The article is predicated on the notion that “The ability to preferentially protect high-risk groups in COVID-19 is hotly debated.” This is a mischaracterisation of the debate. The ability to protect high-risk groups has never been questioned.
The debate would be better characterised as the ability to focus non-pharmaceutical interventions solely on those most at risk of severe disease due to COVID-19, and removing restrictions and allowing widespread infection amongst the low risk groups. The debate has only ever been between those who advocated only applying NPIs to the highest risk cohorts ("focussed protection") and those that advocate that community wide measures are the only effective means to protect those at highest risk.
The stated aim of this paper is to demonstrate whether ‘precision shielding’ was achieved in the first wave, and invents a metric to compare incidence and death in the high risk long-term care population vs the low risk younger population. The author uses seroprevalence data from the elderly and the young to estimate infection prevalence, but takes no account of the differing antibody response that would largely confound this approach.
Using these metrics the author then goes on to ascribe a value judgement as “substantial shielding” or “substantial inverse protection.” Care homes and institutions are already known to be at risk environments for the spread of infectious disease, due to the close contact care work, the m...
The article is predicated on the notion that “The ability to preferentially protect high-risk groups in COVID-19 is hotly debated.” This is a mischaracterisation of the debate. The ability to protect high-risk groups has never been questioned.
The debate would be better characterised as the ability to focus non-pharmaceutical interventions solely on those most at risk of severe disease due to COVID-19, and removing restrictions and allowing widespread infection amongst the low risk groups. The debate has only ever been between those who advocated only applying NPIs to the highest risk cohorts ("focussed protection") and those that advocate that community wide measures are the only effective means to protect those at highest risk.
The stated aim of this paper is to demonstrate whether ‘precision shielding’ was achieved in the first wave, and invents a metric to compare incidence and death in the high risk long-term care population vs the low risk younger population. The author uses seroprevalence data from the elderly and the young to estimate infection prevalence, but takes no account of the differing antibody response that would largely confound this approach.
Using these metrics the author then goes on to ascribe a value judgement as “substantial shielding” or “substantial inverse protection.” Care homes and institutions are already known to be at risk environments for the spread of infectious disease, due to the close contact care work, the multiple staff per patient, and the vulnerability and general immobility of the patient population as a whole. Terming this as “inverse protection” adds very little clarity to this area.
On the basis of this analysis the author concludes 'precision shielding' is possible in 'real-life circumstances' but takes no account of the community-wide transmission which is the actual focus of the debate, and the basis for the statement that this approach is not feasible in reality. When correlated with the cumulative cases/million by the end of the first wave (ourworldindata.org) the shielding metric the author lays out for these 10 countries shows a very strong correlation: (Rsq of 0.82), showing that in the presence of high community transmission, 'precision shielding' isn't possible, while very effective community-wide suppression, such as in South Korea, made this much more feasible. An effective argument, amongst many others including economic impact, ethical considerations, multi-generational families, unknown risk in the community and long-term COVID morbidity, why 'focussed protection' or 'precision shielding' is unfeasible in the real-world.
We read with interest the article ‘How global is global health Research? A large-scale analysis of tends in authorship’ by Dimitris and colleagues published in BMJ Global Health January 2021.1 The authors’ research highlights the slow progress in proportion of studies with any, first, and, last authors affiliated with a low- or middle-income country (LMICs), particularly in first and last authorship. The authors welcome and have called for a thorough discussion about the implications of these findings, particularly in identifying the barriers and facilitators to diversity in authorship.
Reflecting on our experience of international research in infectious diseases and antimicrobial resistance we present here some of the barriers we have faced together with the solutions which we have identified. Recognising however, that addressing this inequity requires broader inclusion and participation from academic institutions, scientific journals and funders, we propose remedial steps at every level which will require a different approach to scientific research funding and communication.
There is a culture and hierarchy within academia which manifests itself in the authorship order. It is accepted that the first leads the writing and last author leads the research with all authors contributing to the final manuscript. There are of course the guidelines from the International Committee of medical Journal Editors which clearly stipulate the rol...
We read with interest the article ‘How global is global health Research? A large-scale analysis of tends in authorship’ by Dimitris and colleagues published in BMJ Global Health January 2021.1 The authors’ research highlights the slow progress in proportion of studies with any, first, and, last authors affiliated with a low- or middle-income country (LMICs), particularly in first and last authorship. The authors welcome and have called for a thorough discussion about the implications of these findings, particularly in identifying the barriers and facilitators to diversity in authorship.
Reflecting on our experience of international research in infectious diseases and antimicrobial resistance we present here some of the barriers we have faced together with the solutions which we have identified. Recognising however, that addressing this inequity requires broader inclusion and participation from academic institutions, scientific journals and funders, we propose remedial steps at every level which will require a different approach to scientific research funding and communication.
There is a culture and hierarchy within academia which manifests itself in the authorship order. It is accepted that the first leads the writing and last author leads the research with all authors contributing to the final manuscript. There are of course the guidelines from the International Committee of medical Journal Editors which clearly stipulate the roles of authors and contributors.2 Writing manuscripts requires not only the skills to undertake research but to communicate it. Barriers to inclusion of LMICs first and last authors often is due to the inexperience of junior researchers writing research to a standard that is accepted by mainstream scientific journals, the majority of which are in English. Hence, writing scientific literature requires not only expertise in research but also in English. In collaborative, international research projects it is imperative to enable space for growth, learning and capacity building within country, and move away from the culture of well-funded high income research institutes dispatching researchers to LMICs to conduct research, leaving little opportunity for knowledge exchange and development. To do this effectively capacity building must be core to research collaborations, including investment in workforce and training.3 We have found success in developing mentorship programmes in our research collaborations which ensure that researchers are employed locally and trained by the extended research team. The mentorship has included supporting junior researchers to participate in writing research papers and have the opportunity to be first authors on work that they have driven locally. This has meant a conscious effort to consistently scrutinise and evaluate the equity and balance in representation in every piece of work that is submitted. As a rule of thumb a baseline expectation should be to ensure that one of either first or last authorship is assigned to LMICs partners for work being carried out in or in collaboration with LMICs. This means that from the outset there are clear expectations on work from each partner and decisions about authorship are not left to the last minute. This approach also clarifies the level of involvement and work that each person in the research team has to contribute to be acknowledged as an author. To do this effectively and sustainably there has to be capacity building in place to ensure that knowledge and skills are developed alongside data gathering and analysis (Figure 1).
Figure 1 The steps required to address barrier to and facilitate equity in authorship of global health research
Another barrier which is increasingly more difficult to address is the costs of publication and unfamiliarity with the submission process, which means that much of the world is not equitably represented in academic publishing. Additionally, the current predominantly anonymised peer review process limits the learning potential from the academic peer review dialogue that often helps transform manuscripts into published articles. Publication costs are an enormous barrier, particularly in LMICs where institutions often do not benefit from the block funding available to many high-income academic institutions to cover costs of publication for their researchers. What this means that occasionally the LMICs researchers have to rely on out-of-pocket expenses which range between £1200 to over £2000 for open access publishing. As we write this letter, we are in the process of trying to reverse one such cost inflicted on colleagues who were invited to submit research undertaken in Uganda. The solution to this lies in part with scientific journals, academic institutions, and funders. Scientific journals need to have clear policies for submitted research from LMICs where there is no institutional support for open access funding, with reduced LMICs fees and options for waiving publication fees from researchers who do not have grant funding or institutional support. Reviewers and editors need to call out academic manuscripts which do not have equitable representation of authors from countries where the research is conducted, and question submitting authors on this. Academic institutions in high income countries need to relax their rules around funding research articles for publications where the first, last, and/or corresponding author is not from their institution. Funders should stipulate a condition of their grant to be that for research that involves LMICs partners the authorship should be equitable and balanced in first, last, and corresponding authorship. Furthermore, they need to recognise that capacity building and research communication costs need to be adequately detailed and costed in international grant applications and be part of the monitoring and evaluation process.
Only when the need for equitable funding is recognised at all these levels, can we address the current disparities in representation in research from LMICs partners.
References
1. Dimitris MC, Gittings M, King N. How global is global health Research? A large-scale analysis of tends in authorship. BMJ Global Health 2021;6:e003758.
2. International Committee of Medical Journal Editors. Defining the role of Authors and Contributors. Website: http://www.icmje.org/recommendations/browse/roles-and-responsibilities/d... Date accessed: 05 February 2021
3. P Veepanattu, S Singh, M Mendelson, V Nampoothiri, F Edathadatil, S Surendran, C Bonaconsa, O Mbamalu, S Ahuja, G Birgand, C Tarrant, N Sevdalis, R Ahmad, A Holmes, E Charani. Building resilient and responsive research collaborations to tackle antimicrobial resistance – lessons learnt from India, South Africa and UK. Int J of Infect Dis 2020;100:278-282.
I congratulate the authors who successfully conducted a survey on the current provision of global health education (GHE) in United Kingdom (UK) medical schools.1 Their findings are in keeping with a recent cross-sectional study into the timetables of UK medical schools.2 In the methods section of the paper, the global health learning outcomes and competencies surveyed were listed. However, global surgery was neither surveyed nor discussed in this paper.
This occurred despite global surgery being added as a mandatory learning objective to the national undergraduate curriculum in surgery by the Royal College of England in 2015.3 Post 2015, GHE studies2 and study protocols4 have typically strived to ensure that global surgery is assessed within their study designs. This is particularly important as global surgery often becomes the ‘neglected stepchild of global health’.5 It is easy to see why given that approximately two-thirds of UK medical courses are reported not to cover this topic within their core curriculum.2 It is not in the best interests of the population for a subject of such importance to be ignored by global health researchers and educational institutions.
Therefore, whilst it is encouraging that a study has been done with the aim of identifying gaps in GHE teaching in UK medical schools, the study design in and of itself has resulted in the researchers missing gaps.2 This exemplifies the importance of having a diverse range of stakeholders involve...
I congratulate the authors who successfully conducted a survey on the current provision of global health education (GHE) in United Kingdom (UK) medical schools.1 Their findings are in keeping with a recent cross-sectional study into the timetables of UK medical schools.2 In the methods section of the paper, the global health learning outcomes and competencies surveyed were listed. However, global surgery was neither surveyed nor discussed in this paper.
This occurred despite global surgery being added as a mandatory learning objective to the national undergraduate curriculum in surgery by the Royal College of England in 2015.3 Post 2015, GHE studies2 and study protocols4 have typically strived to ensure that global surgery is assessed within their study designs. This is particularly important as global surgery often becomes the ‘neglected stepchild of global health’.5 It is easy to see why given that approximately two-thirds of UK medical courses are reported not to cover this topic within their core curriculum.2 It is not in the best interests of the population for a subject of such importance to be ignored by global health researchers and educational institutions.
Therefore, whilst it is encouraging that a study has been done with the aim of identifying gaps in GHE teaching in UK medical schools, the study design in and of itself has resulted in the researchers missing gaps.2 This exemplifies the importance of having a diverse range of stakeholders involved in GHE study designs. A more diverse panel of authors or a more complete patient and public involvement stage could have ensured the inclusion of global surgery into the survey or at least into the discussion section of this paper. For global surgery to truly get the attention it needs, it is critical that it features in global health research, particularly in studies such as this.
There now exists a need to conduct a survey study to better understand the perceived status of global surgery teaching within the UK medical curricula. This survey should evaluate whether medical students are exposed to global surgery during medical school, how they are exposed to global surgery, and whether the types of exposures meet the needs of students. It is equally essential to collect data on the opinions shaped by this experience; therefore, career aspirations and perceived barriers to joining the global surgery workforce must be elucidated also.
References
1 Matthews NR, Davies B, Ward H. Global health education in UK medical schools: a review of undergraduate university curricula. BMJ Glob Heal 2020; 5: e002801.
2 Collaborative IU. Global health education in medical schools (GHEMS): a national, collaborative study of medical curricula. BMC Med Educ 2020; 20: 389.
3 The Royal College of Surgeons England, (RCSENG). National undergraduate curriculum in surgery 2015. RCSENG – Prof Stand Regul 2015.
4 Bandyopadhyay S, Shortland T, Wadanamby SW, et al. Global Health Education in UK Medical Schools (GHEMS) study protocol. J Glob Heal Reports 2019; 3. DOI:10.29392/joghr.3.e2019052.
5 Farmer PE, Kim JY. Surgery and global health: A view from beyond the OR. World J. Surg. 2008; 32: 533–6.
Candal-Pedreira and colleagues showed that for 304 retracted papers, overall citations increased not decreased following retraction, but citations did seem to decrease for retracted papers in higher impact journals and those with higher citation rates, although that decrease might have been temporary.1 It is disturbing that retracted papers continue to be cited.
We approached the issue of changes in citations rates after retraction in a different way. We assessed citation rates of retracted and unretracted publications from individuals with more than one retracted publication in the Retraction Watch database.2 Using this approach, we found that, overall, citations for 989 retracted publications declined after the retraction and citations for 9671 unretracted papers also declined after the author’s first retraction, but the decline was greater for retracted papers. For example, for retracted publications, 671 papers had 3566 citations in the 3rd year before their retraction and 831 papers had 1575 citations in the 3rd year after their retraction. In contrast, 5311 unretracted papers had 17935 citations in the 3rd year before the author’s first retraction, and 7388 papers had 17252 citations in the 3rd year after the author’s first retraction.
Part of the difficulty in conducting and interpreting such analyses is the different lengths of time pre-and post-retraction for different papers. To try to address that issue, we calculated the slope of the citations/yea...
Candal-Pedreira and colleagues showed that for 304 retracted papers, overall citations increased not decreased following retraction, but citations did seem to decrease for retracted papers in higher impact journals and those with higher citation rates, although that decrease might have been temporary.1 It is disturbing that retracted papers continue to be cited.
We approached the issue of changes in citations rates after retraction in a different way. We assessed citation rates of retracted and unretracted publications from individuals with more than one retracted publication in the Retraction Watch database.2 Using this approach, we found that, overall, citations for 989 retracted publications declined after the retraction and citations for 9671 unretracted papers also declined after the author’s first retraction, but the decline was greater for retracted papers. For example, for retracted publications, 671 papers had 3566 citations in the 3rd year before their retraction and 831 papers had 1575 citations in the 3rd year after their retraction. In contrast, 5311 unretracted papers had 17935 citations in the 3rd year before the author’s first retraction, and 7388 papers had 17252 citations in the 3rd year after the author’s first retraction.
Part of the difficulty in conducting and interpreting such analyses is the different lengths of time pre-and post-retraction for different papers. To try to address that issue, we calculated the slope of the citations/year for individual papers for up to 5 years immediately prior to the year of the retraction (or the year of the author’s first retraction for unretracted papers) and for up to 5 years following first retraction. The median change in this slope was greater for retracted publications (−0.3, 95% CI −11.8 to 1.6) than for unretracted papers (0.0, 95% CI −6.3 to 1.7: P < 0.001).2
We agree with the Candal-Pedreira and colleagues that improvements are needed: there is no longer any excuse for citation of retracted publications. Publishers need to ensure that all retractions are clearly categorised on all commonly used bibliographic databases, and authors and journals need to ensure that papers cited have not been retracted, for example by using reference management tools such as Zotero that automatically update references when a retraction occurs.
1. Candal-Pedreira C, Ruano-Ravina A, Fernandez E, et al. Does retraction after misconduct have an impact on citations? A pre-post study. BMJ Glob Health 2020;5(11).
2. Mistry V, Grey A, Bolland MJ. Publication rates after the first retraction for biomedical researchers with multiple retracted publications. Account Res 2019;26(5):277-87.
Editor, the commentary highlights the sad situation the Levant region in the middle east has reached. The Syrian healthcare workers are most needed in Syria and not in Germany. It is their very country which is in most need for their services. Syria now has shortage of trained doctors and nurses to help fellow country men and women recover from war injuries and myriad of infectious and non-communicable diseases. Integrating in Europe is never easy for a people from Muslim countries, even if the were professionals (https://www.dailymail.co.uk/news/article-8854519/Muslim-doctor-refused-s...). I have lived in London for over 30 years and still feel an outsider in the UK. How will these refugees cope with the threat of their children losing their Arabic language or Muslim identity. Careers are not everything. It just baffles me why the Syrians who came to Europe could not seek refuge in rich Arab nations. Something terribly wrong is going on in the middle east and coming to Germany is not the answer. Syrian refugees are looking for a quick fix, but they should go back to their own country and tough it out to rebuild what was demolished before someone else comes and takes their places! Britons and Germans did not run away from their countries during the two world wars! Did millions of Britons leave to America to escape WWII? Why have did almost...
Editor, the commentary highlights the sad situation the Levant region in the middle east has reached. The Syrian healthcare workers are most needed in Syria and not in Germany. It is their very country which is in most need for their services. Syria now has shortage of trained doctors and nurses to help fellow country men and women recover from war injuries and myriad of infectious and non-communicable diseases. Integrating in Europe is never easy for a people from Muslim countries, even if the were professionals (https://www.dailymail.co.uk/news/article-8854519/Muslim-doctor-refused-s...). I have lived in London for over 30 years and still feel an outsider in the UK. How will these refugees cope with the threat of their children losing their Arabic language or Muslim identity. Careers are not everything. It just baffles me why the Syrians who came to Europe could not seek refuge in rich Arab nations. Something terribly wrong is going on in the middle east and coming to Germany is not the answer. Syrian refugees are looking for a quick fix, but they should go back to their own country and tough it out to rebuild what was demolished before someone else comes and takes their places! Britons and Germans did not run away from their countries during the two world wars! Did millions of Britons leave to America to escape WWII? Why have did almost 6 million Syrians leave their country? My parents left Palestine to Lebanon in 1948 anticipating to return to Haifa after few weeks. More than 70 years on we, their children, are still wondering whether we will ever visit Palestine.
In relation to SAM terminology. No one could argue with the logic of acute v chronic. However, SAM is well understood at a policy level. It is however understood at above six months. The work that ENN and MAMI have done on identifying wasting at birth is a narrative change which can lay the foundation for the bridging language that the paper talks about.
Narrative is a story that people can understand.
As pointed out, consistency is important, but consistency must hover across the 1000 day window. Currently, our terminology for narrating fetal undernutrition is very weak. While simplistic, if children are being born wasted, then they are also wasted in utero. To fully open the curtains, we would suggest that the SAM terminology be adapted to include fetal malnutrition. The narrative neither stops nor begins at birth regardless of the terminology we use.
In relation to the false positives and visa versa. Given current programming capacity and coverage rates well below 20% for CMAM false negatives represent only a tiny fraction of those who need treatment and do not receive it. Focus on false positives takes away from the substantive issue of low coverage rates for Essential Nutrition Actions across the 1000 day window.
On a broader theme, it would be helpful to explore how the food system and the food system summit support people in immediate need.
A conversation starter
The food system belongs to...
In relation to SAM terminology. No one could argue with the logic of acute v chronic. However, SAM is well understood at a policy level. It is however understood at above six months. The work that ENN and MAMI have done on identifying wasting at birth is a narrative change which can lay the foundation for the bridging language that the paper talks about.
Narrative is a story that people can understand.
As pointed out, consistency is important, but consistency must hover across the 1000 day window. Currently, our terminology for narrating fetal undernutrition is very weak. While simplistic, if children are being born wasted, then they are also wasted in utero. To fully open the curtains, we would suggest that the SAM terminology be adapted to include fetal malnutrition. The narrative neither stops nor begins at birth regardless of the terminology we use.
In relation to the false positives and visa versa. Given current programming capacity and coverage rates well below 20% for CMAM false negatives represent only a tiny fraction of those who need treatment and do not receive it. Focus on false positives takes away from the substantive issue of low coverage rates for Essential Nutrition Actions across the 1000 day window.
On a broader theme, it would be helpful to explore how the food system and the food system summit support people in immediate need.
A conversation starter
The food system belongs to every one of us. The Food System and so the Food Systems Summit, at its cornerstone must aspire to meet all peoples immediate nutritional needs every day.
We have read this excellent article with interest. As physicians based in Pakistan: a low-middle income country and not having English as our first language, we could relate to the challenges mentioned in this manuscript. Authors have very rightly pointed out that the issue with most of the researchers based in the low-income (LIC) and middle-income countries (LMIC) is not of poor or low-quality science. We need data and experience sharing from all parts of the world in order to complete the bigger picture and understand the issues that we face today in health, environment, and social sciences. One of the main challenges authors based in the LIC and LMIC face is the issue of presentation of that data i a presentable form. Due to the lack of training opportunities, many authors are unable to write manuscripts that meet the high standards of global scientific journals. This deprives these authors of an opportunity to publish in journals with a global audience and the world misses out on reading a different perspective from the LIC or LMIC. In this context, the introduction of PREPSS is an excellent and welcome initiative that must be supported and promoted.
In this context, we would like to highlight the role of AuthorAID: a global platform of more than 17,000 researchers from all around the globe. We have been extensively using this platform for more than a decade to learn and now collaborate and teach other researchers based in the LIC and LMIC. AuthorAID also pr...
We have read this excellent article with interest. As physicians based in Pakistan: a low-middle income country and not having English as our first language, we could relate to the challenges mentioned in this manuscript. Authors have very rightly pointed out that the issue with most of the researchers based in the low-income (LIC) and middle-income countries (LMIC) is not of poor or low-quality science. We need data and experience sharing from all parts of the world in order to complete the bigger picture and understand the issues that we face today in health, environment, and social sciences. One of the main challenges authors based in the LIC and LMIC face is the issue of presentation of that data i a presentable form. Due to the lack of training opportunities, many authors are unable to write manuscripts that meet the high standards of global scientific journals. This deprives these authors of an opportunity to publish in journals with a global audience and the world misses out on reading a different perspective from the LIC or LMIC. In this context, the introduction of PREPSS is an excellent and welcome initiative that must be supported and promoted.
In this context, we would like to highlight the role of AuthorAID: a global platform of more than 17,000 researchers from all around the globe. We have been extensively using this platform for more than a decade to learn and now collaborate and teach other researchers based in the LIC and LMIC. AuthorAID also provides services related to the process of conducting, analyzing, and reporting research. However, the model of AuthorAID is different from the PREPSS. AuthorAID provides a platform for mutual collaboration among researchers based in different parts of the world by connecting them as mentors and mentees. The process entails free registration on the website and completing the profile including details of the collaboration and help one is seeking. The mentee has to identify the mentor from the list available and send a request for mentorship. Once the request is accepted, a formal online agreement has to be signed by both parties. The agreement clearly spells out the nature of the help requested ( formulating the research question, assistance with data analysis, help with the writing process, choosing a target journal, and responding to peer reviewers' comments) , time lines, mode, and frequency of communication planned.
We both have benefited immensely from the free services, resources and online courses offered by AuthorAID and now have progressed from mentees to mentors helping others.
The world has become a global stage open to all. It is very encouraging to see initiatives like PREPSS and AuthorAID which are primarily meant fro the authors and researchers based in the LIC and LMIC. These platforms not only foster global collaboration, create long-term professionals networks but also help researchers based in developing countries to share their rich experiences and publish in international journals with a global readership. This makes the world a better place
Introduction and Brief Overview
The Global Health Security (GHS) Index is the first comprehensive assessment and benchmarking of health security and related capabilities across the 195 countries that make up the States Parties to the International Health Regulations (IHR [2005])1. The GHS Index takes into account countries’ capability to prevent, detect, and respond to public health emergencies while also assessing the robustness of the healthcare system in each country. This index is comprehensive since it has the ability to consider political and socioeconomic risks, as well as adherence to international norms, which can influence countries’ abilities to stop outbreaks1,2. The GHS Index has been the creation of Open Philanthropy Project, the Bill & Melinda Gates Foundation and the Robertson Foundation1.
The GHS Index treats biosafety and biosecurity as critical components of global health security. As such, the tool includes numerous indicators measuring country capacities and accounts for differences in priorities between high income and low/middle income countries. The GHS index is based on 6 categories, 34 indicators, and 85 sub-indicators. The six categories comprise prevention, detection and reporting, rapid response, health system, compliance with international norms, and risk environment5.
This article describes the practical value of the GHS Index and also explains how the methodology of assigning country ranks and scores is helpful in aidin...
Introduction and Brief Overview
The Global Health Security (GHS) Index is the first comprehensive assessment and benchmarking of health security and related capabilities across the 195 countries that make up the States Parties to the International Health Regulations (IHR [2005])1. The GHS Index takes into account countries’ capability to prevent, detect, and respond to public health emergencies while also assessing the robustness of the healthcare system in each country. This index is comprehensive since it has the ability to consider political and socioeconomic risks, as well as adherence to international norms, which can influence countries’ abilities to stop outbreaks1,2. The GHS Index has been the creation of Open Philanthropy Project, the Bill & Melinda Gates Foundation and the Robertson Foundation1.
The GHS Index treats biosafety and biosecurity as critical components of global health security. As such, the tool includes numerous indicators measuring country capacities and accounts for differences in priorities between high income and low/middle income countries. The GHS index is based on 6 categories, 34 indicators, and 85 sub-indicators. The six categories comprise prevention, detection and reporting, rapid response, health system, compliance with international norms, and risk environment5.
This article describes the practical value of the GHS Index and also explains how the methodology of assigning country ranks and scores is helpful in aiding decision making for different countries on their health system preparedness. This concept is especially very timely in the current COVID-19 pandemic in measuring global health security capacities and pointing out areas for improvement. The main learning from the GHS index is that national health security is fundamentally weak around the world. The average GHS Index score among all 195 countries was 40.2 of a possible score of 100.
Methodology
The GHS tool is effectively building on the World Health Organization’s (WHO) Joint External Evaluation (JEE) which results from a collaboration that countries can volunteer to undertake to assess their compliance with the standards that have been agreed upon by the international community. The intuitive technique of scoring and ranking is used for summarizing complex health system capacities across diverse contexts3,4.
Critique/Commentary
Due to the way the tool is structured, GHS Index may be prone to misinterpretation as a forecasting tool which it clearly is not. It is in fact a snapshot in time of a country’s preparedness in tackling infectious disease outbreaks given the prevailing socio economic and political conditions. It would have been fascinating to see Andersen’s Model of Healthcare Utilization being used in the development of this index since it encompasses predisposing, enabling and need factors driving healthcare resource use. Many commonly used indicators of health security capacity like GHS Index are somewhat a rigid framework of outbreak prevention, detection and response. This framing likely fails to account for socio- cultural determinants of health and broader aspects of population health management which are parts of Andersen Model of Healthcare Utilization. The overall GHS index scores summarize country capacities across all categories. However, countries with high overall scores may still have low category-level, indicator-level and sub-indicator- level scores that more strongly influence outbreak-associated outcomes. A startling inconsistency observed was the United States (US), United Kingdom (UK), Netherlands, Australia, and Canada ranked in the top 5 countries on the GHS index. However, the top 5 countries as ranked by the GHS index are among the worst-hit countries by COVID-19, with a high number of cases and mortalities6. What would make the GHS index more comprehensive is some more focus on access to healthcare as even in the US one of the key drivers of health inequity is disparity in access. Based on the way COVID-19 has been handled in an inept manner across the world, there should be more learnings around factors affecting decision making that led to this crisis so that we can be more prepared to handle the next pandemic or global disaster. Besides the metrics in the GHS index it looks like political leadership is the most decisive factor in determining success in dealing with epidemics. Based on other background reading it appears that the GHS index expert panel did not directly engage authorities responsible for emergency preparedness in their respective countries and other key stakeholders. Instead, the panel evaluated information provided by each country which caused methodology to be biased and obscured crucial weaknesses in a country's capacity to confront outbreaks. Thus the GHS index is a good start but needs incorporation of more public health measurement factors and political leadership as a factor to make it more representative and possible a predictive tool for future pandemics.
Reference
1. Ravi SJ, Warmbrod KL, Mullen L, et al. The value proposition of the Global Health Security Index. BMJ Global Health 2020;5:e003648. doi:10.1136/ bmjgh-2020-003648
2. Cameron E, Nuzzo J, Bell J, et al. Global health security index:building collective action and accountability, 2019. Available: https://www. ghsindex. org/ wp- content/ uploads/ 2020/ 04/ 2019- Global-Health- Security- Index. Pdf
3. Peters DH, Noor AA, Singh LP, et al. A balanced scorecard for health services in Afghanistan. Bull World Health Organ 2007;85:146–51.
4. Munda G, Nardo M. On the methodological foundations of composite indicators used for ranking countries. Barcelona, Spain Universitat Autonoma de Barcelona, European Commission; 2003. https:// pdfs. semanticscholar. org/ f308/ aae4 26de ca90 aa7e 0929 9561 bcfe 10e129b0. Pdf
5. 2019 Global Health Security Index. 324.
6. COVID-19 Map. Johns Hopkins Coronavirus Resource Center. Accessed May 31, 2020. https://coronavirus.jhu.edu/map.html
We read with interest your Editorial on Global health and human rights for a postpandemic world and offering our comments on this important issue.1
COVID 19 has rampaged an unprepared world. With its high infectiousness, low virulence and asymptomatic transmission, it has crossed boundaries rapidly and affected millions. The mode of transmission of the disease, whether by large droplet (>5µm) as fomites through surface, short distance aerosol borne or long distance airborne by small particles (<5µm) is still being debated Containment and lock down strategies adopted by all affected countries to control the spread have shown mixed results but has devastated the economy and caused major societal disruptions. The policy makers aggressively contained densely populated urban areas, quarantined ships, care homes and jails but the disease has continued to spread rapidly. High fatality rates in hospitals with sophisticated infrastructures and health workers getting infected have exposed gaps in basic understanding of control of airborne diseases and their management in health care settings. The defence forces, specially the naval ships got affected all over the world. With history of pandemic diseases repeating at regular intervals, it is now amply evident that viral diseases will re-emerge in times to come, either in another novel form or as a bioweapon and effective and holistic mitigation measures will be crucial.2
We read with interest your Editorial on Global health and human rights for a postpandemic world and offering our comments on this important issue.1
COVID 19 has rampaged an unprepared world. With its high infectiousness, low virulence and asymptomatic transmission, it has crossed boundaries rapidly and affected millions. The mode of transmission of the disease, whether by large droplet (>5µm) as fomites through surface, short distance aerosol borne or long distance airborne by small particles (<5µm) is still being debated Containment and lock down strategies adopted by all affected countries to control the spread have shown mixed results but has devastated the economy and caused major societal disruptions. The policy makers aggressively contained densely populated urban areas, quarantined ships, care homes and jails but the disease has continued to spread rapidly. High fatality rates in hospitals with sophisticated infrastructures and health workers getting infected have exposed gaps in basic understanding of control of airborne diseases and their management in health care settings. The defence forces, specially the naval ships got affected all over the world. With history of pandemic diseases repeating at regular intervals, it is now amply evident that viral diseases will re-emerge in times to come, either in another novel form or as a bioweapon and effective and holistic mitigation measures will be crucial.2
Airborne or droplet borne. The infectiousness of a disease is determined by the ability of the primary case to cause secondary cases in a susceptible population. It is based on Susceptibility – Infectivity-Recovery/Death (SIR) model and is quantified by the reproductive number (R0). The R0 is dependent on the proportion of susceptible population in a given cohort and its density and reduces with decongestion.3 The initial R0 for SARS CoV 2 at Diamond Princess, a cruise ship was 14.8 and was lowered to 1.78 with disembarkation of passengers and prevented almost 2000 extra individuals from getting infected.4 The transmission onboard ships would be both airborne through ventilatory ducts and by droplet transmission because of the close environment.
High vs Low Viral Load. Contact tracing data have found the contacts to be located mostly near the cases and did not spread to the rest of the population in the 2.2 square km slum area. Moreover, such transmission zones are comprised of only asymptomatic, mild or moderate cases, who have low viral load. High level of infectiousness in clusters of close quarters of susceptible hosts explains droplet and short distance aerosol transmission as has been endorsed by World Health Organisation (WHO) in their recent statement.5 Breaking the chain of transmission in a densely populated slum would have been possible because of droplet transmission from mildly symptomatic and asymptomatic cases and absence of airborne transmission from them. In the hospital setting however, high viral load in severely symptomatic patients and aerosol generating procedures may be accompanied by airborne transmission. This has been emphasised by several studies and endorsed by WHO.6
Way Ahead. Non-pharmacological Interventions of maintaining social distance, wearing of masks will have to be habit forming in the community. The hospitals have to bring in architectural modifications in their wards to include negative air pressure isolation facility alongwith HEPA filters and use of UV lights. Proper protective gears for health care workers need to be emphasised at all levels. Food habits for the general population will include known immune boosting products, also antioxidants and avoid junk; this will not only reduce the co morbidities like obesity and diabetes but will prevent mild infectious diseases. Future mitigating measures will have to emphasise on alteration of residences with proper ventilation, enough exhausts in bathrooms, multiple air exchange air conditioning system, which are essential measures for prevention and control of airborne diseases.
References
1. Khosla R, Allotey P, Gruskin S. Global health and human rights for a postpandemic world. BMJ Global Health 2020;5:e003548. doi:10.1136/ bmjgh-2020-003548
2. Prem K, Liu Y, Russell TW, et al. The effect of control strategies to reduce social mixing on outcomes of the COVID-19 epidemic in Wuhan, China: a modelling study [published correction appears in Lancet Public Health. 2020 May;5(5):e260]. Lancet Public Health. 2020;5(5):e261-e270.
3. JK Aronson, Jon Brassey, KR Nahtani. When will it be over? An introduction to viral reproduction numbers (R0 and Re). Available at https://www.cebm.net/covid-19/when-will-it-be-over-an-introduction-to-vi.... Accessed on 14 Aug 2020.
4. Zhang S, Diao M, Yu W, Pei L, Lin Z, Chen D. Estimation of the reproductive number of novel coronavirus (COVID-19) and the probable outbreak size on the Diamond Princess cruise ship: A data-driven analysis. Int J Infect Dis. 2020;93:201‐204.
5. Coronavirus: What is the Dharavi model being praised by WHO chief Tedros Adhanom. Available at https://www.indiatoday.in/india/story/what-is-the-dharavi-model-being-pr.... Accessed on 11 Aug 2020
The article is predicated on the notion that “The ability to preferentially protect high-risk groups in COVID-19 is hotly debated.” This is a mischaracterisation of the debate. The ability to protect high-risk groups has never been questioned.
Show MoreThe debate would be better characterised as the ability to focus non-pharmaceutical interventions solely on those most at risk of severe disease due to COVID-19, and removing restrictions and allowing widespread infection amongst the low risk groups. The debate has only ever been between those who advocated only applying NPIs to the highest risk cohorts ("focussed protection") and those that advocate that community wide measures are the only effective means to protect those at highest risk.
The stated aim of this paper is to demonstrate whether ‘precision shielding’ was achieved in the first wave, and invents a metric to compare incidence and death in the high risk long-term care population vs the low risk younger population. The author uses seroprevalence data from the elderly and the young to estimate infection prevalence, but takes no account of the differing antibody response that would largely confound this approach.
Using these metrics the author then goes on to ascribe a value judgement as “substantial shielding” or “substantial inverse protection.” Care homes and institutions are already known to be at risk environments for the spread of infectious disease, due to the close contact care work, the m...
Dear Dr Abimbola,
We read with interest the article ‘How global is global health Research? A large-scale analysis of tends in authorship’ by Dimitris and colleagues published in BMJ Global Health January 2021.1 The authors’ research highlights the slow progress in proportion of studies with any, first, and, last authors affiliated with a low- or middle-income country (LMICs), particularly in first and last authorship. The authors welcome and have called for a thorough discussion about the implications of these findings, particularly in identifying the barriers and facilitators to diversity in authorship.
Reflecting on our experience of international research in infectious diseases and antimicrobial resistance we present here some of the barriers we have faced together with the solutions which we have identified. Recognising however, that addressing this inequity requires broader inclusion and participation from academic institutions, scientific journals and funders, we propose remedial steps at every level which will require a different approach to scientific research funding and communication.
There is a culture and hierarchy within academia which manifests itself in the authorship order. It is accepted that the first leads the writing and last author leads the research with all authors contributing to the final manuscript. There are of course the guidelines from the International Committee of medical Journal Editors which clearly stipulate the rol...
Show MoreI don't think this research is particularly useful for policy analysis.
Any analysis of leader's age, marital status or whether they had children?
These are also likely to effect rhetoric.
The short time period of the analysis also casts doubts on the validity of the study and usefulness of any conclusions.
I congratulate the authors who successfully conducted a survey on the current provision of global health education (GHE) in United Kingdom (UK) medical schools.1 Their findings are in keeping with a recent cross-sectional study into the timetables of UK medical schools.2 In the methods section of the paper, the global health learning outcomes and competencies surveyed were listed. However, global surgery was neither surveyed nor discussed in this paper.
This occurred despite global surgery being added as a mandatory learning objective to the national undergraduate curriculum in surgery by the Royal College of England in 2015.3 Post 2015, GHE studies2 and study protocols4 have typically strived to ensure that global surgery is assessed within their study designs. This is particularly important as global surgery often becomes the ‘neglected stepchild of global health’.5 It is easy to see why given that approximately two-thirds of UK medical courses are reported not to cover this topic within their core curriculum.2 It is not in the best interests of the population for a subject of such importance to be ignored by global health researchers and educational institutions.
Therefore, whilst it is encouraging that a study has been done with the aim of identifying gaps in GHE teaching in UK medical schools, the study design in and of itself has resulted in the researchers missing gaps.2 This exemplifies the importance of having a diverse range of stakeholders involve...
Show MoreCandal-Pedreira and colleagues showed that for 304 retracted papers, overall citations increased not decreased following retraction, but citations did seem to decrease for retracted papers in higher impact journals and those with higher citation rates, although that decrease might have been temporary.1 It is disturbing that retracted papers continue to be cited.
We approached the issue of changes in citations rates after retraction in a different way. We assessed citation rates of retracted and unretracted publications from individuals with more than one retracted publication in the Retraction Watch database.2 Using this approach, we found that, overall, citations for 989 retracted publications declined after the retraction and citations for 9671 unretracted papers also declined after the author’s first retraction, but the decline was greater for retracted papers. For example, for retracted publications, 671 papers had 3566 citations in the 3rd year before their retraction and 831 papers had 1575 citations in the 3rd year after their retraction. In contrast, 5311 unretracted papers had 17935 citations in the 3rd year before the author’s first retraction, and 7388 papers had 17252 citations in the 3rd year after the author’s first retraction.
Part of the difficulty in conducting and interpreting such analyses is the different lengths of time pre-and post-retraction for different papers. To try to address that issue, we calculated the slope of the citations/yea...
Show MoreEditor, the commentary highlights the sad situation the Levant region in the middle east has reached. The Syrian healthcare workers are most needed in Syria and not in Germany. It is their very country which is in most need for their services. Syria now has shortage of trained doctors and nurses to help fellow country men and women recover from war injuries and myriad of infectious and non-communicable diseases. Integrating in Europe is never easy for a people from Muslim countries, even if the were professionals (https://www.dailymail.co.uk/news/article-8854519/Muslim-doctor-refused-s...). I have lived in London for over 30 years and still feel an outsider in the UK. How will these refugees cope with the threat of their children losing their Arabic language or Muslim identity. Careers are not everything. It just baffles me why the Syrians who came to Europe could not seek refuge in rich Arab nations. Something terribly wrong is going on in the middle east and coming to Germany is not the answer. Syrian refugees are looking for a quick fix, but they should go back to their own country and tough it out to rebuild what was demolished before someone else comes and takes their places! Britons and Germans did not run away from their countries during the two world wars! Did millions of Britons leave to America to escape WWII? Why have did almost...
Show MoreA few thoughts on the paper.
In relation to SAM terminology. No one could argue with the logic of acute v chronic. However, SAM is well understood at a policy level. It is however understood at above six months. The work that ENN and MAMI have done on identifying wasting at birth is a narrative change which can lay the foundation for the bridging language that the paper talks about.
Narrative is a story that people can understand.
As pointed out, consistency is important, but consistency must hover across the 1000 day window. Currently, our terminology for narrating fetal undernutrition is very weak. While simplistic, if children are being born wasted, then they are also wasted in utero. To fully open the curtains, we would suggest that the SAM terminology be adapted to include fetal malnutrition. The narrative neither stops nor begins at birth regardless of the terminology we use.
In relation to the false positives and visa versa. Given current programming capacity and coverage rates well below 20% for CMAM false negatives represent only a tiny fraction of those who need treatment and do not receive it. Focus on false positives takes away from the substantive issue of low coverage rates for Essential Nutrition Actions across the 1000 day window.
On a broader theme, it would be helpful to explore how the food system and the food system summit support people in immediate need.
A conversation starter
Show MoreThe food system belongs to...
We have read this excellent article with interest. As physicians based in Pakistan: a low-middle income country and not having English as our first language, we could relate to the challenges mentioned in this manuscript. Authors have very rightly pointed out that the issue with most of the researchers based in the low-income (LIC) and middle-income countries (LMIC) is not of poor or low-quality science. We need data and experience sharing from all parts of the world in order to complete the bigger picture and understand the issues that we face today in health, environment, and social sciences. One of the main challenges authors based in the LIC and LMIC face is the issue of presentation of that data i a presentable form. Due to the lack of training opportunities, many authors are unable to write manuscripts that meet the high standards of global scientific journals. This deprives these authors of an opportunity to publish in journals with a global audience and the world misses out on reading a different perspective from the LIC or LMIC. In this context, the introduction of PREPSS is an excellent and welcome initiative that must be supported and promoted.
Show MoreIn this context, we would like to highlight the role of AuthorAID: a global platform of more than 17,000 researchers from all around the globe. We have been extensively using this platform for more than a decade to learn and now collaborate and teach other researchers based in the LIC and LMIC. AuthorAID also pr...
Introduction and Brief Overview
Show MoreThe Global Health Security (GHS) Index is the first comprehensive assessment and benchmarking of health security and related capabilities across the 195 countries that make up the States Parties to the International Health Regulations (IHR [2005])1. The GHS Index takes into account countries’ capability to prevent, detect, and respond to public health emergencies while also assessing the robustness of the healthcare system in each country. This index is comprehensive since it has the ability to consider political and socioeconomic risks, as well as adherence to international norms, which can influence countries’ abilities to stop outbreaks1,2. The GHS Index has been the creation of Open Philanthropy Project, the Bill & Melinda Gates Foundation and the Robertson Foundation1.
The GHS Index treats biosafety and biosecurity as critical components of global health security. As such, the tool includes numerous indicators measuring country capacities and accounts for differences in priorities between high income and low/middle income countries. The GHS index is based on 6 categories, 34 indicators, and 85 sub-indicators. The six categories comprise prevention, detection and reporting, rapid response, health system, compliance with international norms, and risk environment5.
This article describes the practical value of the GHS Index and also explains how the methodology of assigning country ranks and scores is helpful in aidin...
We read with interest your Editorial on Global health and human rights for a postpandemic world and offering our comments on this important issue.1
COVID 19 has rampaged an unprepared world. With its high infectiousness, low virulence and asymptomatic transmission, it has crossed boundaries rapidly and affected millions. The mode of transmission of the disease, whether by large droplet (>5µm) as fomites through surface, short distance aerosol borne or long distance airborne by small particles (<5µm) is still being debated Containment and lock down strategies adopted by all affected countries to control the spread have shown mixed results but has devastated the economy and caused major societal disruptions. The policy makers aggressively contained densely populated urban areas, quarantined ships, care homes and jails but the disease has continued to spread rapidly. High fatality rates in hospitals with sophisticated infrastructures and health workers getting infected have exposed gaps in basic understanding of control of airborne diseases and their management in health care settings. The defence forces, specially the naval ships got affected all over the world. With history of pandemic diseases repeating at regular intervals, it is now amply evident that viral diseases will re-emerge in times to come, either in another novel form or as a bioweapon and effective and holistic mitigation measures will be crucial.2
Airborne or droplet borne. The infectious...
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