Poverty for the elderly is one of the most urgent social problems when discussing the social problems facing Korean society. The purpose of this study is to identify the causes of elderly poverty problems and to seek countermeasures. According to a systematic analysis of the economic difficulties of the elderly population that applies a socioecological model, the cause of elderly poverty is complicated by the specificity of the labor market and pension system in Korean society. This is compounded by the lack of a public support system that can overcome insufficient family care and a lack of individual preparation. To alleviate elderly poverty, this paper recommends three policy alternatives. First, a robust multipillar retirement income security system must be established. To secure a minimal retirement income for the elderly in poverty, who have been marginalized from the public pension system design, the basic pension should be raised for the bottom 70% of senior citizens. Second, in order to tackle labor market duality and early retirement, the seniority-oriented wage system should be reformed into a job-based wage system. Third, to minimize unemployment and promote quality among re-employment jobs, the government should strengthen vocational skills development by expanding programs tailored to older people. Korea has achieved impressive economic development, referred to as the “Miracle of the Han River”, over the past half-century. Korea overcame absolute poverty by generating strong income growth, but the fruits of this economic growth were not equally distributed. Korea’s old age relative poverty rate is the highest among Organization for Economic Co-operation and Development (OECD) countries. Many experts have suggested that the overwhelming elderly poverty rate proves that income has not been redistributed well between generations and classes ,2,3,4. IThe current poverty and income inequality among the elderly are attributed to the fact that inequality in the labor market is reflected in the social security system at a time when private support for the elderly is weak. A socioecological system perspective that focuses on the interaction between an individual and the environments surrounding that individual indicates diverse poverty factors. First, on an individual level, there is not enough preparation for retirement. Although awareness of preparation for retirement has increased, senior citizens fail to prepare for their retirement due to higher spending. This spending often comprises debt repayment and education expenses for children that are more than these citizens can afford. Second, an increase in women’s social participation and nuclear families at the interpersonal level weakens the family’s private support of aged parents. Third, the legal retirement age in Korea is 65, but the average retirement age is much lower due to corporate labor cost avoidance. Fourth, at a community level, Korea’s labor market is divided between a primary labor market composed of large companies and regular workers and a secondary labor market consisting of small- and medium-sized companies and irregular workers. This division results in high income inequality. Workers in the secondary sector often find preparing for retirement difficult by means other than public pensions, which are not sufficient enough. Moreover, retirement pension, one of the representative public pensions, is often not subscribed to, since only workplaces with more than 300 employees have been obligated to introduce retirement pensions since 2019, so most small- and medium-sized workplaces have offered it voluntarily. Finally, in terms of the legal system, Korea’s public pension has a low-level income replacement rate that refers to the pension as a proportion of income received by the worker, and a wide gap that does not include the elderly who worked in the secondary job market or who were unemployed.Poverty among the elderly is always mentioned as one of the most urgent social problems when discussing the issues facing Korean society. The seriousness of elderly poverty is also evident in the fact that Korea maintains one of the world’s top 10 GDP levels while showing the highest elderly poverty rate among OECD countries. On average, OECD countries do not have much difference in poverty risk by age, but in Korea, poverty risk increases rapidly in old age. The poverty rate of senior citizens in Korea, which saw a median income of 50% in 2016, stood at 43.8%, more than three times that of the OECD national average of 13.5% . Along with this prevalent risk of aging poverty, the world’s fast pace of population aging is rapidly increasing the number of elderly people in poverty . If the Social and economic problems caused by elderly poverty are not just income issues but can affect various aspects of Korean society. Korea has the highest suicide rate among OECD countries , and suiThe study is divided into three domains. First, The dictionary meaning of poverty is a state in which the minimum basic needs required for survival are not met, i.e., a state in which basic material needs cannot be met due to a lack of resources . Here ark) weighted by the OECD [k/The poverty line or poverty thresholds are the minimum income levels needed to achieve a proper standard of living in a given country. The poverty line can be divided into the absolute poverty line belonging to the objective poverty line and the relative poverty line according to the measurement method. The absolute poverty line is determined by estimating the cost of purchasing essential goods in a society and considers the condition that does not reach the objectively prescribed minimum standard of living as poverty. The absolute poverty rate measures the proportion of households below the poverty line to all households after establishing a certain standard of poverty. The World Bank’s global poverty line of one dollar ninety cents per day is widely used. However, relative poverty lines are determined in a comparative manner, such as a specific ratio based on average or median income. Townsend  defined the OECD . The houper year .There is a possibility that the status of poverty is statistically overstated or underestimated due to the measure of relative poverty based on disposable income. For example, people having large assets should be excluded from poor households, even if their income falls short of the poverty line. However, distinguishing the difference with available data is difficult . If the As shown in The poverty rate of Korean male seniors was 37.1%, but that of female seniors was 49%, 11.9% higher . ConsideOne of the changes that should be of interest in the issue of elderly poverty is the change in the family structure in old age. Korea was a family-care-oriented society that supported aged parents . This usThere are various competing theories about the causes of poverty. The debates include advocates who support cultural/behavioral arguments or structural/economic arguments . HoweverEach person’s economic preparation for retirement affects their retirement poverty. Generally, retirement is a predictable event, but economic retirement preparation behavior is different from person to person. According to the Social Security Public Perception Survey conducted by the Ministry of Health and Welfare in 2020 , 57% of Changes in family structure can also be linked to poverty . The weaIn addition, the attitude of the elderly toward supporting their old age is rapidly changing. This change in the value of parental support of children can be explained as a change in values and attitudes toward parental support. Familism centered on filial piety has weakened and social norms and systems have changed. According to the Statistics Korea survey , 70.7% oEarly retirement from jobs reduces lifetime income, adding to the risk of poverty in old age. According to the Senior Employment Promotion Act, early retirement of middle-aged and older workers in their late 40s and early 50s has been considered honorary retirement. According to the 2019 Economically Active People Survey conducted by Statistics Korea , the ageThe main driver for early retirement is the salary pay system. The seniority wage system is a structure in which the basic salary continues to rise depending on the number of years of service. The rigidity of the corporate wage system centered on the salary system is the main reason for the avoidance of employment of middle-aged and older people, early retirement pressure, and the spread of irregular workers . RecentlAnother problem with early retirement from major jobs lies in the growing gap between the age of retirement and the age of receiving benefits from the National Pension Service, a public retirement income security system. The pension age varies based on the year of birth. The pension can be received at 60 or younger for those born in 1952 and at 65 for those born in or after 1969. The “income vacuum” can exist for five to 15 years between retirement from work and the age of receiving the pension. In addition, senior citizens continue to work even after officially retiring from the labor market because public pensions alone are insufficient for maintaining their lifestyles. Korea displayed the highest average effective age of labor market exit, 72.3 years, for both women and men . HoweverAt the community level, the gap in workers’ income in the period of economic activity widens the gap in a life after retirement. The total income of households consists of earned income, self-employment income, asset income, and private/public transfer income. Employment income accounts for 64% of the total income .Earned income varies substantially depending on the size of the enterprise and type of employment . The labBased on data from 300 employees, the wages of small- and medium-sized company workers were 51% of those of large company employees in 2016. This barely increased to 53% in 2019 . The domThe wage gap between men and women has improved, but women’s hourly wages are still under 65% of men’s . This isCorporate size and employment type duality create income inequality for workers and make retirement planning difficult. For example, secondary sector workers’ limited savings, insurance and pension subscriptions are frequently insufficient to develop a viable retirement plan.Korea’s multilayered income security system, consisting of basic pension, national pension, and retirement pension, appears to be adequate , but a wThe National Pension Service was introduced in 1988 for businesses with up to 10 employees and was expanded to cover all citizens in 1999. The National Pension Service serves as a major retirement income source in the absence of postretirement earned income. Korean subscribers between 18 and 60 years of age pay part of their income as insurance premiums to the National Pension Service. However, since the National Pension Service is applying a reserved method that receives as much as individual contributions, it cannot receive benefits from the retirement income guarantee if the contribution is low or if it fails to join the national pension. Only 41.5% of the population aged 65 and older subscribe to the national pension [Basic pensions were introduced in 2008 to support stable retirement income security for older people who do not join the national pension scheme or do not receive sufficient pensions . Since 2The retirement pension system is a system in which employers accumulate funds during the worker’s tenure for retirement benefits. This guarantees that the worker will receive a retirement income that allows for economic stability. Retirement pensions reflect gaps in the dual structure of the labor market. For example, 88.1% of employees of businesses with 300 or more full-time workers have retirement pensions, and 23.5% of employees of small- and medium-sized companies with less than 30 employees have retirement pensions . RegularTo tackle the aforementioned social problems, the South Korean government has pushed to expand the number of people eligible for a basic pension, support national pension premiums, ease the qualifications of the basic living security system, raise the minimum wage, and make nonregular workers regular. However, more effort is still needed to solve the complex problem that has accumulated over a long period of time.As of 2021, Korea’s elderly population ratio is 16.6%, but the level of public spending on welfare for the elderly is 2.8% (2019), which is very low compared to the OECD average of 7.4% . Major OFirst, it is recommended to strengthen the pay adequacy of a multilayered income security system, focusing on basic pensions. Korea operates a national pension, basic pension, and retirement pension to support postretirement aged workers. As the first and foremost solution, the basic pension, pillar 0 or the pension floor should be raised to guarantee that the poor elderly can have lives that meet minimum quality of life standards. This applies to those who are unable to earn an employment income or to expect a private/public transfer . Most ofConsidering that the labor market history reflects the national pension, retirement pension, and elderly poverty, basic pension redistribution should have a stronger antipoverty role. However, although basic pensions have practical poverty alleviation effects, the cost may be unacceptable to central and local governments. Raising the basic pension by KRW 100,000 will cost KRW 932 billion in 10 years and will cost an additional KRW 4997 billion to cover the elderly aged 75 or older . These eA public awareness survey conducted by the Ministry of Health and Welfare last summer found that the public agreed to make social security spending for the elderly a top priority . RegardiThere may be those with the counter argument that individuals will avoid paying the national pension in order to be eligible for the basic pension. However, the prospect of evading the national pension seems excessive because of fears associated with elimination from the basic pension list. In addition, the current national pension is a mandatory system. Premiums are automatically deducted from an individual’s monthly salary. This ensures that those with an income cannot avoid paying the national pension. A plan could also be implemented to raise the income replacement rate of the National Pension Service, which is currently 40 percent, to increase public pension benefits for senior citizens. However, while adjusting the income replacement rate of the national pension may be effective in preventing future generations from poverty , this adFor the middle class, the government should further strengthen the use of retirement pensions to cover old age income. To this end, retirees should be induced to receive these in the form of pensions, not lump sum payments. The retirement pension is a legal obligation system applied to workers employed for at least one year, and the user shall bear the full financial resources. In the reality of Korea’s labor market, not many people are eligible for retirement pensions; retirement pensions are not universal pensions that cover many classes of workers. Nevertheless, most middle- and upper-class workers are bound to receive retirement pensions and can, therefore, play a role in the multilayered pension system by class. The key task at this time is to establish retirement pensions as pensions, not lump sum payments. To this end, the collection of lump sum payments may be restricted by designating mandatory receipt of retirement pensions for a certain period of time or by strengthening tax support for the receipt of pensions. The reason that retirement pensions are often received as lump sum payments is the resemblance to the severance pay tradition. There is a considerable demand for lump sum payments. If an individual retires in their 40s and 50s, the individual is not old enough to leave the job market yet. Lump sum payments may be necessary to provide an initial investment for self-employment. According to the 2019 Statistics Korea survey , 58.6% oHowever, some maintain that conditions for joining should be eased so that workers under one year can receive retirement pensions in order to resolve the gap in retirement pensions . In 2016In order to solve low-income problems caused by the early retirement of elderly workers and the dual structure of the labor market, the same wage principle of equal value labor should be realized. Currently, those who do the same job have a large wage gap. The wage depends on whether the employee is a regular or nonregular worker and belongs to a large company or to a small- and medium-sized subcontractor. Therefore, realizing equal wages for equal value labor is an important task for Korean society. Once employees enter low-wage jobs, they become highly dependent on them. Elderly workers who have received low wages even in life-long jobs are likely to suffer from poverty with fewer wages after retirement . AccordiTo apply the “Equal Pay for Work of Equal Value” principle, the wage system should be shifted to be job-oriented rather than seniority-driven. A job-centered wage system is a wage system that gives a job rating based on the relative job value and determines the relative level of wages . This isIn order for job pay to succeed, solidarity and bargaining power of all workers must be supported . In EuroHowever, Korea’s trade union organization rate is only 12.5 percent (2019), and more than 90 percent of workers have no organization to represent their interests . In addiTherefore, consideration for establishing the labor chamber as a way to improve the bargaining power and representation of the entire workforce is necessary. All workers with a certain period of employment insurance payments, including irregular workers, special types of workers, and the unemployed, are obligated to sign up to the chamber. The Chamber of Labor, a labor representative organization corresponding to the Korea Chamber of Commerce and Industry, can be in charge of job-oriented wage negotiations at the national level, not at the company level . In addiThe Austrian Chamber of Labor could serve as a reference model for the Korean Chamber of Labor. The Austrian Chamber of Labor was established in 1920 as a counterpart to the Chamber of Commerce . The mosThere may be resistance from some unions to the introduction of the labor chamber, but effective measures are urgently needed considering the fact that there is no organization representing the ever-expanding interests of vulnerable workers. In response to this, a central labor-management organization called the Chamber of Labor could be effective in easing the dual structure of the labor market. This requires that regular unions of small and large companies overcome the problem by representing the entire labor community and form solidarity with super-business agreements to switch to job-based pay structure.Alternatives are needed to minimize unemployment and allow re-employment with decent jobs in response to early retirement. One option is to increase productivity by providing vocational training to retirees o1r prospective retirees. Generally, negative stereotypes and prejudices that older people are less productive are common . Most buThere are employment education centers for senior citizens specialized in vocational training, but there are only 15 centers nationwide. This is insufficient to meet the needs of workers aged 50 and older, and most of the centers’ programs are focused on simple work such as cleaning and janitorial work . To imprDespite the government’s steady efforts, the relative poverty of the elderly population remains unresolved. According to a systematic analysis of the economic difficulties of the elderly population that applies a socioecological model, the cause of elderly poverty is complicated by the specificity of the labor market and the pension system in Korean society. This is compounded by a lack of a public support system that can overcome insufficient family care and a lack of individual preparation. First, the national pension, which is the core of public pensions, has a wide gap and insufficient pension receipts due to the immaturity of the system. Most retirement pensions are received as lump sum payments and lose their function as pensions. Second, the duality of the labor market creates income inequality by size, employment type, and gender and has a negative impact on the subscription and maintenance of multilayered pension systems. Third, the seniority wage system leads to early retirement from primary jobs in life, which generates an income crevasse until the time of receiving the public pension. To alleviate elderly poverty, this paper recommends three policy alternatives. First, a robust multipillar retirement income security system must be established. To secure minimal retirement income for the elderly in poverty, who have been marginalized from the public pension system design, the basic pension should be raised for the bottom 70% of senior citizens. Even if the national pension system, the core of the multilayered income security system, matures, the existing wide gaps cannot be resolved, so strengthening the social safety net will be a feasible alternative to elderly poverty. The role of the retirement pension should also be strengthened as an income source by granting tax benefits to the pension recipient to reduce lump-sum payouts. Second, in order to ease the dual structure of the labor market and prevent early retirement from jobs, the seniority-oriented wage system should be reorganized into a job-based wage system. In order for wage structure transition reform to succeed, a Chamber of Labor, an institution that can represent the interests of all workers, is necessary. The ultra-corporate collective bargaining process centered on the Chamber of Labor can contribute to reducing unfair wage dispersion. Third, to minimize unemployment and maintain re-employment job quality, the government should advance vocational skills development accounts by expanding programs tailored to older people. This study contributes to identifying the causes of elderly problems facing our society and suggests ways to solve those problems. The study, though, used the national level data to provide a snapshot of senior poverty in Korea. Future research could consider comparing regional characteristics, determinants, and trends between rural and urban areas. Given the fact that in rural areas of Korea, the proportion of the elderly population is higher than that of urban areas, the problem of elderly poverty may appear more dramatic in rural areas. This approach could provide more sophisticated targeted policy measures to reduce poverty among the elderly in Korea. For the elderly to escape poverty on their own is practically challenging, if not virtually impossible. In order to realize an inclusive society, the government’s social security policy and labor structure need to be reformed in concert with individual efforts.


Despite proven advantages for the use of telemedicine in psychiatry, mental healthcare professionals have shown deep-seated mistrust and suspicion of telepsychiatry, which hinders its widespread application. The current study examines the attitudes of Israeli mental health professionals towards telepsychiatry and seeks to uncover the effects of experience and organizational affiliation on its adoption. The methodology included qualitative and thematic analysis of 27 in-depth interviews with Israeli mental health professionals, focusing on three major themes—clinical quality, economic efficiency, and the effects on the work–life balance of healthcare professionals. The attitudes of mental health professionals were found to be widely divergent and sharply dichotomized regarding different aspects of telepsychiatry and its suitability for mental healthcare services. However, there was a general consensus that telemedicine may not fulfil its promise of being a panacea to the problems of modern public medicine. In addition, attitudes were related to hierarchical position, organizational affiliation, and personal experience with telepsychiatry. Specifically, organizational affiliation influenced experience with and support for the assimilation of telepsychiatry. The study also revealed the role of organizational leadership and culture in promoting or inhibiting the proliferation and adoption of innovative technologies and services in modern medicine. Telemedicine has become increasingly popular in medical practice and in academic research, especially so following the outbreak of COVID-19. This is partially because of its distinct ability to overcome barriers of time and space and its ability to bring diverse and advanced medical services to remote and rural areas ,4,5,6,7.Academic research on telemedicine and telepsychiatry has experienced a significant surge in publications over the last 30 years ,8,15,16.However, studies examining the experiences and attitudes towards telepsychiatry have demonstrated a significant gap between healthcare professionals and the general population. These studies reveal deep-seated levels of concern, suspicion, and distrust in telepsychiatry among therapists and psychiatrists, which is not shared by their clients ,13,14,23Israel has a universal and compulsory public healthcare system, in which every citizen in insured from birth until death and is entitled to a basic level of healthcare services. Healthcare services are provided by four public HMOs , which compete over customer enrollment and satisfaction and are reimbursed for services that are rendered by the government ,26.Since 2015, mental healthcare services are provided by the HMOs. Additionally, there are several government-owned regional clinics as well as general and psychiatric hospitals that are able to provide emergency and long-term treatment. In addition, many Israeli psychiatrists and other MDs supplement their day job in the public healthcare system with a private clinic in the afternoons ,27.Telemedicine technologies have been gradually introduced into the Israeli public healthcare system over the last decade. Significant differences were observed in the rate and depth of implementation between various healthcare providers. The field of mental healthcare has been a late comer to this innovative process, with the introduction of online child psychiatry consultations being introduced in 2016 . TelepsyA qualitative study consisting of in-depth interviews with mental healthcare practitioners in the Israeli public healthcare system, including senior- and mid-level professional managers.After identifying over a hundred HMO- and government-owned local clinics as well as psychiatric and general hospitals within the public mental-healthcare system, potential interviewees were contacted by phone and e-mail. The research population consisted of psychiatrists working within the public healthcare system. Participants were selected on the basis of purposive sampling quotas ,33, whicIndividual in-depth semi-structured interviews were conducted with each participant in a location of his/her choosing. The guidelines for these interviews were developed after a thorough review of the literature on telepsychiatry and included open-ended questions and prompts regarding the themes and issues that emerged from the literature. The interviewees were questioned regarding their perceptions and attitudes towards different aspects of telepsychiatry as well as their actual familiarity and experience with it . They represent a cross-sectional and diverse sample of the public mental healthcare system in terms of both organizational affiliations and hierarchical positions. The thematic analysis yielded the following three themes of attitudes towards telepsychiatry: (a) quality of treatment using telepsychiatry, (b) efficiency and economic advantages associated with telepsychiatry, and (c) effects on the professional and personal lives of psychiatrists. In the following, we present each theme and provide quotes from the interviews. Finally, we analyze the relationship between organizational affiliation, experiential knowledge, and support for telepsychiatry services.When asked about the effects of telepsychiatry on the quality of psychiatric examination and treatment, approximately half of the interviewees felt that the quality of treatment was as good as face-to-face, while the other half thought it to be inferior. In other words, there was no clear consensus on the matter. For example, about half of our respondents expressed their opposition to online examination and diagnosis, emphasizing its inferiority and inadequacy compared with traditional face to face examination. These respondents referred to one’s inability to gather non-verbal and pre-interview cues, such as movement, smell, body language, disquiet, etc. Additionally, they referred to lack of unmediated and intimate acquaintance with the patient, which they said would negatively affect interpersonal contact and therapeutic alliance. A regional manager for an HMO explained:In a preliminary meeting with a patient, there is paramount importance to direct interpersonal interaction and body language. There are lots of senses, sensors, and skills that need to be employed in order to formulate a preliminary assessment of the patient—and the online medium is very restrictive in that sense. [Interviewee 13]Some interviewees also referred to the social role of face-to-face therapy sessions—forcing the patient to exit his house, mingle with other people, and spending some quality time in meaningful conversation with their therapist. They expressed concern that the use of videoconferencing would all but isolate these patients, cutting their social ties and “releasing” them of the “burden” of social interactions. A senior psychiatrist in a general hospital emphasized:With some of my patients, the most significant improvement in their situation stems from the fact that they need to get up in the morning, leave their home, take the bus, and interact with other people on their way to the clinic. From my perspective, there is a significant therapeutic value in leaving one’s home… I fear we will lose that significant something when interacting through a screen [telepsychiatry]. [Interviewee 26]By contrast, a significant group among our respondents expressed their confidence in their ability to perform a proper examination online and issue a recommendation for the involuntary commitment of a patient following such examination. In a similar vein, these respondents also perceived tele-psychiatric treatment to be clinically comparable to conventional face-to-face treatment. For example, a psychiatrist from the northern region expressed the opinion that:There are no limitations on conducting a proper psychiatric examination in telepsychiatry. I do not conduct a slopier or less thorough examination online. My personal feeling is that there is no impairment on my ability to diagnose a patient via telepsychiatry. [Interviewee 04]In conclusion, the participants in this study were evenly divided in their estimation of the quality of treatment with telepsychiatry. No clear consensus was found regarding the question of clinical comparability of telepsychiatry with traditional face to face treatment or its effect on therapeutic alliance. Some of the participants expressed their concerns regarding its effects on increased social alienation in patients.The interviewees referred to two aspects of efficiency and economic benefits: for the patients and for the HMOs. Regarding the patients, the vast majority of our interviewees referred to the efficiency and economic benefits of telepsychiatry in terms of accessibility, travel costs, commute times, and loss of daily income. A regional manager in northern Israel phrased this succinctly:The most significant advantage in telepsychiatry is in reducing the costs for patients—in travel costs, commute time, and loss of wages. [Interviewee 08]However, concerning the advantages for the HMOs in terms of reducing no-shows, wait times, or economic costs, our interviewees were far less conclusive and expressed evenly divided opinions. With regard to economic costs, about half of the respondents estimated that HMOs will indeed be able to benefit from lower expenditure on office space, but this may be rolled on to the independent psychiatrists and online therapists, who will have to bear the costs of a private clinic or of working from home. By contrast, the other half of the interviewees estimated that HMOs will increase their expenditure on office-space rentals in order to accommodate both patients and psychiatrists, who are now present at different locations. These divergent views can be partially predicated based on organizational affiliation, as some HMOs have enacted stringent limitations on telemedicine through private computers and cellphones. A senior manager for one of the HMOs explained:In reality, telepsychiatry is more expensive for HMOs because you need to occupy two rooms at the same time—one for the doctor and another for the patient. This means double rental and maintenance costs. [Interviewee 02]Additional economic benefits associated with telepsychiatry included the possibility of lower payment to the psychiatrist for conducting an online treatment compared to face-to-face. While viewed as an advantage for the HMO, many interviewees perceived such possibility as frugality at their own expense. A therapist from a local HMO clinic put it bluntly:The HMO is paying less for an online therapist, compared to what they pay a regular therapist, or even in comparison to an independent/freelance one. [Interviewee 17]Another efficiency and economic issue that was raised in the interviews is the high no-show rate in current face-to-face treatment, which results in both wasting the therapists’ time and in longer waiting times for patients. About half of our respondents claimed that telepsychiatry would not solve the problem of no-shows. They thought that it would be very difficult to fill up vacancies with short notice (less than 3 h), even with the availability of virtual waiting lists. A senior psychiatrist in a general hospital remarked:From our experience, the percentage of no-shows in telepsychiatry is very similar to traditional treatment. People treat it as no different from a regular appointment. The usage of virtual waiting rooms might reduce this rate somewhat. But, it’s something we have yet to try. [Interviewee 23]About two-thirds of the interviewees referred to the issue of long wait-times between referral and appointment. About half of them believed that the ease and accessibility of telepsychiatry would create additional demand for mental health services. Which, in turn, would negate and even roll back any improvement in wait times. The lead psychiatrist in a regional clinic in Israel’s center succinctly explained:In my opinion, even if it works wonderfully and without malfunctions, telepsychiatry will only serve to extend wait times because of a well-known rule in health economy: the more efficient and accessible a service is, the higher its demand and usage. [Interviewee 22]The respondents also referred to the possibility of utilizing telepsychiatry to shorten the length of therapeutic sessions, thereby enabling the reception of more patients per hour. A majority among them opposed the possibility of shortened sessions either because it was perceived to be professionally inappropriate or because of expected technical difficulties. Head of a department in a psychiatric hospital remarked:In my opinion, a session of less than 30 min is not a “real” and meaningful session… it’s not even long enough in order to maintain rapport and build a working alliance. [Interviewee 16]Taken together, these examples illustrate the duality of the participants’ perspectives regarding the efficiency of telepsychiatry. A vast majority of the participants concurred that telemedicine is very economical and efficient from the patients’ point of view. However, the participants were vehemently divided regarding its efficiency for the HMOs or for the therapists themselves. Many of them expressed concerns that the HMOs would roll additional costs onto the therapists in order to ensure economic efficiency.The participants in this study were evenly divided in their assessment of the effects of telepsychiatry on the work–life balance of therapists. While many interviewees acknowledged the advantages of telepsychiatry, others raised concerns regarding its effects on the work environment of psychiatrists and therapists. A sizable group of our interviewees adamantly objected to the possibility of extending work hours in telepsychiatry to the late afternoon and evening time, referring to the need for private life, the maintenance of work–life balance, as well as the need to supplement their income through private practice. One such therapist, from a psychiatric hospital in the center of Israel, clearly stated:My wife will not be happy if I’ll be closed-off in the study from 19:00 to 22:00, videoconferencing with patients, instead of spending time with my children. It will be very damaging to the work–life balance, which we strive so hard to preserve. [Interviewee 16]Many of the participants emphasized the difficulty of maintaining a proper and dignified setting for their online sessions, referring to household disturbances or poor location choices by their patients. Household disturbances refer to phone calls, children, delivery people, or pets suddenly appearing in the frame. Poor location choices refer to the places where the patients choose to conduct the session from. The most commonly sighted improper locations include bedrooms, bathrooms, and cars as well as the patient’s workplace.A significant portion of the interviewees sighted technical difficulties associated with telepsychiatry—such as with Internet/network connectivity or with the operability of the software employed—as a major obstacle that undermines the very possibility of conducting regular psychiatric sessions online. A regional clinic manager from Israel’s center expressed frustration:It’s very difficult to overcome the technical issues involved [with telepsychiatry]. The conversation is interrupted regularly, and it takes a few minutes to resume connection. A significant portion of session-time is wasted on connectivity issues. Even afterwards, the sound quality is poor, and it is hard to hear the patient. [Interviewee 22]While most participants concurred that telepsychiatry would dramatically reduce the risk of physical violence against therapists, some of our interviewees referred to increases in “negative social behavior” by their online clients. These phenomena—such as rudeness, impatience, and “window shopping” between therapists—are also prevalent among offline patients. However, these participants perceived a correlation between the ease and comfort of online telepsychiatry and the spread of these phenomena. A senior psychiatrist form the Jerusalem area put it succinctly:Convenience [of telepsychiatry] is all well and good, as long as it’s available to the patients... However, the moment there is a problem, and this level of convenience and service they’ve gotten used to is no longer available, from a verity of reasons, this raises the level of frustration and anger, which may lead to aggressiveness and even violence. [Interviewee 13]In summary, the participants raised significant concerns regarding the effects of telepsychiatry usage on the work environment of mental healthcare professionals. These concerns included technical and logistical difficulties that affected the ease and flow of communication, increases in negative behavior by patients, as well as effects on the therapists’ work–life balance.Finally, we sought to examine the relationship between attitudes towards telepsychiatry and personal experience with this method of treatment. We found organizational differences in support for telepsychiatry as well as correlations between experience and support for telepsychiatry see . ParticiBy contrast, the employees of HMO A showed low levels of support for telepsychiatry, regardless of experiential knowledge or management role. The trend line for HMO A reveals a slightly negative correlation between experience and support for telepsychiatry. These results may be indicative of a negative organizational atmosphere towards telepsychiatry, or a poor online infrastructure and technical support in HMO A, which enjoys an extensive and widespread infrastructure of local clinics throughout Israel. However, it is important to remember that, due to the small sample size and the biased nature of the sampling technique, such findings should be seen as inconclusive in nature.Another interesting finding is the lack of participation by HMO B employees. Despite numerous inquiries and recuring invitations, only one therapist from HMO B participated in this study. Several other “potential participants” from this HMO attributed their refusal to “lack of authorization by superiors”. We hypothesize that this avoidance/refusal to participate might be indicative of an organizational atmosphere of opposition to or insecurity regarding telepsychiatry.The goals of the present study were to explore the attitudes and perceptions of mental healthcare professionals towards the usage of telepsychiatry. Relying on previous research ,17,19,22Overall, the present study revealed a positive correlation between the participants’ experiential knowledge with telepsychiatry and their support for its usage. However, this correlation seems to be mitigated by one’s employment and organizational affiliations. Therefore, while most of our participants exhibited a similar correlational trendline indicating that higher experience with telepsychiatry leads to higher support for its usage, The employees of a single HMO (A) exhibited a contradictory and negative trendline. For these participants, more experience with telepsychiatry also meant stronger opposition for its utilization. These findings may indicate that while a positive correlation is the norm, a conducive organizational climate and hierarchical support are necessary conditions for the assimilation and proliferation of telemedicine. . We fouA small sample size, selection bias, and lack of generalization are among the most common limitations associated with the implementation of qualitative research methods. In the present study, the authors attempted to rectify some of these limitations by employing regional and organizational quotas for participant selection to ensure diversity and representation. However, the sample size and generalization still remained an issue. Furthermore, the application of a quasi-statistical method and language in the second part of this article is meant purely for illustrative purposes and should not mislead readers to attribute any statistical power to our findings. Future research should aspire to further examine the relationship between experiential knowledge and support for telepsychiatry, utilizing more robust statistical methods.Our findings show that attitudes towards telepsychiatry are dependent on the position of interviewees within the organizational hierarchy as well as on their experience with telepsychiatry. That is, psychiatrists in managerial roles who are generally also more experienced with tele-mental health services exhibited a more positive approach towards telepsychiatry. As was shown in this study, the attitudes of mental health professionals are divergent and often dichotomized regarding different aspects of telepsychiatry and its suitability for the Israeli public mental healthcare services. At the same time, these attitudes are related to one’s hierarchical position, to the distinct institution, and to his/her personal experience with telepsychiatry. Nonetheless, personal experience is influenced by the institution’s attitude towards telepsychiatry, which determines the support in its assimilation. The mental health professionals who participated in this study were in consensus that telemedicine may not fulfil its promise of being a panacea to the problems of modern public medicine. Although qualitative in nature, our findings are also relevant to other countries that provide mental health services through a public health system, including Western and Central European countries. Importantly, practitioners’ experience with telepsychiatry is related to positive attitudes towards this service and may help overcome prejudice towards online mental health treatment. This can help healthcare systems to provide better mental healthcare services in times of high demand, such as during crisis or epidemic as well as in rural and remote regions, which often suffer inequality and neglect in access to healthcare services.The study was conducted shortly before the COVID-19 pandemic and therefore provides a snapshot of the pre-COVID situation. This pandemic accelerated the introduction of telemedicine into all fields of medicine, including telepsychiatry. The current situation emphasizes the importance of research on telepsychiatry in order to overcome barriers and to provide improved mental health services. The study also revealed the role of organizational leadership and culture in promoting the proliferation and adoption of innovative technologies and services in modern medicine. Future research should further examine the role of hands-on experience and institutional culture in the proliferation of innovative health technologies and services, and examine the perceptions of patients regarding telepsychiatry.


Background: The coronavirus disease 2019 (COVID-19) pandemic warrants an immediate response. Persons with disabilities (PWDs) are one of the most vulnerable populations susceptible to marginalization. While there are existing guidelines in the Philippines that aim to assist their basic needs, a call for inclusivity in policymaking for the COVID-19 response is highly advocated. This paper aims to analyze existing policy guidelines concerning the welfare of PWDs in the country based on several policy domains. Methods: Relevant documents were acquired through extensive search of government and nongovernment websites and news agencies. Literature included memorandums, circulars, and news bulletins in the period between January 2020 to May 2021. This study conducted a framework analysis on policies enacted by the Philippine government during the COVID-19 pandemic concerning PWDs. The framework was divided into eight areas: access to (1) information, (2)healthcare, (3) education, and (4) financial support, (5) protection from infection in residential settings, (6) reasonable accommodation, (7) consideration for disabled people facing multiple exclusions, and (8) inclusion to decision-making process. Results: Fifteen PWD related COVID-19 response documents from the Philippines were reviewed and analyzed. Most policies corresponded to themes related to financial support and reasonable accommodations. Most documents were limited to proposals and suggestions with only a few documents including specific details on how the program will be implemented and monitored. Conclusion: The state has proven its cognizance for PWDs; however, implementation and its impact remain to be seen. The government needs to evaluate these efforts to identify gaps and barriers. A comprehensive national database should be implemented to centralize registration of PWDs, and efforts should be made to inform and educate PWDs of their rights and of existing programs. Most importantly, PWDs should be included in the discourse and decision-making process to ensure programs are acceptable and accessible. In the Philippines, approximately 1.44 million or 1.57% of its population have a certain disability.2 The Philippines is currently second among the Southeast Asian regions in terms of COVID-19 infections, which logged a total of 1 240 716 active cases as of June 3, 2021.3The ongoing coronavirus disease 2019 (COVID-19) pandemic has significantly affected the lives of many. One population group highly impacted are persons with disabilities (PWDs). They are disproportionately affected not only because of their already heightened vulnerability to the disease, but also due to the regulations implemented to control the spread of COVID-19.4 They experience inequality, violation of dignity, and deprivation of autonomy,5 which is only expected to worsen because of the global health crisis. United Nations Special Rapporteur, Catalina Devandas, stated that persons with disabilities are not provided with the adequate support and protection they need with the ongoing pandemic.6Even before the pandemic, PWDs have remained one of the most vulnerable and most unheard voices in our society.1The regulations put in place in response to the pandemic produced multiple problems to its population. Most of the PWDs are more likely to be unemployed or working in the informal sector, making them financially insecure, and further increasing the burden on this population group.7 International guidelines have already been established in response to the call for disability inclusion. Because of the diversity of disabilities, it is encouraged to collect information from various groups of people through means completely devoid of discrimination or exclusion. In return, public information, especially regarding health and safety measures, must also be translated into accessible formats through accessible technology8 Aside from information accessibility, persons with disabilities must be ensured with proper medical and income security.9 The International Labor Organization emphasized that both mainstream and targeted measures must be taken to ensure social protection during COVID-19 lockdowns.10 It is recommended that significant funding and support be provided to non-government organizations, especially those concerned with humanitarian responses to maximize their operational capacity and mobilization.9Stakeholders, such as the government and leaders of humanitarian sectors, are called to actively participate in the empowerment of PWDs by addressing the barriers they may face with COVID-19.Everyone must understand that inclusivity is critical in forming guidelines that would fortify the nation’s COVID-19 response. Providing data analysis to the existing policies may alleviate the lack of studies promoting PWD inclusivity in the Philippines and provide awareness of the gaps in the national COVID-19 response strategies for PWDs.In assessing the current policies and guidelines, this paper aims to identify the existing gaps and barriers of PWD inclusivity in the Philippines, ensure disability-inclusive COVID-19 response and recovery, and promote PWD inclusivity in the future policy-making processes of the country. We had the objective of analyzing existing policies regarding PWDs during the COVID 19 pandemic in the Philippines. We will categorize the existing guidelines according to each policy domain and provide updates on the ongoing progress of the approved policies by the designated government organizations.Relevant documents were retrieved through extensive search of government websites and news agencies. Google search engine and Google Scholar were also used. Included data came from peer-reviewed journals, gray literature, and reports. Gray literature included memorandums, circulars, and news bulletins from the different branches of the Philippine government and national and international advocacy organizations and was restricted to the period between January 2020 to May 2021 to focus on the efforts made during the COVID-19 outbreak. Key search terms used were persons with disabilities, Philippine government, COVID-19, policy, and government agencies .11 which used documents from the WHO, United Nations and the Economic Commission for Latin America and the Caribbean. The applicability of the framework to the Southeast Asian setting was assessed using regional guidelines from the WHO and organizations such as the International Labor Organization and was found to be applicable and comprehensive enough without need for further modification.Documents were assessed and analyzed employing framework analysis based on the framework created by Sakellariou et al ,11 whichA total of 15 PWD related COVID-19 response documents  from theThe Emergency Social Management Framework (ESMF) and congressional resolutions required Filipino sign language interpreters on broadcast media and community-based training of Filipino sign language to facilitate information dissemination regarding COVID-19 screening and quarantine facilities. ESMF’s integration of information for preparedness activities were also given importance to provide accessible formats such as print materials in Braille or large print, sign language interpretation, captions, audio provision, and graphics for PWDs.The government, especially the Department of Health, provided measures to include PWDs in their access to healthcare. Sickness and disability benefits, medical reimbursements, and free physical and occupational therapy for PWD beneficiaries of KaGabay Program were provided by the Employees Compensation Commission (ECC). Furthermore, healthcare inclusivity was covered in full force by the Philippine Health Insurance Corporation . This is seen in the deployment of the vaccination program in the Philippines which included PWDs under group B, along with frontline workers and the indigenous population. Under this priority group, PWDs will be the second group prioritized after Group A which includes frontline health workers, senior citizens, and those with comorbidities.In response to education access, DOLE’s Employees Compensation Program provides PWD beneficiaries with free skills and entrepreneurial training. Although these were not expounded elaborately, these will be of importance to the PWDs due to the unpredictable economic changes brought about by the COVID-19 pandemic.Regarding financial support, PWDs are entitled to receive employment opportunities, livelihood packages, and monetary benefits through different programs. The ECC together with IATF has agreed to give out cash and livelihood assistance to PWDs. Through Administrative Order 39 which follows Article 177 of Presidential Decree No. 626 (s. 1074), entitled “Further Amending Certain Articles of Presidential Decree No. 442”, 20 000 Pesos (420 USD) were given to pensioners of the employees’ compensation program including PWDs under this. For venturing entrepreneurial PWDs, Biz-Ability Online Trade Fair (online trade fair) was made for PWDs to be able to safely sell their products. Discounts for health services and treatments for their disability were provided to PWDs through PhilHealth.Community Quarantines were implemented to protect people in their residential settings from COVID-19 infections. This entails restriction of mass gatherings and only allowing travel for essential needs. Vulnerable groups such as ages 18 and below, seniors and other vulnerable groups including PWDs have stricter quarantine measures. They are not allowed to enter public spaces unless absolutely necessary. Government groups such as the IATF also distributed face masks and face shields to vulnerable groups such as PWDs for further protection.New policies were implemented to adapt to the needs of PWDs amidst the COVID-19 pandemic. These include recommendations to allocate priority lanes and penalize acts that vilify PWDs. PWDs were allowed to send representatives to claim their emergency subsidies. Cash assistance was also delivered door-to-door especially to PWDs who are heads of their family. Standby ambulances and paramedics at subsidy payout sites were provided. Continuation of physical therapy services were also allowed for PWDs. PWDs were allowed to go outside their residential homes as part of their exercise regimen in therapy upon presentation of a PWD ID or prescription from the physician. Apart from these, PWDs were also allowed to request transportation help from their local government unit should they need it.In an effort to recover from the effects of COVID-19 pandemic the government created a referral unit, the Regional Federation of PWD, to help PWDs access their needs and services. Surveys were also deployed to determine the needs of PWDs in labor and employment.Only one document recommended the inclusion of PWDs in the decision-making processes in their concerns about policies about accessibility, acceptability, and quality criteria and in emergency response. However, it remains to be seen if this was properly implemented.12 To make matters worse, most of them are poor, finished lower levels of education, and face discrimination and difficulty finding employment.13 The global health crisis has placed them in an even more precarious situation. They are left unprotected from COVID-19 related health issues on top of trying to provide for their needs.PWDs continue to belong to the most vulnerable populations. Despite increasing calls for inclusivity, they still face several health and financial challenges.14 Because of these restrictions, the economy was greatly halted and millions of Filipinos, including PWDs, were left jobless. In a rapid assessment survey, 70% of PWDs reported that their employment had been affected by the pandemic, ranging from a shift to work from home to being at risk of losing their jobs.15 Consequently, PWDs and other marginalized groups face increasing fears due to uncertainty magnified by COVID-19.In March 2020, as COVID-19 cases started to rise in the Philippines, the initial response of the government was to impose quarantine measures of varying severity. Under the highest classification of community quarantine, the general population was ordered to stay home. Travel was limited to accessing essential goods and services, and most forms of public transportation were suspended. These restrictions loosened as the area’s quarantine classification decreased. However, even under the lowest classification, those under the age of 15 or over the age of 65, pregnant women, and those with immunodeficiency, comorbidities or other health risks were still prohibited from traveling outside of their residences unless absolutely necessary.16 In line with this, is the enactment of R.A. No. 11106, known as the Filipino Sign Language Act. It mandates the use of Filipino sign language in broadcast media and government transactions among other situations.17 The response of the Philippine government to the increased and novel needs of the PWDs during this pandemic has been guided by these provisions, as evidenced by the COVID-19 responses that fall under the themes of the framework. Unfortunately, there are gaps in implementation of these acts that have been highlighted by the pandemic.The Philippine government recognized these issues and enacted policies and programs to account for the needs of PWDs prior to and during the pandemic. Examples of these include the Magna Carta of Disabled Persons’ and the Filipino Sign Language Act. The Republic Act (R.A.) No. 7277 also known as the Magna Carta for Disabled Persons’ grants rights and privileges for disabled persons. Disabled persons under this act are defined as those suffering from restriction or different abilities, because of a mental, physical, or sensory impairment, to perform an activity in the manner or within the range considered normal for a human being. Through this act, disabled persons are granted rights under the following domains: employment, education, health, auxiliary social services, telecommunications, accessibility, and political and civil rights. It also prohibits discrimination against disabled persons on employment, transportation, and on use of public accommodation and services.18 The deaf and mute also face additional challenges such as the inability to report verbally to emergency hotlines.19 This leads to difficulty in accessing timely healthcare services and must be addressed by providing alternative means of communication.One such example is under the theme of accessible information. Despite the presence of R.A. 7277 and 11106 there are still noticeable shortcomings on this matter as revealed by the need for private volunteer groups to fill the information gap for the hard of hearing community. The situation was acknowledged by the House of Representatives when they called for a comprehensive report on the monitoring and implementation of RA No. 11106 and for an investigation on its delay.Access to healthcare services is one of the most important needs of PWDs, more so in this pandemic since their existing comorbidities place them at greater risk of infection and complications from COVID-19. In a country wherein private out-of-pocket payments continue to be the main form of accessing healthcare, financial resources would be easily drained should they get infected. In order to offset some of the costs, PhilHealth, the nation’s health insurance program, included hospitalization and testing for COVID-19 under their list of benefit packages. PWD livelihood programs by different departments of the government also provide healthcare services, together with skills and entrepreneurial training, and financial aid.20 Several government programs also require PWDs to register and require proof of disability to be considered a beneficiary. However, these mechanisms are nonuniform, ambiguous, and pose several challenges, causing several PWDs to be overlooked.21 The Department of Social Welfare and Development Social Amelioration Program, a key response of the government to financial difficulties brought about by the pandemic, is another example of this unequal distribution. Local governments were tasked to deliver this cash assistance, but due to vague implementing guidelines and requirements, several members of the vulnerable population remain unassisted. Countless PWDs reported inability to receive cash aid due to reasons such as being unregistered PWDs, non-inclusion to beneficiary lists, inability to produce documents which are hard to acquire during the crisis, and even lack of available forms to fill up.22Although these programs are greatly beneficial, they are only able to provide for a small number of PWDs and require certain conditions to be met. One example is the KaGabay program of the Department of Labor and Employment which provided livelihood and financial aid during the pandemic to 49 beneficiaries. This program only included persons with work related disabilities who have lost employment due to work related sickness or injury.Apart from these shortcomings, it was notable that some of these policies treated PWDs as a homogenous group without considering their specific needs and barriers to accessibility. This was seen in the Department of Interior and Local Government’s method of distributing food packs, vitamins, and medicine. Because each PWD experiences different barriers due to their unique impairments and functional limitations, the PWD community should be viewed as composed of several subsets. For these reasons, it is important to include PWDs and their representatives in the development of policies.This study has revealed the responsiveness of the Philippine government to include PWDs in their COVID-19 response. The presence of several policy instruments has proved the state’s cognizance for PWDs. This was exemplified by the advisory series released by the Philippine Commission on Human Rights which provided extensive guidelines on the rights of PWDs and the standards to uphold for them amidst the pandemic. Despite this, the study demonstrated that implementation remains to be a problem, and because of this impact from these policies has yet to be seen. There is a tendency for these policies and advisories to overgeneralize PWDs. It is important to recognize the heterogeneity of PWDs to better account for their specific needs. Moreover, there is not enough focus on adequate implementation and on evaluation of existing policies and programs. It is important to identify existing gaps and barriers to address these shortcomings and to be able to cover as many PWDs as possible. A comprehensive national database should be instituted to centralize registration across all local government units. This will also assist in creation of policies and programs that are suited to the PWDs needs. Efforts should be made to inform, guide, and educate PWDs of their rights and of existing programs. Most importantly, PWDs should be included in the discourse and decision-making process for policies that concern them to ensure programs developed are acceptable and accessible.No funding received from any institution or department.The authors completed the ICMJE Unified Competing Interest form (available upon request from the corresponding author) and declare no conflicts of interest.This study did not use data collected from human subjects; informed consent was not required.JVV, JCO, and DELP conceived the idea. JVV, JCO, AP, HKA, and PMV wrote the manuscript, collected data and literature with joint equal contribution by DELP. DELP assisted with article interpretation, supervised the development of work, helped in data interpretation and manuscript evaluation. All the authors read and approved the final manuscript.


All of the data are publicly available under the HCP guidelines using the Connectome Coordinating Facility and the NIMH Data Archive. Locally, we use these data to address specific questions related to structure, function, AD, aging and vascular disease in multi-modality studies leveraging the differential advantages of magnetic resonance imaging (MRI), functional magnetic resonance imaging (fMRI), MEG, and in vivo beta amyloid imaging.The natural history of Alzheimer’s Disease (AD) includes significant alterations in the human connectome, and this disconnection results in the dementia of AD. The organizing principle of our research project is the idea that the expression of cognitive dysfunction in the elderly is the result of two independent processes — the neuropathology associated with AD, and second the neuropathological changes of cerebrovascular disease. Synaptic loss, senile plaques, and neurofibrillary tangles are the functional and diagnostic hallmarks of AD, but it is the structural changes as a consequence of vascular disease that reduce brain reserve and compensation, resulting in an earlier expression of the clinical dementia syndrome. This work is being completed under the auspices of the Human Connectome Project (HCP). We have achieved an equal representation of Black individuals  and enrolled 60% Women. Each of the participants contributes demographic, behavioral and laboratory data. We acquire data relative to vascular risk, and the participants also undergo  The natural history of Alzheimer’s Disease (AD) includes significant alterations in the human connectome, and this disconnection results in the dementia of the Alzheimer’s type (DAT). Data from structural and functional magnetic resonance imaging (MRI) , as well1 of the Human Connectome Project.2 Our project is organized around the idea that the natural history of AD is affected by multiple independent factors . We used different measures of brain function because fMRI and MEG rely on fundamentally different biological processes to generate “signal”  imaging, and positron emission tomography (PET) imaging of “signal” , and thi“signal” . Becauseectivity  among inThis is a longitudinal, community-based study of brain structural and functional connectivity among cognitively normal and cognitively impaired individuals aged 50–89 years.5 and the Pitt + Me web portal .6 Additional individuals were identified through active links with the Heart SCORE Study . The participants are escorted to the Center for Advanced Brain Magnetic Source Imaging7 where they are prepared for the MEG scan, and complete task training. Once in the magnetically shielded room, the individuals complete task free MEG, and one task MEG (working memory). Individuals will then take for a short break and for the placement of the electrodes for the motor stimulation; then they will complete the Language/Math and Motor MEG task scans. Following a break for either a snack or lunch, the participants are escorted to the UPMC PET Facility for their PiB scan.All study participants are tested/scanned over three days. On Day One, all study enrollees complete the informed consent process and the intake forms. They are then escorted to the MR Research Center (MRRC) and where they complete the two fMRI tasks , and the structural imaging. Following a break, the individuals complete the behavioral tests that are Each participant undergoes a brief neuropsychological test battery for group classification purposes. The test battery is based on that of the ADRC and includes the Montreal Cognitive Assessment (MoCA) , verbal NIH Toolbox,8 the Promis battery,9 and additional paper-and-pencil tests .10 and pushed to a receiving server at Washington University in St. Louis for processing by the Connectome Coordination Facility and eventual upload to the on-line, public HCP database.All the MRI data are processed locally through the HCP pipeline, as modified to work in the local environment. The raw data are stored on an XNAT serverMagnetoencephalography (MEG) studies are completed on an Elekta-Neuromag Vectorview 306 MEG system. The whole-scalp neuromagnetic measurement system uses 102 triple sensors – 102 magnetometers and 204 planar gradiometers – in a helmet-shaped array. The locations of three cardinal anatomical landmarks  and of four head localization coils are digitized prior to each MEG study using a 3D-digitizer  to define the subject-specific Cartesian head coordinate system. 30–50 anatomical points are digitized on the head surface to provide for more accurate co-registration of the MEG data with the reconstructed volumetric MR image. Eye movements are measured and recorded simultaneously with the MEG. The MEG sensor unit, the floor-mounted gantry, the subject chair and bed, together with the patient audio-visual monitoring and stimulus delivery systems are contained in a magnetically shielded room.Once a subject is comfortably positioned in the MEG machine, a short electrical signal is sent to the head coils enabling their localization with respect to the MEG sensor array. The MEG data are acquired at a sampling rate of 1 kHz, with on-line filtering of 0.10–330 Hz. The acquisition includes two memory tasks, as well as 10 min of “resting state” data – 5 min with eyes open followed by 5 min with eyes closed. At the end of the scan, we collect 2 min of “empty room” data to assess the validity of any signal in the test conditions.Recordings were filtered offline using a tempo-spatial filtering algorithm   to elimiThe raw data are stored on an XNAT server and are pushed to the NDA for eventual inclusion in the study database (C3159).The PET amyloid tracer, Pittsburgh Compound B (PiB) is synthesized by a simplified radiosynthetic method based on the captive solvent method . High spThe Siemens/CTI ECAT HR + scanner gantry is equipped with a Neuro-insert (CTI PET Systems) to reduce the contribution of scattered photon events . PositroThe raw data are stored on an XNAT server and are pushed to the NDA for inclusion in the study database (C3159). The data include the dynamic images as well as a single SUV image.All the MRI data are pushed to the HCP CCF XNAT server where they are processed using standard quality control measures, and analysis via the HCP Pipeline. The processed data are made available by the CCF. The MEG and PET data are saved to the NIMH Data Archive as.FIF files (MEG) and DICOM images (PET SUV images). What follows below is the description of the local processing of these data.We briefly describe here the HCP Minimal Processing Pipelines that are implemented at the CCF prior to the release of the data . There were also two subgroups among the cognitively impaired participants: those who reported no concerns or loss of abilities [Impaired Without Complaints (IWOC)], and those who reported loss of abilities  see –3.The proportion of Black individuals was greater within the cognitively impaired group, as was the proportion reporting being left-handed. As would be expected, the Crystallized and Fluid Intelligence measures from the NIH Toolbox were significantly lower among the impaired participants.14The two subgroups of individuals who were cognitively normal did not differ in terms of age, years of education, distribution of men and women, race, or handedness see . The MoCbetter cognitive abilities (higher scores) and fewer cognitive concerns (lower scores) than the people in the MCI group. They reported higher scores on the Meaning and Purpose questions from the Promis battery.Between the two subgroups of individuals with Impaired Cognition those in the IWOC group were younger, less well educated, and more likely to self-identify as Black; they had decreased physical endurance see . The IWOt(132) = −4.39, d = 0.76], and reported significantly more concerns about their cognition . By contrast, the individuals in the IWOC group did not differ significantly on the Cognitive Abilities scale , and reported fewer concerns about their cognition than did the healthy controls . Finally, when we compared the MCI and IWOC groups, we found that those with MCI had lower scores on the Cognitive Abilities questionnaire , and reported significantly more concerns  about their cognition than the IWOC group.The participants with MCI had significantly lower scores on the Promis Cognitive Abilities questionnaire relative to the healthy controls . Furthermore, the rate of abnormal thickness differed significantly between groups  with the controls and the IWOC having the lowest rates, and the SCC and MCI groups having the highest.The mean cortical thickness differed as a function of group  . As can be seen in One hundred and eighty-six individuals contributed MEG data that met all quality control standards. We examined the relative power across all five MEG frequency bands in regions of interest (ROI) extracted using the AAL templates . The rep15 The MRI brain images are being uploaded to the CCF and the behavioral and cognitive data, PET PiB scan regional SUVRs (and raw SUV images), and the raw data from the MEG are being uploaded to the NDA (ID C3159).The purpose of this report is to describe the creation of the Connectomics of Brain Aging and Dementia study.When this project was initially proposed to the NIH, we specified that the sample would consist of 50% women and 50% black participants. We further proposed that the 50:50 splits be maintained in each subject group. While we were able to achieve this goal in our sample of healthy controls, some subgroups of participants did not conform to these expectations which in fact reveals much about the characteristics of those phenotypes. We believe that the single biggest advantage of using data derived from this study, and which will continue to be acquired and deposited for public consumption, is the composition of the study sample. We found that by carefully tailoring our public face on Pitt + Me we were able to recruit individuals across a wide range of socioeconomic strata as well as a high rate of Black volunteers. While many studies successfully enroll Black participants at a rate consistent with the population distribution, we specifically chose to oversample Blacks. The individuals that we ended up enrolling, both White and Black, were frequently new to research, and often had relatively low health-related knowledge. In our view, these are the people who need to be enrolled in studies such as COBRA in order to see the process of aging and neurodegeneration as it exists in the broader community.However, we learned several things about the execution of the protocol that had not been self-evident prior to the study. First, and perhaps most important, the research participants require a great deal of “hands-on” care than the typical research participant. In the end, each participant is assigned to a Research Associate who is, in effect, a concierge. They escort the participant around the medical center for the various procedures. They may be an examiner or interviewer who sits with the participant during neuropsychological testing or completion of healthcare questionnaires. They may take the participant to the cafeteria for lunch, or if time is short, purchase the lunch from the hospital cafeteria. These are also the individuals who make interval telephone calls to maintain the necessary contact with the participants during follow-up. This means that we had underestimated our need for support staff by as much as 50%.injecting radioactive compounds (or any other solution) is not universally accepted without good explanation. To facilitate this process, we talk in terms of the important changes that can occur in the brain with dementia, and that we can take a picture of those changes using that injected solution.We also learned that because many of these individuals were new to research, many of the procedures that we use must be explained to them in ways that differ from the more research-experienced individuals we are more accustomed to working with. For example, the PET procedures are explained in more detail as the notion of After our participants have completed their baseline examinations, we send them a signed certificate of participation accompanied by a color image of the surface of the brain using the Freesurfer parcellations. Frequently, this results in our getting telephone calls being asked to explain “what it means.” One of the Investigators always returns these calls; it is critically important to “give back” to the communities. We also attend monthly gatherings at local Community Engagement Centers – just being present increases our familiarity to the community.We also found that it was important to pay close attention to transportation needs. Many of our participants live in neighborhoods where public transportation is less than ideal . Consequently, we had to develop relationships with ridesharing services to obtain the quality of service that we wanted for our participants. Everyone is met at the door to the hospital by their “concierge,” and from there escorted to all of the tasks that they will do during the day. At the end of the day the ride is scheduled, and the “concierge” takes the volunteer back to the lobby and awaits the arrival of the car.Finally, while all imaging researchers are familiar with the problem of incidental findings, the quality of those findings in a study such as this is different than that which we have encountered in the past. Many of the individuals in the study had limited healthcare resources which might have identified potential problems; many participants do not have a regular annual physical. However, we have also had instances of more severe brain injury that was a consequence of the participants living environment. One individual, for example, had suffered a severe closed head injury, and the sequalae were evident on the scan. However, there was no mention of this event despite multiple opportunities during screening and interview. The individual seemed surprised that spending more than three days in the hospital, much of the time in coma, would result in brain damage. This view is likely due in part due to lack of awareness of health-related issues.p = 0.055) .better cognitive abilities, and fewer cognitive concerns than did the cognitively normal controls. The near absence of PiB retention means that these individuals were not as yet, on the AD pathology spectrum; although with a mean age of 60 years, the amyloid cascade may not be well developed, or perhaps other non-amyloid factors may be in play .that are outside of an individual’s control. At a population level, Black communities experience racism and more adverse social determinants of health, including negative work, living and educational conditions, that can lead to long-term negative biological consequences  are the children or grandchildren of the people who migrated from the rural South to cities like Pittsburgh. Growing up Black in a northern city in the 1950s and 1960s was likely associated with poorer educational quality, poor access to medical care and health maintenance, as well as a range of psychosocial consequences of explicit and implicit discrimination. It may be that any racial inequities in the development of cognitive impairments are driven by pervasive institutionalized inequities that shape risk and disadvantage individuals at multiple levels, including biological, environmental, behavioral, sociocultural . Althougequences . Indeed,equences . While tequences . This viequences .The data included in this project provides investigators around the world with the opportunity to investigate the spectrum of aging and AD effects on the brain and cognition using true-multimodal imaging, and detailed cognitive/behavioral evaluations. Genetic analyses will be completed starting at the end of 2020, and those restricted data will be available directly from the study investigators. Longitudinal follow-up of the individuals in the study is underway, and there are plans to enrich the sample of pre-DAT participants and continue follow-up. These data, combined with the main HCP dataset, the HCP Lifespan and Aging datasets, and the other CRHD project related to AD provide richest and most comprehensive resource for the neurobiological study of AD and related dementias.The study has two unique characteristics. First, the data are acquired using standard and standardized procedures that are shared by other CRHD studies, including the HCP Lifespan Study . This prThis leads us to what we believe is the most important implication of our data, and which is a weakness of the study as currently described. Specifically, we, like many others, make the mistake of “analyzing [our] findings by race/ethnicity without appropriate contextual data [which] could lead to inaccurate, misleading, or stigmatizing conclusions that may detract from the overall goals of diversity in research: to enhance the accuracy, utility, and generalizability of scientific evidence” . Race isreducing the impact of the positive social determinants of health (SDOH)  and increasing the impact of negative SDOH . Significant advances in AD and dementia prevention and management will be made as we accumulate more information SDOH and how racism affects their relationship with resilience, diagnosis, prognosis, and response to treatment.There is still considerable disagreement on the factors contributing to disparities in many AD- related outcomes, e.g., dementia onset and course. Much of this is likely due to the focus on individual behavior or “lifestyle factors” without consideration for the social, physical, and policy environments that are inextricably linked to the individual and are key to understanding health disparities . PerhapsThe CoBRA Study team includes: Ann D. Cohen, Beth E. Snitz, Ted Huppert, Tae Kim, Yue-Fang Chang, Yu Cheng, Jack Doman, Ricardo Bruña, Fernando Maestu, Avniel Ghuman, Anto Bagic, Ilyas Kamboh, Anne Newman, Steven Reis, Rebecca Roush, Lara Fatukasi, Leslie Kovach, Katey Potopenko, Howard J. Aizenstein, Lewis H. Kuller, William E. Klunk, Caterina Rosano, Oscar L. Lopez, and James T. Becker.With the exceptions of AC and JB, the order of the authors is alphabetical.https://www.humanconnectome.org/study/connectomics-brain-aging-and-dementia; NIMH Data Archive https://nda.nih.gov/edit_collection.html?id=3159.The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found below: HCP Connectome Central Facility The studies involving human participants were reviewed and approved by Human Research Protection Office; University of Pittsburgh. The patients/participants provided their written informed consent to participate in this study.AC and JB made the initial draft of the work while the remaining authors revised it for important intellectual content. All authors made substantial contributions to the conception and design of the work, as well as the acquisition, analysis, interpretation of data for the work, and had final approval of the version to be published.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Following the coup in Myanmar, humanitarian assistance, including coronavirus disease 2019 (COVID-19) control, must be implemented on the Thai-Myanmar border in the framework of international cooperation. The actual number of refugees was expected to increase in the Karen state at the end of March 2021, and they are at risk of contracting COVID-19 as they live in overcrowded conditions without access to basic sanitation. The global community has been hesitant to provide direct support because of fearing that such support would benefit the military. To reach this most vulnerable population, further strengthening of support through the Thai-Myanmar border as an alternative channel that was used before Myanmar's democratic transition in 2011 is necessary. Following the February 1st coup in Myanmar, the number of refugees likely preparing to cross the Thai-Myanmar border is expected to increase. Not only is the military unilaterally persecuting the general population, as is occurring in Yangon, but a state of war is likely beginning between the national army and ethnic minorities. From information received from the Mae Tao clinic, a health facility established by refugees from Myanmar to Thailand in 1989, more than 10,000 people have fled to the Karen and Karenni states from cities including Yangon and Mandalay, and most seem to be activists, non-governmental organization leaders, and participants in civil disobedience. Further, intensified attacks in ethnic areas since December 2020 have internally displaced over 8000 people according to the Free Burma Rangers  despite Although World Health Organization (WHO) reported that these vulnerable people are generally at low risk of transmitting communicable diseases to host populations , they arShould COVID-19 spread to the refugees’ border camps, it would be inhumane to leave them unattended, and ordinary activities of conventional medical facilities would likely come under great pressure. Further, discrimination and prejudice would deprive the refugees of work opportunities and exacerbate domestic violence and human trafficking .We recommend the provision of refugee assistance within an internationally coordinated framework at the Thai-Myanmar border that includes COVID-19 response and care. In particular, Japan can play a certain role because of its experience in providing humanitarian assistance to Myanmar both before and after the democratic transition in 2011. Although there are currently no official reports of increased cross-border refugees on the Thai side, many ordinary residents on the Myanmar side are already hiding in the jungle to avoid persecution by the Myanmar military, and the risk of these people becoming cross-border refugees is high.Global society is willing to provide direct humanitarian support to Myanmar, but the Myanmar people are refusing all international support that might benefit the military, including any kind of official developmental assistance. Thus, we believe that further strengthening of support through the Thai-Myanmar border as an alternative channel, which was used when Myanmar was under sanctions, is necessary to reach the people in this most vulnerable and difficult situation. To aid Indochinese refugees, we have been working with Thai and international societies  even thoAlthough the risk of COVID-19 spreading across the border is unclear, it is probably not low. In January 2021, just before the military coup, approximately 300 to 700 new cases were confirmed daily in Myanmar, and the number of cases totaled 140,145 . HoweverEven though Thailand has achieved some success in COVID-19 control, this issue must be addressed within the framework of international cooperation beyond the health sector. Since before Myanmar’s democratization in 2011, Japan has continued to provide support to the health and education sectors and has worked with the Ministries and Myanmar government to provide humanitarian assistance. Furthermore, Japan’s medical assistance to Indochinese refugees in the 1980s was pioneering in health sector support in Japan. We expect Japan to continue to work with Thai and international civil societies to address this potential current crisis at the Thai-Myanmar border.