but I use the word invest advisedly because these are investments and they do have returns and it's, it's an investment, which it's well worth making.

There are also certain maybe cultural settings where there isn't such a tradition. of adoption, and maybe that's a particular barrier to overcome. Unfortunately, as I mentioned earlier, there's also the system of voluntourism, which perpetuates firstly the idea of institutional care being a normal thing, and secondly, to an extent, financially supports it.

And this is, to my mind, a mind blowing thing, which is that you've got It's about young people from high income countries who are going off to low income countries and middle income countries to support the sorts of institutions which, in the UK, in North America, in Western Europe, we wouldn't for a moment countenance our own children being cared for in.

So this is a difficult subject, because clearly the people who participate in that, a lot of them think they're doing the right thing, but you want to be able to redirect that energy into this more constructive long term solution which is better for the children. 

Jessamy: And I suppose that's takes us on to the sort of the second part of the commission which it calls for the implementation of these practices that support families and, just briefly, broadly, what are those?

Niall: Everyone can do something is the first thing to say. So the first thing is The funding from NGOs, from governments needs to be redirected to community and family based programs rather than institutions. And part of that as well is that we need better data to inform the policies, to inform where to put the money.

Globally, I think there's a need for global institutions to work together. to eliminate institutions, but that needs to be progressive. I, to refer again back to the analogy of community care and mental health, that, I think, was a noble cause, but I think the execution of it was suboptimal, to say the least, in various countries.

And you've got to be careful that you don't create more problems than you solve by shifting without adequate preparation from one form of care to another. At a national level we need to encourage countries to start child protection systems that really prioritise the role of families. And then locally we need to look at the specific factors in communities, the specific needs of each child and the specific need of each family to really support successful adoptions.

Jessamy: And is that partly, I mean we hear all the time in the UK about mishaps. Problems in social care of things being missed, children being placed in unsafe environments. Some of the reasons that, that happen is because of a lack of training, a lack of resources. It really seems like there's such a huge systems approach that needs to happen to improve the care for these children.

At times it feels a little bit overwhelming, and I guess that's what's nice about this commission, it does come up with some practical kind of solutions. When you finish the commission with you and the commissioners, do you feel hopeful? 

Niall: Yes, I am hopeful. And I think that one of the things that people are saying at the moment in our current pandemic situation is that the world is in a state of flux, and that there are clearly terrible challenges we face, but there are also opportunities to do things differently, and in terms of hopefully a reset of priorities for the world after the pandemic, this will be among them.

So yes, I am hopeful for the future. I think that this is part of the global conversation now. I think that this commission hopefully will make it certainly a prominent part of that conversation, and we can look forward to a much better future for this huge number of very vulnerable children. 

Jessamy: That's great, Niall.

And I just wanted to finish on you telling us a story because it's a great story about one of the commissioners who is actually, was raised in an orphanage and whether you could tell us a little bit about her and how she contributed and what that meant for the commission. 

Niall: Yes, that was Ionica, who was adopted by an English family from a Romanian orphanage at a very young age.

And she was really in a considerable state of mental, physical illness at the point that she was adopted. And her chances in life were thought to be very poor. And thanks to growing up in a family environment, being moved from an institution into a family she now not only has a successful career in acting, but she's also an advocate for future deinstitutionalization of children.

And at the launch event, which we held with our friends at United for Global Mental Health, Ionica said that by adopting a child, you give them And I think that's really what this commission is about. It's about giving individuals, we've talked about the big numbers. We've talked about the global situation, but in the end, this is about giving individuals.

I've often experienced terrible hardship at a very young age, the chance of a life of a happy and a productive and a flourishing life. And I think that's the important thing to bear in mind. 

Jessamy: Thank you so much, Niall. That's really beautiful. 

Gavin: Thank you. So I think it was really interesting. And just me listening to Niall talking about how the institutionalization of children has been quite prominent and Obvious problem in terms of developmental outcomes for the last 30, 40 years since, as Niall was saying the struggles with Romanian orphanages in the 1980s.

But that actually, there hasn't been a huge amount of combined research. There hasn't been any kind of overview of it. And as Niall said, it's this kind of problem that was talked about a lot, but hasn't really been moved on, so to speak. 

Jessamy: Yeah, and I think it's so difficult because, obviously, just from a common sense point of view, having children in institutions where, they might not have any connection to staff members who might be rotating on shifts, at the kind of fragile environment, they're very vulnerable.

We intuitively know that this is wrong for a child. Everything that we know about development of children suggests that they need those, attachment, they need adults and other children who they are able to see and connect with regularly. And yet In, the vast majority of the world, we still continue to have them.

Five to six million children are still institutionalized. 

Gavin: Yes, it's a, it's an amazing number really, isn't it? And it's it's good to have this kind of research to back up the idea that a shift away from from how we've been handling children separated from their parents to a more family based model of care would be not only so effective, but have so many improved outcomes.

Jessamy: Yeah, what's hopeful about this research and about the, all of the research that has been done so far is that as soon as you take children away from those institutional settings, then you are able to, see a huge improvement in their sort of both physical and mental development.

And it's just sad that it doesn't happen enough. And I suppose. What sort of strikes particularly with me and our kind of, middle class white English sort of view is that we all know of friends and friends children who are going off to work in orphanages potentially to do good.

And ultimately, this is just feeding into this system of extreme inequality for children. 

Gavin: The way Niall put it was really interesting in that Reflexively, if you thought about your child leaving them with a stranger for seven hours a day to gain this kind of attachment over a week and then rotating in a different stranger every week, it's intuitively sounds like something that is a bad idea.

And yet that is how this kind of voluntourism works. 

Jessamy: It's sadly a whole industry. It's a whole sector that's designed around giving Western children, Western adolescents, some experience and giving them, a view of a different culture and a different life. Often they have to pay for these experiences.

And that, that money then is never fed back to those children. So it's an extremely thorny topic, I think, because obviously nobody's wanting to go and do harm to children. But at the same time, these orphanages ultimately. need to be changed. And I suppose, then there's the other aspect of if there weren't orphanages, would there be anything, is this kind of, Is this the best that there can be?

And I think that's what's so important about the commission is that it's saying, look, we just cannot accept this as a way of treating, the next generation. It's unacceptable. And we have to make some major changes. 

Gavin: Yeah, it's a really fascinating piece and I hope some of our listeners will go and go and read it on the Lancet Psychiatry and the Lancet Child and Adolescent Health websites.

Jessamy: Thanks for listening to this episode of the Lancet Voice. You can reach Gavin and I at podcasts at lancet. com if you'd like to offer any suggestions and we'd love to hear your feedback. We'll see you again next time.