By George Gotsadze, President of Curatio International Foundation, and Executive Director of Health Systems Global
As I embark on writing this blog, the global outbreak of COVID-19 is posing a growing threat to the health and well-being of our societies. The unfolding global health and economic crisis demands bold actions from all of us, but most importantly from policymakers. Governments are forced to balance policy choices between minimizing the death toll caused by the infection while reducing the negative economic impact expected in the aftermath of the COVID19 outbreak, when hard-hit economies with rising unemployment are expected to leave millions of households without subsistence income.
By now, most of us realize that post-COVID-19 times will come at a significant societal and economic cost, slowing the pace of global development for some years to come. Wealthy nations, at least, are announcing hefty economic packages, supporting middle and low-income families and responding to the economic downturn. Poor countries, meanwhile, are left to choose between: (a) using social distancing to delay the epidemic spike and reduce its magnitude, thereby allowing weak health systems to cater to their patients; and (b) deciding on the length of the “lock-down”, which curtails economic activity for a significant length of time but is highly detrimental to many people living on subsistence, or even average, incomes. Such decisions demand evidence about the virus and its epidemiological characteristics, modeling results estimating the burden on the health system and the economic cost arising from social distancing, information about health systems capacity and available human resources, etc.
The policymaking process in my own country revealed numerous shortcomings in the available evidence, but it also opened up promising and welcoming developments. I decided to reflect on these experiences to reveal the developments, challenges, and possible knowledge gaps that need to be filled:
- Firstly, disease models are essential when dealing with an epidemic of such magnitude. They help to estimate (with a significant degree of uncertainty) the growth of infection spread and the possible burden on the health system – a critical element for health sector preparedness planning. While a search on Google Scholar using the “Epidemic AND Modelling AND LMIC” search term, which was constrained to the last decade, produced 4,130 search results (as of March 30, 2020), we were only able to locate a single user-friendly Excel-based modeling tool developed by US CDC FluSurge2.0 for seasonal flu. This was the only tool in the public domain, but it was not suitable for COVID19 estimates. Thus, if you live in an LMIC setting not surrounded by experienced disease modelers (which I assume is the case in many similar settings), you are most likely left without any support. In the current, interconnected world, it should not be allowed for valuable weeks to be lost when drawing up hospital and health sector preparedness plans, especially when hundreds of millions are spent on the disease modeling globally. The Penn Medicine – COVID-19 Hospital Impact Model for Epidemics emerged during the week of March 15th, and thanks to our colleagues around the world, user-friendly modeling tools were developed swiftly and placed online in free public space legally within the subsequent two weeks. I think that in the future, research funders should mandate modelers not only to publish their papers but to also make the models publicly accessible if the world has to prepare for the next pandemic in the Global North and South alike.
- Secondly, it seems there is a significant gap around the impact of non-medical interventions for epidemic control. Most questions asked by policymakers about the impact of social distancing measures on transmission spread and economic costs were hard to answer due to largely patchy evidence. It seems this is an area for future research, not only in high-income settings. It is also important for systematic reviews to support answering such questions when asked in the future.
- Thirdly, close to 390 published papers and pre-prints emerged during the month of March 2020 alone (based on our search). New evidence is being produced almost daily, conveying the “fresh” and essential information needed for preparedness planning and for learning from different country experiences (good and bad alike), etc. Thanks to all those making pre-publications available freely online. Nobody should underestimate the value of this public good, especially in settings similar to ours. While these papers were not peer-reviewed, the benefits probably outweigh the shortcomings, especially when the papers are disseminated through social media and peers render immediate reactions revealing the strength and weaknesses of the studies in question. Looking at peer comments on social media, which was extremely helpful, I was left wondering whether global health journals should consider using artificial intelligence to capture these comments for re-imagined and accelerated peer-review process? It may take time, but if this were possible, it could accelerate the publication of quality and peer-reviewed papers and could be hugely beneficial for the scientific field.
- Finally, the challenges of evidence search revealed the value of global networking, especially for those operating online. We were lucky, as part of Health Systems Global as well as other networks that allowed us to call for help (using appropriate social media and other communication channels), which came without delay. It was great to observe the value of peer support with suggestions, offering online help when faced with technical or other challenges, referring to great websites and repositories, etc. However, I wondered how many of our peers who work on knowledge production-translation are aware of or are able to mobilize such peer support at short notice? All of this led me to the desirability of collecting personal stories around the world about the peer-support channels one could tap into when conducting rapid evidence review. Such stories could help to develop a knowledge product – guidance document benefitting many around the world and enhancing our collective ability to support knowledge to policy links.
To conclude, I am sure that COVID-19 will be over, and that we will learn to live with it after paying a high cost as a society. We will return to “new normal” lives with new lessons and with new opportunities to explore. Of course, this is far from being a full account of our experiences, and I hope to have more time in the future to better reflect on policymaking and evidence needs, knowledge gaps, and emerging opportunities. But it is time to stop here and wish you all good health in this COVID-19-challenged world.