The Harvard Global Health Institute (HGHI) in partnership with the Department of Global Health and Population (GHP) at the Harvard T.H. Chan School of Public Health offer the Harvard Learn, Engage, Advance, and Disrupt (LEAD) Fellowship for Promoting Women in Global Health. LEAD is a transformational fellowship designed to promote leadership skills in women from low- and middle-income countries. The fellowship aims to provide women global health leaders dedicated time to reflect on their careers, refine their leadership skills, and chart a new path post-fellowship. During the year-long program, Harvard LEAD fellows work closely with Harvard faculty, immerse in a tailored leadership training program, engage in speaking and networking opportunities across the University, and build a custom course curriculum that speaks to their unique interests. 

The 2022-2023 cohort includes Ifrah Abdi of Somaliland, Choolwe Jacobs of Zambia, Flora Nwagagbo of Nigeria, and Ana C. Gonzalez-Veléz of Colombia. Learn more about the fellows.

HGHI and GHP are thrilled to host the LEAD fellows in Cambridge this spring for the on campus portion of the fellowship, which will build off of the virtual programming from fall 2022. Over the past four months, the fellows engaged in 1:1 leadership coaching with Jacqueline Franklin, an Executive Leadership Coach with Coach2Growth, who has worked with all four cohorts of LEAD fellows since the fellowship’s inception. The fellows also connected with their Harvard faculty mentors and mapped out plans for leadership growth and exploration, which will guide their in-person time this spring. Fellows Ana Cristina Gonzalez-Velez and Ifrah Abdi had the opportunity to share their global health research and experience with the Harvard community through participation in the GHP Brown Bag Seminar Series at the T.H. Chan School of Public Health 

Ifrah Abdi, Associate Dean of Nursing at Edna University Hospital, speaks to the Harvard Community on Assessing Factors that Impact Maternal Health Outcomes in Maroodijeh Region, Somaliland

Dr. Ana Cristina Gonzalez-Velez, an expert in the fields of health, sexual and reproductive rights, and gender equality, spoke to Harvard community on the Biolegitimacy and Restrictive Abortion Regulations in Latin America: Overview and Perspectives

In the spring, the fellows will complete multidisciplinary and executive leadership courses across Harvard University as well as exclusive workshops led by Harvard faculty. Examples of some of the courses and workshops the fellows will take include:

Courses: (linked)

1. Negotiation Strategies: Building Agreement Across Boundaries
2. Women and Power
3. Strategic Leadership: Enhancing Your Personal Effectiveness
4. Strategy Execution for Public Leadership
5. Organizational Leadership
6. Women Leading Change

Workshops:

1. Self-Promotion – Led by Dr. Kathy Rexrode 
2. Public Speaking and Effective Communication – Led by Professor Jill Slye 
3. Decolonizing Global Health – Led by Professor Jesse Bump
4. Negotiation – Led by Professor Daniel Shapiro 
5. Navigating Bias and Designing Equitable Organizations as a Women Leader – Led by Professor Siri Chilazi 
6. Policy Writing and Analysis for Effective Communication – Led by Professor Lauren Brodsky 

HGHI is honored to host these four women leaders this spring. We look forward to the opportunity to connect more deeply, learn from their wealth of knowledge and experience, and collaborate on innovative global health solutions.

For media inquiries or questions about the fellowship program, please contact Fellowship Manager, olivia_mulvey@harvard.edu

The Harvard Global Health Institute is dedicated to health equity and social justice. We are also committed to individual autonomy and bodily integrity. Our belief in these core values does not stop at city, state, or country borders. As such, we believe it is critical in this moment to recognize the impact of the U.S. Supreme Court Decision today in Dobbs v. Jackson Women’s Health Organization.

We condemn the 6-3 ruling that rolls back decades of protections for those seeking safe reproductive health choices, that includes the right to terminate a pregnancy. Not only does this decision end reproductive freedoms in the U.S., it undermines public health and the right to privacy.

A women’s right to choose is a fundamental human right that is protected under numerous international and regional human rights treaties and national-level constitutions around the world. By grounding safe abortion within the rights to privacy, life, equality, and non-discrimination, human rights bodies have consistently recognized that restrictive abortion laws are incompatible with human rights.

970 million women live in countries that broadly allow abortion. This represents 59% of women of reproductive age. The United States is no longer part of the majority, and it will be left up to the states to decide who will be able to access safe reproductive healthcare. According to the World Health Organization, 23,000 women die of unsafe abortions each year and tens of thousands more experience significant health complications.

Today, we stand in solidarity with leaders of the reproductive rights movement as we continue the fight for health equity for all.

Comparing prisons to nursing homes may feel like comparing apples and oranges, but the current COVID-19 pandemic has revealed their disconcerting similarities. Both the settings have been hotbeds for the worst COVID-19 outbreaks in the country (data here & here). Prisons and nursing homes share similar features: they are crowded, congregate living facilities with high rates of staff and population turnover, and neither are environments conducive for adhering to social distancing practices and limiting contact with outside communities. At the same time, both house populations that have a disproportionally high risk for infection and severe complications or death from COVID: the elderly and those with preexisting medical conditions. As a result, 28% of the country’s incarcerated population has tested positive for the virus compared to about 9% of the total US population and nursing home residents have accounted for 34% of deaths.  

Yet when it comes to COVID-19 vaccine distribution, people who are incarcerated face a very different outlook compared to those in nursing homes. Following the current guidance from the CDC recommends that nursing home residents be first to be vaccinated alongside healthcare workers, all 50 states placed them in Phase 1a. By contrast, there are no federal guidelines on which group people who are incarcerated fall into.s With States left in charge of decision making, wide discrepancies in vaccination prioritization between these two groups have emerged. Across the board, States have swiftly vaccinated their nursing homes with high priority: more than 4.5 million residents and staff have received at least one dose of the vaccine. As a result, the impact of this population has been strong and clear:  between late December and early February new cases among nursing home residents decreased by more than 80 percent, nearly double the rate of improvement in the general population. Deaths in nursing homes have decreased by 66%. But for those currently incarcerated who are equally vulnerable, the response has been very different. By October 2020, only four states explicitly placed people who are incarcerated in the first phase of their vaccine distribution plans. While updated CDC guidance0, along with pressure from advocacy groups and a new policy from the American Medical Association has played a role in increasing this number, to date, only 10 states place people who are incarcerated in Phase 1. An additional 18 states explicitly place their prison population in Phase 2 alongside such groups as agricultural workers, U.S. Postal Service workers and public transit workers and eight states have not included them in their plans at all.  The following table, from the Prison Policy Initiative, summarizes vaccination distribution plans for 49 States.

So how does this all play out? Differently, depending on what State you live in.  As of February 22, only 15 states were actively distributing vaccines to prison populations. California sits at the top of the efforts, having vaccinated about 40% of its incarcerated population. In contrast, Colorado has  deprioritized vaccinations in prisons as a result of public backlash for putting them ahead of the elderly and medically vulnerable. Many states have opted to only vaccinate people who are incarcerated who belong to other priority groups, including people older than 65 or those with preexisting health conditions. Further complicating matters, there isn’t a clear picture of the percentage of the incarcerated population that has been vaccinated, as only a handful of States have reported vaccination data. 

The patchwork nature and delayed priority of vaccine distribution to incarcerated populations raises concerns for equitable vaccine distribution. These concerns builds off an interwoven web of inequity at the intersection of health and criminal justice like the disportionate rates of COVID-19 infection and death in communities of color and the hyperincarceration of Black men, and the history of medical exploitation of people who are incarcerated. 

Unsurprisingly, these inequities are being repeated in the current pandemic:  28% of the incarcerated population in state and federal prisons has tested positive for COVID-19 since the start of the outbreak, with those incarcerated being 5.5 times as likely to contract the virus and three times as likely to die from it than the general population. For many, the lack of adequate prevention measures or medical treatment for COVID-19 has become the life sentence they were never served in court, and this consequence is now being prolonged by inaccessibility to the vaccine. 

The stark contrast between the care given to nursing home residents and the negligence shown to people who are incarcerated builds on a long record of incarcerated populations being left out of public health efforts and having their well-being disregarded. The impact of current carceral practices and conditions on viral transmission adds to the growing evidence for the harmful consequences of incarceration to the health of individuals, their families, and communities. This lack of care and attention ultimately serves to underscore the long standing contention about how we view the rights and humanity of incarcerated people. 

Special Issue: International Comparisons of High-Need, High-Cost Patients: New Directions in Research and Policy

Sponsored by: The Health Foundation

Submission deadline: November 30, 2020

Health Services Research (HSR) and the International Collaborative on Costs, Outcomes and Needs In Care (ICCONIC) are partnering to publish a Special Issue on International Comparisons of High-Need, High-Cost Patients: New Directions in Research and Policy.

Health systems around the world have similar goals: maximizing quality of care for their populations, offering services that are responsive to patient needs and providing value for money. International comparisons can be a useful tool to provide national policy makers and clinical leaders with a benchmark that helps determine whether countries are achieving their goals. However, due to the inherent gaps in data, underdeveloped analytic methodologies and lack of consideration of key structural differences across health systems, poor comparisons can lead to unwarranted policy interpretations with adverse consequences for policy makers. Properly conducted cross-national comparisons can provide a rich source of data to learn from and inform health policy.

One key challenge facing many health systems is how to best design services to provide care to a small number of high-need, high-cost individuals. These patients are expensive and often the most vulnerable to experiencing the ill effects of poor quality care. In recent years, policy makers and clinical leaders have increased their efforts to understand how best to care for this heterogeneous group of patients with a diverse set of needs stemming from multiple physical conditions, mental and behavioural health issues and complex social problems. However, despite the enormous importance of this population, there are limited data on how different nations and health systems manage these patients.

Therefore, the goal of this Special Issue is to highlight cutting-edge work that showcase the potential to learn from international comparisons of high-need, high-cost individuals. A portion of the Special Issue will feature the work of the International Collaborative on Costs, Outcomes and Needs in Care (ICCONIC). ICCONIC consists of 12 partners from North America, Europe and the Pacific who use national and regional patient-level datasets to explore variations in the utilization and costs of health services for particular types of high-need individuals. The rest of the Special Issue will consist of invited submissions that examine areas related to the delivery of care for high-need, high cost-individuals.

Key dates proposed:

• November 30, 2020: Submission deadline for abstracts for the Special Issue.
• December 21, 2020: Notification sent to authors of manuscript invitation for Special Issue.
• March 1, 2021: Submission deadline of manuscripts for the Special Issue.
• October 1 2021: Notification of assignment of accepted manuscripts to the Special Issue.
• December, 2021: Print Publication Date for Special Issue.

Questions can be directed to Kristen Riley at kriley@hsph.harvard.edu

The First Ever International Day of Clean Air for Blue Skies Underscores the Environmental Link to Human Health

UHC Benefits from Clean Air

For the inaugural International Day of Clean Air for Blue Skies on September 7, 2020, HGHI and the One by One: Target 2030 campaign is highlighting clean air as a necessity to achieving Universal Health Coverage (UHC). Contributing to over 7 million premature deaths every year, the burden of air pollution on healthcare systems threatens any achievement towards effective UHC. While air pollution is the largest environmental risk to public health globally, it is a solvable problem. Many affluent countries have greatly improved their air quality in recent decades. However, air pollution continues to inequitably affect populations in low-and middle-income countries, and in particular, women and children. Across the African continent, the economic costs of premature deaths from outdoor and indoor air pollution are estimated to be almost USD$450 billion annually or equal to the entire GDP of Nigeria. With air pollution’s relationship to climate change and crop yields, as well as its implications in the current COVID-19 pandemic, ensuring clean air will not only save lives but support cleaner environments, alleviate poverty and increase shared prosperity. For these reasons, UHC advocates must integrate reduction of air pollution into Universal Health Coverage initiatives, and national and sub-national plans for UHC must work in collaboration with efforts to promote clean air and energy.

Impacts on Health Outcomes and Access

Air pollution causes both acute and chronic diseases and is one of the leading contributors of preventable death in Africa, including 400,000 annual infant deaths. These deaths are mainly due to non-communicable diseases such as stroke, chronic obstructive pulmonary disease (COPD), adverse pregnancy outcomes, and lung cancer, which often require visits with specialized medical personnel, expensive drugs and treatments like chemotherapy and reliable access to a healthcare facility. These medical costs cause a formidable strain on families and health systems. By improving long-term health outcomes and reducing healthcare costs, ensuring clean air can help save lives and support a higher quality of life. 

​

Impacts on Health Systems

Air pollution is inextricably tied to energy. Barriers to access clean energy, as an alternative to fossil fuels, not only increase pollution but also make communities and health facilities more vulnerable to power outages and costs. Energy sources such as kerosene for lamps, diesel generators for energy and open fires for cooking all require the burning of fossil fuels like coal, crude oil and natural gas. Each of these fuels emits harmful pollutants and toxic chemicals, emissions that would be eliminated with the adoption of solar or wind energy. The lack of these sustainable or “clean” energy sources also contributes to a lack of quality care within health facilities. In sub-Saharan Africa, only 28% of healthcare facilities have access to reliable electricity. Lack of energy access can mean vaccine spoilage, interrupted surgeries, equipment failure, lack of access to electrically-pumped water, and unsafe birth practices, all barriers to care for patients suffering from air pollution-related illnesses. Renewable energy can provide health facilities an

efficient, low-cost, and reliable source of energy, while cutting down on harmful emissions that contribute to air pollution and climate change. Having reliable energy can also help expand and improve health care access and delivery in remote rural areas where electricity is lacking. Small photovoltaic (PV) solar power systems are already widely in use across Africa, and help health workers provide care and diagnoses, charge cell phones for communication, and safeguard vaccines and other medications in portable cooler units. Therefore, efforts to achieve sustainable energy for all is integral for reducing pollution, and is a critical investment for sustainable UHC. 

​

Impacts on Social Equity​

Air pollution is foremost an equity issue. Due to traditional gender roles that relegate activities such as cooking and raising children to women, women spend more time indoors, they are more likely than men to suffer from air pollution-induced diseases. Of the 7 million annual deaths due to air pollution, more than half are of women and children. In 2015, 920,000 children died of pneumonia; over 50% of these deaths occured in African countries. Air pollution is associated with roughly half of these childhood deaths from pneumonia. For women in low-and-middle-income countries, household air pollution is the single leading environmental health risk and is the main cause of non-communicable diseases like strokes, COPD, lung cancer and heart disease. In Africa, only 17% of the population has clean cooking access, meaning the majority of the population still cooks with biomass or open fires and is thus exposed to indoor air pollution. Poverty is also strongly correlated with disproportionate exposure to air pollution because of low-income populations’ reliance on unclean energy sources. The health burden associated with the use of such energy sources is further compounded by the lack of information and access to health resources. The burden from air pollution can keep populations in unending cycles of poverty.

Next Steps

To achieve sustainable and effective Universal Health Coverage in Africa, clean air is essential to protecting human health. Reducing air pollution is not only fundamental to our quality of life, but to breathe clean air is a human right. Air pollution is a solvable problem and there are many steps that governments, communities and health systems can take to improve the quality of air. For the first-ever International Day of Clean Air for Blue Skies, those who advocate Health for All should support clean air initiatives and improve sustainable energy access as a key component to all Universal Health Coverage plans. To learn more about how clean air can be integrated as a priority in universal health coverage plans, visit: www.onebyone2030.org/cleanairday

An Interview with Vamba Lolleh, Partners In Health

Vamba Lolleh is no stranger to using digital health tools for infectious disease response and contract tracing. As an electronic health officer for Partners In Health (PIH), Sierra Leone, he and his organization were instrumental in responding to the 2014 Ebola outbreak. Yet as COVID-19 spreads, Vamba filled us in on how many of the lessons learned haven’t been as seamless to carry out as hoped.

Early in the COVID-19 response, Sierra Leone, alongside other West African countries, implemented infection control measures that were used during Ebola. Successful programs to stop the spread of misinformation through the use of radio and TV were quickly adapted for COVID-19. An aptly named policy called ‘less touching,’ aimed at reducing contact points between people was resurrected, and ‘selective quarantine’ was put in place for high-risk individuals. Yet as the government took steps to mitigate the spread of COVID-19, unprecedented challenges emerged.

According to Vamba, contact tracing, for example, has proved more difficult. During Ebola, it was one of the most effective strategies for identifying and controlling new cases. Through the use of CommCare, a digital platform developed by Dimagi, Vamba and his team were able to collect, store, and manage critical data in real-time. The tool was lauded as an essential aspect of the response; it was widely used by those on the front lines of the epidemic, and its lack of reliance on internet connectivity meant that it had utility in all parts of the country. 

Yet despite the success of CommCare during the Ebola outbreak, digital engagement hasn’t been as central in the COVID-19 response. According to Vamba, there are no digital tools being used for COVID-19 contact tracing in Sierra Leone.  

The Ministry of Health and Sanitation (MoHS) has taken steps to identify potential digital health solutions for their COVID-19 response, largely through the creation of an E-Health Technical Working Group, which Vamba is participating in. During these meetings, it became clear that the barriers to swift decision making and adoption of a digital contact tracing tool have been high, which is leading to delayed data collection on the ground and incomplete reporting. While the country is currently using a paper-based contact tracing system, Vamba believes that CommCare could still have potential. As he explains, “we have used this tool for five years now, we have over 100 Community Health Workers who know how to use it [CommCare].”

We asked Vamba why the digital response to COVID-19 was so different from that of Ebola. One of the biggest factors, he explained, was that as soon as the Ebola outbreak was controlled, many of the international NGO’s that used digital tools, quickly left Sierra Leone. “All the organizations that came to support the Ebola response, they brought lots of good programs and tools. But when they left, the programs were not handed over to the MoHS. The tools that existed during Ebola are not here anymore,” he noted. While Vamba believes the MoHS should be the organization leading the pandemic response, he acknowledges that they were left to start from scratch. “There are a lot of lessons that were learned during the Ebola response that could help with COVID-19 but those lessons were not shared with the Ministry,” Vamba said.  

As the government tries to get a handle on the burgeoning health crisis, a lack of essential resources is hampering their efforts. Sierra Leone continues to battle shortages in personal protective equipment and testing-kits, and their laboratory diagnostics capabilities are limited. Healthcare personnel have gone on strike, a situation that mirrors difficulties faced during Ebola. The pandemic has only exacerbated healthcare challenges that existed before the crisis; including a weak healthcare infrastructure, limited funding for the health sector, and a shortage in medical personnel.

While organizations like PIH continue to carry out their existing programs while supporting the COVID-response, Vamba says they are eager to continue to work with MoHS on a shared mission of reducing suffering and saving lives. Collaboration, both regionally and within government agencies, was critical in ending the Ebola outbreak; a lesson that can and should be applied to fight the COVID-19 pandemic. Vamba’s biggest takeaway after working and living through Ebola and now COVID-19? “The sustainability of the programs is what is actually important.” 

To get in touch with Vamba Lolleh, you can email him at: vlolleh@pih.org

To learn more about Partners in Health – Sierra Leone, follow them on Twitter @pihsierraleone

In this pandemic, scientists around the world share preliminary information quickly and openly with each other by posting “preprints” online. Preprints are research papers that have not been reviewed by other experts yet but enable a speedy exchange of initial findings and observations amidst great uncertainty, and contribute to the generation of better evidence.  The downside: Because they may still contain errors, are easy to quote out of context, misunderstand or misinterpret, preprints have become a major source of misinformation and confusion, and are abused by those hoping to stir chaos, peddle their products and businesses, or drive towards false messages for political gain. 

RT via CT_Bergstrom: Another preprint arguing for a 10-20% herd immunity threshold. I agree this mathematical possible. I don't find it empirically plausible. https://t.co/HmOc5QQv2J https://t.co/Hq2qzriZFH

— preprintsifter (@preprintsifter) July 26, 2020

Amplifying the Experts

In response, Twitter has emerged as a great tool for experts to discuss, assess and evaluate the studies, methods and findings that are posted in preprints.   

The Preprint Sifter makes it simple and easy for anyone to access these sources of expert assessment in real time.  By curating authoritative tweets on Twitter, and gathering and publishing curated collections once a week, the Sifter helps journalists, policy makers and the public put individual studies, initial observations and preliminary findings in context, and understand the limitations of and potential errors in preprints. 

We created the Preprint Sifter to enable all of us to look at preprints the way experts do. We hope you find it helpful.

The Breakdown

Sign up for the weekly newsletter from the team behind the Preprint Sifter that gives you a curated summary of the key conversations on the preprints posted throughout the week. We put together a list of the week’s most notable preprint papers and highlight the expert analysis worth paying attention to. 

An interview with Mahadia Tunga, Tanzania dLab

“There’s a digital divide being witnessed in Africa,” said Mahadia Tunga, Co-Founder and Director of Capacity Development at the Tanzania Data Lab (dLab). While the divide is not new, the COVID-19 pandemic has highlighted how differential access to the internet can shape who receives access to education, and when. As social distancing restrictions push day-to-day activities online, those who do not have consistent access to the internet and key health information are at risk of being left behind.

Tanzania was on a partial lockdown until the end of June with only 38.7% of the population having access to the internet. While containment measures were markedly less strict than many neighboring states, schools and universities were closed and citizens were encouraged not to leave their homes. Amidst the lockdown, Mahadia and her team looked for innovative ways to overcome this digital divide.

In 2018, Mahadia co-founded the dLab, with a focus on training community members in health data science and disseminating important health information through SMS. The dLab has pivoted to expand their existing online training modules to encourage its students to continue building their data science skills virtually. Yet while online modules have shown great promise by doubling participation, there are limits to who the modules can reach. “We have online materials, but only those who are already empowered with the internet and resources can access them. We are seeing how vulnerable people can become even more vulnerable,” Mahadia noted. 

To address this, Mahadia’s team developed the ‘Smart Girls’ program, which aims to reach young girls in rural settings who do not have the resources to attend in-person data science training. “We specifically targeted schools that might not have power and computers. We would take computers and train the girls, and during the holidays invite them to our organization’s computer lab.” This program encouraged girls who typically lack access to computer education, or a data science curriculum, the skills to pursue future careers in science, technology, engineering, and mathematics (STEM). 

Yet the restrictions put in place in response to the COVID-19 pandemic have essentially stripped the dLab’s access to these young girls; and in turn, has limited their ability to continue their data science education. Mahadia feels that not being able to reach these girls when they have even more time than normal to devote to their data science training is a huge missed opportunity.

While Mahadia’s team is still seeking a way to provide training to participants of the ‘Smart Girls’ program, the dLab has successfully adapted some of their other programs in the face of COVID-19. The ‘Code Like a Girl’ program, for example, which also teaches young girls coding and data science skills, has been able to thrive due to a partnership with telecommunications provider, Vodacom Tanzania. With their support, the dLab is able to provide free internet bundles and access to online learning modules. 

Another program the dLab has successfully pivoted is ‘Talk To Data’(#Sema_Na_Data), which provides targeted messaging and partners with social media influencers to disseminate information to young men who are vulnerable to HIV/AIDS. With the onset of COVID-19, Mahadia knew that staying connected to this at-risk population was not only more important than ever but presented an opportunity. “People living with preconditions are more vulnerable to COVID… when COVID hit, we said ‘let’s find a way to be relevant.’” Now, Mahadia’s team has integrated COVID-19 messaging into their existing work, encouraging more young men to get tested for HIV so that they can know their status and take necessary precautions against the virus.

While Mahadia has been challenged to reorient her work due to the COVID-19 pandemic, the essence of it remains unchanged. “We are trying to share an evidence-based message. Analyzing the data and digesting it in a simple way so that people can understand the impact of COVID.” “But most importantly,” Mahadia continued, “we are telling a story that people can relate to their own activity, their own work, their own health. We are trying to get those big numbers into a level that everyone in the community can understand.” The messages may have changed since the start of the pandemic, but Mahadia remains committed to reaching the most vulnerable in her community.

To learn more about the Tanzania dLab, follow them on Twitter @dLabTz and Facebook

America’s testing infrastructure is collapsing. As cases surge around the country, laboratories are facing crippling shortages of key supplies and growing backlogs of samples. In many states, it now takes 10-15 days to get test results – rendering these tests useless as a tool to prevent transmission and bring the pandemic under control. For most people, the peak period of infectiousness lasts about a week.  And, in the middle of this testing collapse, cities and towns are preparing to return millions of children to school this fall with neither the intention nor the capability to test them. At this critical moment in our nation’s fight against COVID-19, it is time to radically rethink our approach to testing. The way forward is not a perfect test, but one offering rapid results.

Over the past months, much of the conversation around testing has focused on accuracy. Tests have been touted for their high sensitivities, correctly identifying more than 98% of positive cases. The intuition is clear: we want a test that won’t miss positive cases and send infected individuals back into the world to spread the virus. These qPCR tests have become the backbone of our testing infrastructure, yet their high costs and slow rates of analysis have undermined any attempt to put their high sensitivities to good use. CDC analyses suggest that we are identifying only about 1 in 10 cases of COVID-19, mostly because we are testing so few people. This means that from a public health perspective, the ability to identify and isolate positive cases that matters most for disease control is only about 10 percent. By putting a premium on the accuracy of tests, we fail to test a majority of people with COVID-19 and these built in delays actually undermine our ability to timely identify cases which is the key purpose for widespread testing.

Imagine spitting on a special strip of paper every morning and being told two minutes later whether you were positive for COVID-19. If everyone in the United States did this daily, we would dramatically drop our transmission rates and bring the pandemic under control. Schools and businesses could reopen with the peace of mind that infectious individuals had been identified and were staying home. Michael Mina of the Harvard School of Public Health has been a major proponent of this idea, and has pushed the idea of a $1 test that the government could mass-produce and provide freely to everyone. In fact these technologies exist today. Antigen tests are significantly cheaper and faster than qPCR tests, and Quidel has already received FDA approval for their antigen-based test on a strip of paper. Another $1 antigen test has been put to use in Senegal. Many other U.S.-based companies are developing antigen tests. Why, then, have these cheap and rapid tests not become the foundation of our national testing strategy?  The answer lies with test sensitivity.

Antigen tests require higher levels of virus than qPCR to return a positive result. There has been a significant pushback from those who believe it would be irresponsible to widely use a test that might miss many positive cases. But the frequency of testing and the speed of results counters that concern. The qPCR tests are currently slowing laboratories to a crawl. If everyone took an antigen test today—even identifying only 50 percent of the positives—we would still identify 50 percent of all current infections in the country – five times more than the 10 percent of cases we are likely currently identifying because we are testing so few people. Accuracy could be further increased through repeated testing and through the recognition that quicker test results would identify viral loads during the most infectious period, meaning those cases we care most about identifying – at the peak period of infectiousness—are less likely to be missed. Even better, we would be identifying these cases while they are still infectious, rather than in 10 days when the virus may have already been transmitted repeatedly. Mina and colleagues have shown through modelling that this logic holds up; speed matters much more than test sensitivity in controlling a pandemic.

The evidence makes clear it is time for a paradigm shift on testing. Our goal should be to identify and prevent every cluster and every outbreak of COVID-19. Cheap and rapid antigen testing can achieve that goal, even if the test sensitivity never matches that of qPCR. It is time for the federal government to take strong leadership on directing our resources toward this new strategy. The U.S. has the ability to print paper-strip antigen tests in massive capacities and to distribute them all over the country. It has the capability to bring antigen tests to tens of millions of Americans daily. If we do these things, we can move past 10-day delays, quash the current outbreaks, and ensure that we can safely go to work, do our shopping, and send our kids to school.

UPDATE: Please see new guidance, “Schools and the Path to Zero: Strategies for Pandemic Resilience in the Face of High Community Spread”, published December 18, 2020.

July 20th, 2020

Finding ways to get kids back to school safely as the virus continues to spread across the nation is a daunting task. Our new guidance helps schools and districts devise plans based on the size of the outbreak in their community  

Across the United States, cities and states are struggling to devise plans for safely bringing children back to school this fall. It’s a daunting task: We know the coronavirus spreads especially fast in groups confined to indoor spaces. Children are at risk either way — if they go to school, they may get sick and new outbreaks may spike. If they don’t, they miss out on in-person classes, which play an essential role in supporting the mental health of children. The shift to online learning, while harmful for all kids, also exacerbates existing racial and socioeconomic disparities in education, and risks setting back an entire generation of children.

Many have pointed to European nations who have successfully reopened schools. What is often overlooked, however, is that these countries all have one thing in common: they had achieved low case incidence levels by the time they reopened their schools. And since opening, they have maintained focus on infection control and ongoing TTSI programs for disease control. 

In The Path to Zero and Schools: Achieving Pandemic Resilient Teaching and Learning Spaces, a new guidance document for schools and school districts, Harvard’s Edmond J. Safra Center for Ethics and the Harvard Global Health Institute, together with collaborators from Harvard’s Graduate School of Education and Harvard’s T.H. Chan School of Public Health, make the case that similarly, schools and school districts need to consider the size of the outbreak in their community when deciding on school reopening policies. 

Some states—for instance, Maine, Montana, Alaska, and Hawaii—currently have sufficiently low case incidence levels across counties/districts to plan for full re-openings of the K-12 system, with adaptations to teaching and learning spaces for pandemic resilience. Other states—for instance, Arizona, California, Minnesota, Texas, and Florida—currently have such high case incidence in many counties/districts that those counties/districts should plan to begin the fall semester with online learning. 

“Society has to forge a path forward with school openings based on the reality facing us,” says Joe Allen, Assistant Professor and Director of the Healthy Buildings Program at Harvard T.H. Chan School of Public Health. “We wanted to provide guidance not just on when it’s okay to open, but also evidence-based strategies for how to do it safely.” 

“Our students should not have to learn in conditions of suffering; our educators should not have to teach in conditions of suffering. We owe it to our children to get them back to school safely,” says Danielle Allen, director of the Edmond J. Safra Center for Ethics at Harvard University.

“We need a surge for education, just as we surged for health care. We redesigned hospital spaces and learned how to protect patients and essential workers. We invested in this. We’ve even done it for restaurants. We can do it for our schools.”

The new report bases its incidence level assessments on the color-coded COVID Risk Levels developed by leading public health and policy experts under the leadership of Harvard’s Edmond J. Safra Center and the Harvard Global Health Institute. 

“If you are in a red zone, there is simply no way to safely open schools now. Orange zones will struggle as well. If you open schools in these areas, the chances are that those will likely close quickly when teachers, staff, and possibly students start getting sick in large numbers. If leaders in these counties want to reopen schools in the fall, they must bring down the level of virus, starting now,” says Ashish K. Jha, director of the Harvard Global Health Institute. “Yellow counties are in a slightly better position, but must still make hard choices. To prevent a resurgence of cases, these districts must close bars and indoor dining too and really consider how much non-essential retail they are willing to tolerate. Getting to green will make opening schools much safer.” 

The new guidance document for schools explains how risk incidence levels, the creative adaptation of infection control guidelines for healthy buildings, and national investment in pandemic resilient schools can optimize operations, keep people safe, and restore our schools as trusted sites of learning in a densely populated world.

Severe testing shortages and processing delays are hampering the COVID-19 response. Here is how to rapidly build the arsenal of timely tests we need to suppress and defeat the coronavirus 

As coronavirus cases soar across the United States, viral testing has become a bottleneck. People are standing in line for hours in some hotspot states to get tested, and many wait over a week or longer for their results. Containment of the virus is impossible in such conditions – slower than 48 hour turnaround times for test results makes contact tracing ineffective. We cannot break the chain of transmission if the virus outpaces us at every step. 

This is the second time the nation faces severe testing shortages as case counts rise. Yet this time, innovators and labs are ready to unleash millions more tests. The reason they haven’t done so already is that these entrepreneurs need to know there is a market for the tests, that someone will buy them — while the state leaders wanting to buy these tests need to know they can afford them.  

What both the innovators and the state leaders need is a framework to quickly settle this supply-and-demand problem. In the absence of a national strategy to procure tests and distribute to states as needed based on outbreak size, states are currently asked to figure this out on their own. But with the exception of California, no state alone needs the large number of tests that would make it worthwhile for a biotech or other company to build or switch production to COVID-19 testing.  

“Next-generation genome sequencing labs, for instance, could process 1 million samples a day,” explains Danielle Allen, director of the Edmond J. Safra Center for Ethics at Harvard University.  “But no single state needs that many.” 

By buying and bargaining as regional groups, however, states can overcome these obstacles and get the number of tests they need at an affordable price. 

Empowering States

“There is a solution: Congress can activate and fund regional interstate compacts that would have the express job of investing in the testing capacity we have not yet activated,” says Allen.“Interstate compacts are valuable tools for addressing problems that are complex, require scale to solve, and also require state leadership because of on-the-ground variation. They are tools for empowering states.”

Interstate compacts are legally binding agreements between states, territories, and/or tribal nations that allow them to take collective action to solve shared problems or enact a common agenda. The Port Authority of New York and New Jersey is such a compact, as is the Emergency Management Assistance Compact, which enables states to deploy personnel across state lines to help in times of crisis, such as wildfires or hurricanes.

The Compacts Clause of the U.S. Constitution grants states the right to create interstate compacts for their common benefit. The text of the Compacts Clause requires congressional consent to these agreements. Compacts that receive congressional approval have the force of federal law and therefore supersede state laws. 

Activating ALL Labs That Could Test For Coronavirus

By working together, states could activate several lab types that could but aren’t currently doing any coronavirus testing: The U.S. has six categories of labs — state public health labs, clinical commercial labs (for instance, Quest Diagnostics and Lab Corp), hospital labs, academic research labs, commercial nonclinical labs (for instance, 23andMe and other labs running genome sequencers), and veterinary labs. But to date only commercial and state labs are fully activated, while hospital labs are partially activated, and all the other labs are used only very sporadically or not at all.

More Certainty in Testing Markets

“Compacts would have the scale and market power to make guaranteed off-take contracts for a million tests. On the supply side, these contracts would bring certainty and eliminate demand volatility for test suppliers, giving existing firms an incentive to expand production and new firms an incentive to enter the marketplace and compete on price,” explains Puja Ohlhaver, chief executive of ClearPath Surgical.“On the demand side, these contracts would turn test suppliers from price-makers into price-takers.”

Harvard’s Edmond J. Safra Center for Ethics and the Harvard Global Health Institute are working with experts and political leaders across the country to brief governors and congress on the way forward that interstate compacts provide. For details on compacts, and how they fit into the TTSI COVID-19 suppression framework, please explore our documents below.