Analysis: Early lessons from the COVID-19 pandemic

Benyam Worku, MD @benyam_wd &

Bizu Gelaye, PhD, MPH @b_gelaye

Addis Abeba, August 13/2020 – As we have seen it in other pandemics, the COVID-19 pandemics will pass too. The world will pick up the pieces, try to come to terms with the unfortunate loss of loved ones and begin to deal with the medical, psychological, social and economic ramifications of the crisis. Numerous articles and books will be written and films made about it for years to come. People from all walks of life will put forward their hypothesis on how and where it all began, how governments and regions dealt (or failed to deal) with it and lessons learned from it.

And once the dust settles down, international organizations and non-governmental organizations (NGOs) will reflect on lessons learned to ensure preparedness for next time. This is important. For instance, lessons learned from the Ebola pandemics allowed the creation of African Center for Disease Control and Prevention (CDC) and many countries in sub-Saharan Africa to have emergency preparedness plans.

Countries around the world have already realized that they have been woefully unprepared or underprepared on so many levels.  

It is equally, if not more, important to reflect on lessons we are learning even when we are in the middle of battling the pandemics. In this brief article, we outline the lessons we can learn from the pandemic while we are still in the midst of it. We are doing this for two reasons. First, once the pandemic is over it is going to be much harder to get the attention of multidisciplinary stakeholders including policy makers and the medical establishment. Second, it is usually while we are grappling with a current pandemic that we start formulating how we are going to react to the next big crisis. Our ability to critically reflect now provides a valuable window of opportunity to interrogate our health system. Otherwise, he price we pay for the next large-scale disaster is going to be of a higher order of magnitude

Countries around the world have already realized that they have been woefully unprepared or underprepared on so many levels.  

It is very likely that Low and middle income countries (LMICs) will eke out whatever they can afford to prepare for the next flu-like pandemic. In the coming months and years, one should not be surprised to see even remote hospitals and health posts stocked with hundreds of expired N95 masks and even some with ventilators despite lacking health professionals that can work with them.

But the risk of being overly-focused on the next flu-like pandemic is that countries, especially LMICs, will leave themselves exposed to the next unexpected disaster.

In the event of such a health crisis happening again, countries will be once again scrambling to find the right fix. LMICs, having invested their meager health budgets on extensive flu-related preparedness will once again face the barrel of the gun, so to speak.

How should LMICs prepare for the next high impact event?

We propose that the focus should be on how rather than what. One should think of as many high impact events as possible and try to figure out the least common denominator across them and work on refining them continuously. The right lessons from the current pandemic are the ones that are systemic and non-specific. These lessons should be the ones that are going to make our future response more agile and our systems more robust and resilient.

Countries should definitely be prepared for similar pandemics that might happen in the future. It is advisable to make sure that PPEs, ventilators and other equipment are available both for current and future emergency needs. It is important to ensure that countries have reasonable number of critically needed medical equipment and PPE in storage. However, an important lesson to learn from the current crisis should be the need for strategies to enable relevant factories to develop the capacity to adapt to the exigencies of the situation and be able to produce lifesaving medical supplies on short notice. The lesson is not necessarily building more factories dedicated for the production of hand sanitizers or gloves but building a multi-purpose factory with a certain amount of inbuilt capacity and flexibility to adapt to different needs and enable the production of, for example, iv fluids for  a cholera epidemic.

Many institutions at high income countries have been able to set-up urgent ethical reviews of SARS-CoV-2/COVID-19-related research studies despite competing priorities and challenges of assembling members of their review boards remotely. There are over 500 clinical trials related to Covid-19 in high-income countries. LMICs should also reexamine the efficiency of their regulatory institutions and make sure there are provisions put in place for emergency research such as this pandemic without necessarily compromising safety requirements and scientific rigor. The same should hold to any and all other sectors that are needed to react with speed to the demands of the crisis.

Rapid response teams or divisions within ministries should be dynamic rather than static structures and should be composed of professionals with different backgrounds that pertain to risk analysis and expertise in complex systems. These teams should always be flexible to change or attract new members based on the evolution of a crisis and its handling.

Bias to action should be the order of the day in scenarios where there is significant asymmetry between the consequences of acting and not acting early. As is evident from the current crisis, what appears to be an overreaction might end up being the right response in hindsight. Usually the fallout from a genuine overreaction is either reversible or the cost minimal in comparison with complacency.

Today’s world is extremely interconnected. Infectious diseases from one end of the world can travel to the other at a speed never seen before. Another effect of this interconnectedness is the interdependence of nations in far flung countries for various products and services. While globalization has bestowed upon the world great benefits, it has also introduced some degree of vulnerability. The global supply chain might get stretched or break under sudden or prolonged stress. A natural or man-made disaster in one corner of the world might result in severe shortage of food or medicine in a country very far away from it. LMICs should build a reserve for critical supplies and/or develop the capabilities for local production when importation becomes a challenge.

We propose that countries develop a backup system and strategies based on the above mentioned considerations and principles that would serve analogous function as a safe mode: a system that keeps a nation going while it figures out how to deal with the crisis at hand and serving as a portal of entry for more sophisticated and more specific interventions.

Arguably, the most important lesson is to keep an open mind to study the effects of the current pandemic on existing health systems as well as other systems. The pandemic is ruthlessly exposing the strength and weakness of already over-stretched health care systems. While exposing the frailties of health systems all over the world, it also revealed the strengths of almost all countries affected by it: the strength of the federal system in the United States, the benefits of socialized medicine in Canada and the UK, the efficiency of the German system, the role of technology in South Korea to name a few.

One should revisit pandemic related local experiences, for example Community Based Intervention for Ebola in West Africa and the potential of other community based resources such as the experiment with Health Extension Workers in Ethiopia

The same is true for LMICs. It is going to reveal the strength of local traditions and values as well as the potential of LMICs to innovate.  It is important to capitalize on local initiatives rather than copying wholesale approaches that proved successful in other parts of the world. One should revisit pandemic related local experiences, for example Community Based Intervention for Ebola in West Africa and the potential of other community based resources such as the experiment with Health Extension Workers in Ethiopia. 

Local mobilization of resources in terms of local production of PPEs and ventilators using locally available resources and technologies such as 3d printing is also encouraging. These initiatives demonstrate the potential of local entrepreneurs, scientists and technologists to transcend economic limitations and rise to the occasion. Using this as a launching opportunity to kick start local innovations in LMICs should be one important takeaway.

In conclusion, while countries should definitely be prepared for similar pandemics that might happen in the future their response should not be constrained by the specific nature of the current pandemic. LMICs should reexamine the efficiency of their regulatory mechanism; rapid response teams or divisions within ministries should be multidisciplinary and dynamic rather than static. We also propose for countries should follow the precautionary principle and build a reserve for critical supplies and/or develop the capabilities for local production. Last but not least, keeping an open mind to study the effects of the current pandemic on existing health systems as well as other systems is indispensable. AS

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Editor’s Note: Benyam Worku, MD, is an Assistant Professor at the Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Abeba University (AAU). He is also a Consultant Psychiatrist at Tikur Anbessa Specialized Hospital and Psychotherapy, Humanities, and Psychosocial Interventions Fellow at Department of Psychiatry, University of Toronto. He can be reached at: benyam.worku@aau.edu.et

Bizu Gelaye, PhD, MPH, is an Assistant Professor at The Chester M. Pierce, MD Division of Global Psychiatry, Massachusetts General Hospital, Harvard Medical School, and The Harvard T. H. Chan School of Public Health. He is also Co-Director of Research Ethics, Center for Bioethics, Harvard Medical School and Associate Director of the Global Initiative for Neuropsychiatric Genetics Education in Research. He can be reached at: bgelaye@hsph.harvard.edu