Authors: Aditya Achanta¹, George Agyapong¹, Isaac Alty¹, Jeremie Kyle Angeles², Kathryn Ellyse Burgonio², Noelle Castilla-Ojo¹, Hassan Ali Daoud³, Parisa Fallah¹, Luis Freitas⁴, Philippe Jefferson Galban², Jessica Laird¹, Jean Wilguens Lartigue⁵, Jonathan Niyotwambaza⁶, Gavin Ovsak¹, Kirstin Woody Scott¹, Ulrick Sidney⁷, Julius Nico Valdez², Angela Zou¹

Editor: Michael Dykstra¹

¹ Harvard Medical School, Boston, MA, USA ² Ateneo School of Medicine and Public Health, Pasig City, Philippines ³ Amoud School of Medicine and Surgery, Somaliland ⁴ Federal University of Parana, Curitiba, Brazil ⁵ Faculté de Médecine et de Pharmacie, Université d'État d'Haïti, Port-au-Prince, Haiti ⁶ University of Rwanda, College of Medicine and Health Sciences, Kigali, Rwanda ⁷ Faculty of Medicine, Bel Campus University of Technology, Kinshasa, Democratic Republic of Congo

Reviewers: Agne​s Binagwaho, MD, PhD¹; Cameron Nutt, MD²; Leonard Kabongo, MD, MSc³ ¹ University of Global Health Equity, Butaro, Rwanda ² Brigham and Women’s Hospital, Boston, MA, USA ³ Ministry of Health and Social Services, Gobabis, Namibia

Introduction

As of early April 2020, the reported morbidity and mortality from COVID-19 in low and middle income countries (LMICs) has been relatively limited but is increasing. Due to a variety of historical injustices and chronic lack of investments into robust health systems, many LMICs lack the essential resources to prevent, diagnose, and treat COVID-19. These resources include social support systems for impoverished daily wage-earners without income during social distancing, capacity to feed citizens during lockdown, and health care resources to isolate, test and treat critically ill patients. This module features a set of case studies that illustrate a range of responses to the COVID-19 pandemic, while also featuring examples of innovations that are being utilized in resource-limited settings. This material is organized by the “4 S” analysis framework, advanced by Dr. Fernet Leandre and Dr. Paul Farmer of the global health non-profit Partners In Health:

• Staff: Doctors, nurses, community health workers (CHWs), respiratory therapists, environmental health practitioners, custodial staff, and other medical professionals

• Stuff: Essential medical equipment, both for treating patients and protecting healthcare workers

• Space: Availability of and access to clean and sanitary environments to test, treat, and isolate patients as well as living spaces conducive to limiting disease spread

• Systems: Infrastructure, logistical organization, and governance required to ensure the effective delivery of quality health care

This module will explore collaborative innovations of each component of the 4 S model, including interventions developed in LMICs that could be implemented in high income countries (HICs), and innovations developed in HICs that could be adapted for LMICs. We then conclude the module with a final integrated case study on refugees and migrant health.

Though this module covers a number of examples from various settings on how COVID-19 is being addressed, it is by no means a comprehensive analysis of best practices and is unable to feature all innovations from all settings. We encourage you to consider how the 4 S framework may apply to where you train or practice in the setting of COVID-19 (or any health threat) as you progress through the module. Indeed, a core value of our group is that we believe those who are closest to the problem are the best people to design the solutions. For this reason, you will see that our authors and faculty reviewers span many parts of the globe. We also want to invite you, our readers, to participate by sharing innovations which you have developed or witnessed on a website made for this purpose called LeadChange. We hope that this platform will help to facilitate multi-directional communication directly across diverse contexts about innovations that are contributing to the COVID-19 response. Via LeadChange, you are able to discuss problems, propose solutions, or ask questions, all while interacting with existing posts and sharing pictures.

Learning Objectives

At the end of this module, medical students should be able to:

• Design two ways to redistribute clinician responsibilities through task shifting/sharing that can be applied to surges in demand for triage or critical care in the COVID-19 pandemic.

• Articulate how community health workers constitute an essential component of the healthcare system in some LMICs and how that could be translated into other contexts.

• Consider innovative approaches to designing personal protective equipment (PPE), treatment resources such as oxygen therapy and ventilator use, and facility design to decrease cost without sacrificing efficacy.

• Assess how structural violence may help explain why essential social supports required for people to adhere to public health requests like ‘shelter-in-place’ are not equitably distributed, and the importance of considering those who are most vulnerable in society when making policy recommendations.

• Describe the challenges and strengths regarding quarantine and contact tracing of positive cases in diverse contexts.

• Apply lessons from past infectious disease outbreaks in lower-resourced settings to the COVID-19 pandemic and how the lessons from the current COVID-19 pandemic in high income countries can be translated in other settings.

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