The "Corona Warriors"? Community health workers in the governance of India's COVID-19 response.

India's nearly 1-million strong band of quasi-volunteer accredited social health activists (ASHAs) have been key actors in government efforts to control COVID-19. Utilizing a nationalist rhetoric of war, ASHAs were swiftly mobilized by the government in March 2020 as 'COVID warriors' engaged in tracking illness, disseminating information, and caring for quarantined individuals. The speed at which ASHAs were mobilized into mentally and physically grueling labor was all the more stunning given these minimally paid community health workers have long been seen to have low morale given their precarious, informalized work arrangements. Building on work examining the spatialities of global health governance alongside literature on geographic contingency, this paper explores the ways that nationalist COVID-19 war rhetoric promulgated from Delhi worked as a technology of health governance to propel ASHAs into certain forms of action, yet also opened up spaces of potentiality for them to reimagine their relationship to both the state and the communities they serve. In particular, in our analysis of in-depth telephone interviews with ASHA workers in the state of Himachal Pradesh, we find that their hailing as COVID warriors inspired patriotic calls to duty and legitimized their (long over-looked) roles as critical governance actors, yet also was subject to resistance and reworking due to a combination of institutional histories, local politics, as well as happenstantial everyday encounters of ASHA work. The precarious employment of ASHAs - in terms of basic remuneration as well as the great on-the-job risks that they have faced - underscores both the fragile nature of India's health governance system as well as possible political movements for its renewal. We conclude by calling for geographers to give greater attention to community health care workers as a key window into understanding the uneven ways in which health systems are made manifest on the ground, and their ability to respond to citizens' healthcare needs - both in the COVID-19 pandemic and beyond.

Dark and bright spots in the shadow of the pandemic: Rural livelihoods, social vulnerability, and local governance in India and Nepal.

The global COVID-19 pandemic has brought unprecedented disruption to lives and livelihoods around the world. These disruptions have brought into sharp focus experiences of vulnerability but also, at times, evidence of resilience as people and institutions gear up to respond to the crisis. Drawing on intensive qualitative enquiry in 16 villages of Himalayan India and Nepal, this paper documents both dark and bright spots from the early days of the pandemic. We find intense experiences of fear and uncertainty, heightened food insecurity, and drastic reductions in livelihood opportunities. However, we also find a wide range of individual and collective responses as well as a patchwork of policy support mechanisms that have provided at least some measure of basic security. Local elected governments have played a critical role in coordinating responses and delivering social support, however the nature of their actions varies as a result of different institutional arrangements and state support systems in the two countries. Our findings highlight the changing nature of vulnerability in the present era, as demographic shifts, growing off-farm employment and dependence on remittances, and increasing market integration have all brought about new kinds of exposure to risk for rural populations in the context of the present disruption and beyond. Most importantly, our research shows the critical importance of strong systems of state support for protecting basic well-being in times of crises. Based on these findings, we argue that there is a need for greater knowledge of how local institutions work in tandem with a broader set of state support mechanisms to generate responses for urgent challenges; such knowledge holds the potential to develop governance systems that are better able to confront diverse shocks that households face, both now and in the future.

Forest livelihoods and a "green recovery" from the COVID-19 pandemic: Insights and emerging research priorities from India.

For those concerned with the future of forests, the COVID-19 pandemic has simultaneously offered cause for great concern, and renewed hope. On one hand, the pandemic is occurring at a time when forests are already under unprecedented pressures from climate change, amplifying concerns about unsustainable forest extraction in the name of economic recovery. On the other hand, however, the crisis has helped to gather momentum around the notion of a "green recovery," including setting aside additional land for forest conservation. Drawing insights from past and ongoing research in India, we highlight an issue that exemplifies the tension between these two poles: the role of forests as social safety nets for rural communities in developing countries. It is well established that forests can provide critical resources for rural livelihoods, especially in times of crisis, and preliminary reports suggest that these resources have become even more important in the context of India's COVID lockdowns, and mass return migration from urban to rural areas. As the second wave of the pandemic continues to unfold in India, we highlight some key research priorities, including: 1) understanding how and to what extent forest-dependent communities and industries are changing their use of wood- and non-wood resources in the context of return migration and economic stress; 2) tracking shifts in forest cover, structure, and composition that may result from increased extractive pressures; 3) assessing the role of institutions, whether local, national, or international, in mediating these outcomes. Drawing on these observations, we suggest some key principles for integrating forest-based livelihoods into "green recovery," founded on principles that articulate forests as complex and integrated social-ecological systems, prioritize equity, and build on past learnings of community-based forest management.

The local governance of COVID-19: Disease prevention and social security in rural India.

Countries around the world have undertaken a wide range of strategies to halt the spread of COVID-19 and control the economic fallout left in its wake. Rural areas of developing countries pose particular difficulties for developing and implementing effective responses owing to underdeveloped health infrastructure, uneven state capacity for infection control, and endemic poverty. This paper makes the case for the critical role of local governance in coordinating pandemic response by examining how state authorities are attempting to bridge the gap between the need for rapid, vigorous response to the pandemic and local realities in three Indian states - Rajasthan, Odisha, and Kerala. Through a combination of interviews with mid and low-level bureaucrats and a review of policy documents, we show how the urgency of COVID-19 response has galvanized new kinds of cross-sectoral and multi-scalar interaction between administrative units involved in coordinating responses, as local governments have assumed central responsibility in the implementation of disease control and social security mechanisms. Evidence from Kerala in particular suggests that the state's long term investment in democratic local government and arrangements for incorporating women within grassroots state functions (through its Kudumbashree program) has built a high degree of public trust and cooperation with state actors, while local authorities embrace an ethic of care in the implementation of state responses. These observations, from the early months of the pandemic in South Asia, can serve as a foundation for future studies of how existing institutional arrangements and their histories pattern the long-term success of disease control and livelihood support as the pandemic proceeds. Governance, we argue, will be as important to understanding the trajectory of COVID-19 impacts and recovery as biology, demography, and economy.

Use of FDA-Approved Medications: Biologics for Psoriatic Arthritis in Patients at an Urban Outpatient Rheumatology Clinic.

OBJECTIVE: Psoriatic arthritis (PsA) is an inflammatory arthritis associated with psoriasis that manifests as peripheral arthritis, dactylitis, enthesitis, and spondylitis. Biologics, particularly tumor necrosis factor inhibitors (TNFis) and some interleukin 17 (IL-17) and interleukin 23 (IL-23) inhibitors, are the only US Food and Drug Administration (FDA)-approved treatments shown to limit joint damage in clinical trials for PsA. Conventional synthetic disease-modifying antirheumatic drugs have also been adapted to PsA treatment. Current 2018 American College of Rheumatology (ACR) guidelines regard TNFis as first-line therapy in treatment-naïve patients. The aim of this project is to review the prescribing practices for patients with PsA at an urban rheumatology office, with a focus on biologic prescribing. METHODS: A retrospective chart review was performed to search for patients seen from June 1, 2017, to June 1, 2018, using International Classification of Diseases, 10th Revision codes for PsA. A log of prescribing practices listed the use of biologics versus oral small molecules (OSMs) (methotrexate, sulfasalazine, leflunomide, and apremilast) across different ages, sex, and disease severity. RESULTS: This study included a total of 97 patients (40 women and 57 men), and 66% were on biologics (60% of women and 70% of men). There was no sex bias in biologic prescribing (P = 0.59). Use of biologics was highest in the 38 to 57 years age group and lowest in the 78 to 97 years age group, although, statistically, there was no age bias in biologic prescribing (P = 0.22). Biologics provided superior disease control (84.37%) compared with nonbiologics (66.6%) (P = 0.0016). OSMs provided slightly better control (69.5%) over apremilast monotherapy (61.5%) (P = 0.016). CONCLUSION: There is no age or sex bias in prescribing practices for PsA. In accordance with the ACR, patients with controlled symptoms on OSMs are being appropriately maintained. Although apremilast is allocated as an add-on therapy, 13.4% of patients were on apremilast monotherapy. This quality improvement project reveals that in most instances, biologics are being appropriately initiated as the primary mode of therapy for patients with PsA at our outpatient practice; however, treatment modifications can be made regarding patients who are managed with apremilast alone.

Improving communication with low-income women using today's technology.

The authors of this article examine reasons for missed appointments and preferences for appointment reminders among inner city obstetrics and gynecology clinic patients having a high missed-appointment rate. Sixty low-income women, including African Americans, Caucasians, and members of other ethnic groups, with a mean age of 27 years, were interviewed by telephone. The most frequently cited reason for missed appointments was forgetfulness. Almost all study participants indicated that they would like a text message reminder of upcoming appointments along with telephone and/or postal letter reminders. In this article the authors review the literature addressing both missed appointments and trends in mobile technologies, report their study of missed appointments, and conclude that text messaging appointment reminders can decrease missed appointments among young, low-income women.

Perivascular carotid inflammation: an unusual case of carotidynia.

A 59-year-old woman was admitted to the hospital with a fever and rigors for 2 days. She was on chemotherapy (docetaxel, carboplatin, and trastuzumab) for her stage II invasive ductal carcinoma of the breast. Her physical exam was unremarkable except for the fever. The white blood cells were 21,200/mm(3) with 92% of neutrophils. ESR was 106 mm/h. An extensive infectious workup was negative. On day 6, while still febrile, the patient complained of a left-sided neck pain. She exhibited tenderness over the left carotid artery. A CT scan of the neck without intravenous contrast showed perivascular inflammation of the left common carotid artery, without evidence of a collection, arterial thrombosis, aneurysm, or dissection. The etiology of this finding was possibly chemotherapy related. It dramatically responded to oral prednisone. A repeat CT scan of the neck with IV contrast 2 weeks later showed a remarkable improvement. Drug reactions can simulate systemic inflammatory diseases and should always be considered in the diagnosing process.

Treatment of recalcitrant pemphigus vulgaris with the tumor necrosis factor alpha antagonist etanercept.

The treatment of pemphigus vulgaris (PV) is generally regarded as challenging. Patients with the disease require long-term systemic therapy, creating concern for the toxicities of these treatments. Corticosteroids, as drugs of first choice, often must be combined with steroid-sparing agents to prevent hazardous long-term side effects. We describe a 62-year-old woman with long-standing PV whose cutaneous disease responded to therapy with the tumor necrosis factor alpha (TNF-alpha) antagonist etanercept, which was started for treatment of her inflammatory seronegative arthritis. To our knowledge, this is the first report of its efficacy in the treatment of PV.