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      Where are the women? Gender inequalities in COVID-19 research authorship

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          Abstract

          Summary box Women account for about a third of all authors who published papers related to COVID-19 since the beginning of the outbreak in January 2020. Women’s representation is lower still for first and last authorship positions. Gender biases seem to be affecting COVID-19 research similar to other scientific areas, highlighting that women are consistently being under-represented. This may have implications for the availability and interrogation of sex-disaggregated data and therefore our understanding of COVID-19. These gender biases hint at wider gender inequalities in our global response to the pandemic, which may reduce the chance of dealing with it robustly and speedily. Women are under-represented as authors of research papers in many scientific areas, particularly in senior authorship positions. Introduction Despite some progress over the last decade, gender inequalities persist in academic and research settings. Previous studies have shown that women have a lesser share of authorship positions overall and are less likely than men to be first or last author, the most relevant positions to career progression.1 The gap between total authorships for women and men has been stable in recent years, but has grown for senior authorships.2 With lockdowns enforced across the globe due to the COVID-19 pandemic, many researchers are now working from home and face competing demands from parenting, homeschooling and other caring duties. These roles are predominantly assumed by women, especially in countries with high gender inequality. Women’s representation in research generally, and specifically in the study of COVID-19, may be disproportionately affected by lockdown measures. Under-representation of female researchers tends to create under-representation of issues that are relevant to women in research — in our current situation this may create important gaps in our understanding of COVID-19. Therefore, we investigated whether gender differences existed in authorship of COVID-19 research since the onset of the pandemic. We conducted a systematic search in PubMed, using the MeSH term for ‘COVID-19’ in Medline, on 1 May 2020. All references were extracted, irrespective of language, study type and date of publication. Differences between women and men were estimated overall and separately for first and last authorship positions. Joint first or last authorships were considered for the analyses of all authors but not for first or last authorship; single authors were included as both first and last authors. Papers where only authors’ initials were available or there was a group were excluded. We estimated the percentage of women as authors overall as well as in first and/or last authorship positions and tested whether these percentages were significantly different from what would be expected under the null hypothesis of equally distributed authorship between genders. Similarly, we estimated, and tested for gender equality the relative percentage of women in the author list of each paper. In addition, we performed subgroup analyses according to region, time of publication, type of article and impact factor of the journal. The country of origin was defined by the affiliation of the first author and countries were grouped into continents. Time of publication was taken as the date when the record of the paper was created in PubMed. Type of article was split into case report, journal article, editorial, letter, comment, news and other. Impact factor was considered both as a continuous variable and a categorical variable with three levels: lower than 2, 2–7 and >7, reflecting an approximately equal distribution of papers by impact factor. Our analysis has two potential limitations. First, we did not include preprints. However, those preprints have not been peer reviewed, and including them would risk double counting papers. Second, although we employed a widely used and validated software, it is still possible that it may have misclassified the gender of some authors. Fewer women as first and last authors in COVID-19 research publications We identified 1445 papers related to COVID-19, of which 1370 were included in the overall analysis, with a total of 6722 authors. After applying the aforementioned exclusion criteria, we included 1235 and 1216 papers in the analysis for first or last author, respectively. Overall, women represented 34% (95% CI 33% to 35%, p<0.001) of all authors, irrespective of the position. The percentage of women as first and last authors was lower (29%, 95% CI 27% to 32%; and 26%, 95% CI 24% to 29%, p<0.001, respectively) (figure 1). If both first and last positions were considered together, the percentage of women was 42% (95% CI 39% to 45%, p<0.001). There were no major differences in the percentage of women as first or last author according to region and type of article (figure 1). Figure 1 Women in first and last authorship positions of COVID-19-related papers according to journal impact factor, continent and type of article. Values represent percentages of women as first and last authors with respective 95% CIs. Although women’s representation was lowest in Africa, the wide CIs precluded drawing definite conclusions. The percentage of women as first author was higher in journals with impact factor above 7 in comparison with those with impact factor below 2, but there were no differences for the last author position between impact factor categories. The mean percentage of female authors within each article was 31% (95% CI 29% to 33%), with no evidence of significant differences according to type of paper or journal impact factor (figure 2). However, there were differences between regions, with the lowest percentage observed in Africa and the highest percentage in Oceania. The proportion of women as first and last authors, as well as the proportion of women within each article, has remained broadly consistent since the emergence of COVID-19. Figure 2 Relative representation of women within the authorship lists of COVID-19-related papers according to journal impact factor, continent and type of article. Values represent percentages of women among all authors for each paper with respective 95% CIs. Reasons for under-representation of women in COVID-19 authorships The low percentage of female authors was in keeping with similar studies in other areas of research. In an analysis of 20 years of publication in high-impact general medical journals, female first authorships were seen in 34% of the articles. This study also demonstrated that female first authors in infectious disease publication topics declined by 4% from 1994 to 2014.3 In a 2017 study of 1.5 million research papers, women comprised 40% of first authors and 27% of last authors.4 Our figures are lower than these two studies for first authors (29%) and last authors (26%). This shows that raising awareness on gender inequalities in research in general, and in authorship of papers in particular, has not led to substantial improvements.5 It is possible that the current restrictions imposed during the COVID-19 pandemic have contributed further to this decline. In the case of COVID-19-related research, the reasons for under-representation can be manifold. First, COVID-19 research may be shaped by those in leadership positions, who remain more often men. Second, COVID-19 is a high-profile and dynamic topic where women may either be overtly or covertly denied access to COVID-19 research, because of its anticipated high impact.6 Third, women may have less time to commit to research during the pandemic.7 Fourth, COVID-19-related papers are likely to be affected as much as other papers by gender bias in the peer-review process.8 Fifth, a relatively large amount of the early COVID-19 publications are commissioned articles, which are, in general, more likely to be published by men.9 There is a pressing need to reduce these gender inequalities because women’s participation in research is associated with a higher likelihood of reporting gender and sex-disaggregated data,4 which in turn improve our understanding of the clinical and epidemiological dimensions of COVID-19. This is especially true as evidence continues to accrue regarding sex and gender differences in mortality rates and in the long-term economic and societal impacts of COVID-19, making a balanced gender perspective ever more important.10 11 One possible solution to overcome the persistently low representation of women in authorship of scientific papers in general and COVID-19 papers specifically would be to promote voluntary disclosure of gender as part of the submission process. This would allow editorial teams to monitor gender inequalities in authorship and it would encourage research teams to foster equality in authorship. A further step would be to consider gender quotas, as these have shown to help rectify women’s under-representation in prominent positions, for instance, in political, economic and academic systems.12 Conclusion Women have been under-represented in COVID-19 research since the beginning of the outbreak. Gender equality and inclusiveness in COVID-19 research are key to succeed in the global fight against the pandemic. The disproportionate contribution of women to COVID-19 research reflects a broader gender bias in science that should be addressed for the benefit of men and women alike.

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          Mitigating the wider health effects of covid-19 pandemic response

          Countries worldwide have implemented strict controls on movement in response to the covid-19 pandemic. The aim is to cut transmission by reducing close contact (box 1), but the measures have profound consequences. Several sectors are seeing steep reductions in business, and there has been panic buying in shops. Social, economic, and health consequences are inevitable. Box 1 Social distancing measures Advising the whole population to self-isolate at home if they or their family have symptoms Bans on social gatherings (including mass gatherings) Stopping flights and public transport Closure of “non-essential” workplaces (beyond the health and social care sector, utilities, and the food chain) with continued working from home for those that can Closure of schools, colleges, and universities Prohibition of all “non-essential” population movement Limiting contact for special populations (eg, care homes, prisons) The health benefits of social distancing measures are obvious, with a slower spread of infection reducing the risk that health services will be overwhelmed. But they may also prolong the pandemic and the restrictions adopted to mitigate it.1 Policy makers need to balance these considerations while paying attention to broader effects on health and health equity. Who is most at risk? Several groups may be particularly vulnerable to the effects of both the pandemic and the social distancing measures (box 2). Table 1 summarises several mechanisms through which the pandemic response is likely to affect health: economic effects, social isolation, family relationships, health related behaviours, disruption to essential services, disrupted education, transport and green space, social disorder, and psychosocial effects. Figure 1 shows the complexity of the pathways through which these effects may arise. Below we expand on the first three mechanisms, using Scotland as an example. The appendix on bmj.com provides further details of mechanisms, effects, and mitigation measures. Box 2 Groups at particular risk from responses to covid-19 Older people—highest direct risk of severe covid-19, more likely to live alone, less likely to use online communications, at risk of social isolation Young people—affected by disrupted education at critical time; in longer term most at risk of poor employment and associated health outcomes in economic downturn Women—more likely to be carers, likely to lose income if need to provide childcare during school closures, potential for increase in family violence for some People of East Asian ethnicity—may be at increased risk of discrimination and harassment because the pandemic is associated with China People with mental health problems—may be at greater risk from social isolation People who use substances or in recovery—risk of relapse or withdrawal People with a disability—affected by disrupted support services People with reduced communication abilities (eg, learning disabilities, limited literacy or English language ability)—may not receive key governmental communications Homeless people—may be unable to self-isolate or affected by disrupted support services People in criminal justice system—difficulty of isolation in prison setting, loss of contact with family Undocumented migrants—may have no access to or be reluctant to engage with health services Workers on precarious contracts or self-employed—high risk of adverse effects from loss of work and no income People on low income—effects will be particularly severe as they already have poorer health and are more likely to be in insecure work without financial reserves People in institutions (care homes, special needs facilities, prisons, migrant detention centres, cruise liners)—as these institutions may act as amplifiers Table 1 Health effects of social distancing measures and actions to mitigate them Mechanism Summary of effects Summary of mitigations Economic effects • Income losses for workers unable to work• Longer term increase in unemployment if businesses fail• Recession • Protect incomes at the level of the minimum income for healthy living• Provide food and other essential supplies• Reduce longer term unemployment• Prioritise inclusive and sustainable economic development during recovery Social isolation • Lack of social contact, particularly for people who live alone and have less access to digital connectivity• Difficulty accessing food and other supplies • Encourage and support other forms of social contact• Provide supplies• Provide clear communications• Restrict duration of isolation Family relationships • Home confinement may increase family violence and abuse• Potential exploitation of young people not in school • Offer support to vulnerable families• Ensure realistic expectations for home working and home schooling• Provide safety advice and support services for women at risk of domestic abuse Health related behaviours • Potential for increased substance use, increased online gambling, and a rise in unintended pregnancies• Reduction in physical activity as sports facilities closed and less utilitarian walking and cycling • Advice and support on substance use, gambling, contraception• Encourage daily physical activity Disruption to essential services • Direct effects on health and social care demand• Unwillingness to attend healthcare settings may affect care of other conditions• Loss of workforce may affect essential services • Robust business continuity planning• Prioritise essential services including healthcare, social care, emergency services, utilities, and the food chain• Guidance, online consultations, and outreach, for conditions other than covid-19• Attention to supply chains for non-covid medicines Disruption to education • Loss of education and skills, particularly for young people at critical transitions• Likely increase in educational inequalities from reliance on home schooling • Provide support for young people in critical transitions, and low income or at-risk children and young people who lack IT and good home study environments Traffic, transport, and green space • Reduced aviation and motorised traffic with reduced air pollution, noise, injuries, and carbon emissions in short term• Restricted public transport may reduce access for people without a car• Longer term reluctance to use public transport may increase use of private cars• Restricted access to green space, which has benefits for physical and mental health • Discourage unnecessary car journeys• Support active travel modes• Support safe access to green spaces• Post-pandemic support for public transport Social disorder • Potential for unrest if supplies run out or there is widespread discontent about the response• Harassment of people believed to be at risk of transmitting the virus • Mitigation of other effects will reduce risk of social disorder• Avoid stigmatising ill people or linking the pandemic to specific populations Psychosocial impacts • High level of public fear and anxiety• Community cohesion could increase as people respond collectively • Provide clear communications• Support community organisations responding to local needs Fig 1 Effects of social distancing measures on health Economic effects People may experience loss of income from social distancing in several ways. Although some people can work at home, many cannot, especially those in public facing roles in service industries, a group that already faces precarious employment and low income.2 Others may be affected by workplace closures, caused by government mandate, an infected co-worker, or loss of business. Yet more may be unable to work as school closures require them to provide childcare. In the UK, 3.5 million additional people are expected to need universal credit (which includes unemployment payments) as a result of the pandemic.3 The growth of the informal, gig economy in some countries has created a large group of people who are especially vulnerable as they do not get sick pay, are on zero hours contracts, or are self-employed.4 They can easily lose all their income, and even if this is only temporary they often lack the safety net of savings. An important risk is housing security, with loss of income causing rent or mortgage arrears or even homelessness. School closure will affect low income and single parent families especially severely because they need to meet an unexpected need for childcare and lose the benefit of free school meals. They may also face increased costs for heating their homes during the day. In some countries, welfare systems impose strict conditions on recipients that cannot be met by those in isolation. The link between income and health is well established and acts through several mechanisms.5 Income allows people to buy necessities for life, access health enhancing resources, avoid harmful exposures, and participate in normal activities of society. Low income also increases psychosocial stress. The minimum income for healthy living establishes a standard required to maintain health in different settings.6 Crucially, not everyone is equally likely to lose income. Women, young people, and those who are already poor will fare worst. To avoid widening health inequalities, social distancing must be accompanied by measures to safeguard the incomes of poor people. Future challenges The longer term effects may be substantial. If businesses fail, many employees will become unemployed. Those losing their jobs in middle age may never return to the workforce. Sectors that are especially vulnerable include hospitality, entertainment, transport, leisure, and sport. Unemployment has large negative effects on both physical and mental health,7 with a meta-analysis reporting a 76% increase in all-cause mortality in people followed for up to 10 years after becoming unemployed.8 The pandemic has already caused downgrading of economic forecasts, with many countries facing a recession. The health consequences of a recession are complex. Economic downturns have been associated with improvements in some health outcomes, especially traffic injuries, but worsening mental health, including increases in homicide and suicide.9 However, these harmful effects can be prevented by progressive social policies; it is the policy response to a recession, rather than the recession itself, that determines longer term population health.10 Throughout history, some people have viewed any crisis as an opportunity. Klein described how “disaster capitalists” take advantage of natural and human influenced disasters.11 There is clear potential for price gouging (profiteering through increased prices during supply or demand shocks) on essential goods. Once the pandemic recedes, there could be profound changes to the economy that may disadvantage less powerful populations, such as through privatisation of public sector services. However, there may also be opportunities for the economy to be rebuilt “better,” depending on public and political attitudes and power balance.12 Social isolation Advising or compelling people to self-isolate at home risks serious social and psychological harm. Quarantine of people exposed to an infectious disease is associated with negative psychological effects, including post-traumatic stress symptoms, which may be long lasting.13 The effects are exacerbated by prolonged isolation, fear of the infection, frustration, boredom, inadequate supplies and information, financial loss, and stigma. These effects are less when quarantine is voluntary and can be mitigated by ensuring clear rapid communication, keeping the duration short, providing food and other essential supplies, and protecting against financial loss.13 In Scotland, a third of the population lives alone and 40% of this group are of pensionable age.14 Older people are also less likely to use online communications, making them at particular risk of social isolation during social distancing. Social isolation is defined as pervasive lack of social contact or communication, participation in social activities, or a confidante. Long term, social isolation is associated with an increase in mortality of almost a third.15 Prolonged periods of social distancing could have similar effects. People who are socioeconomically disadvantaged or in poor physical or mental health are at higher risk.16 Online and telephone support needs to be provided for vulnerable groups, especially those living alone. Family relationships Social distancing measures will place many people in close proximity with family members all or most of the time, which may cause or exacerbate tensions. Concern has been raised about potential increases in family violence during restrictions in the UK.17 Risk factors for partner and child abuse include poverty, substance misuse in the home, and previous history of abuse.18 19 Around 60 000 domestic abuse incidents occur in Scotland every year, with young women most affected, 20 and over 2500 children are on the child protection register.21 It is important to maintain social work and community support for vulnerable families, including safety advice for women at risk of abuse. Domestic abuse advocates have called for enhanced support, including allocation of hotel rooms for women at risk.17 School closures may add to stress in families as parents try to home school children, often juggling this with home working. This burden may fall disproportionately on women. As well as academic learning, schools support development of social and other skills. Prolonged school closures could cause adverse effects on educational and social outcomes for young people in families that lack study space and access to home computing.22 Some children who are not at school may be at risk of online or other forms of exploitation—for example, by drug dealers—or of being recruited into gangs. Realistic expectations of home schooling, provision of food for those eligible for free school meals, and outreach support for the most vulnerable children will be needed during school closures. Many children will need extra support on return to school.22 Mitigating adverse effects In addition to the direct disease burden from covid-19, the pandemic response is already causing negative indirect effects such as those described above. These are borne disproportionately by people who already have fewer resources and poorer health. Prolonged or more restrictive social distancing measures could increase health inequalities in the short and long term. Our assessment is based on rapid scoping of potential impacts and a non-systematic review of diverse publications, so there is a high degree of uncertainty about the extent of some impacts. However, the range of health concerns identified, beyond those directly attributable to the virus itself, should be recognised in developing and implementing responses. The effects may also vary by context. In low and middle income countries without social safety nets, the effects on population health and health inequalities are likely to be worse than in richer countries, as is beginning to be seen in India.23 Actions must be targeted to support the most vulnerable people. The extraordinary measures in the UK to allow businesses to continue paying staff will help mitigate the harms for many workers. But it is important to consider people in precarious work who will not be covered by these measures, and to consider longer term support for those who continue to experience problems once the measures expire. A large multiagency response will be needed to deal with the wide range of needs we have identified. In the longer term, policy decisions made now will shape the future economy in ways that could either improve or damage sustainability, health, and health inequalities. These include decisions about which sectors to prioritise for support, whether to direct financial support to business or workers, and how to fund the costs. To protect population health it will be essential to avoid a further period of austerity and the associated reductions in social security and public service spending. Instead we must build a more sustainable and inclusive economy.10 Key messages Social distancing measures to control the spread of covid-19 are likely to have large effects on health and health inequalities These effects have numerous mechanisms, including economic, social, health related behaviours, and disruption to services and education People on low incomes are most vulnerable to the adverse effects Substantial mitigation measures are needed in the short and long term
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            The pandemic and the female academic

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              Governance of the Covid-19 response: a call for more inclusive and transparent decision-making

              Summary box Not all countries make their Covid-19 task force membership list public—the available information varies by country. There is currently a predominance of politicians, virologists and epidemiologists in the Covid-19 response at the country level. Experts on non-Covid-19 health, social and societal consequences of Covid-19 response measures are, for the most part, not included in Covid-19 decision-making bodies. There is little transparency regarding whom decision-making bodies are consulting as their source of advice and information. From the available data on Covid-19 decision-making entities, female representation is particularly paltry. In addition, civil society is hardly involved in national government decision-making nor its response efforts, barring some exceptions. We need to be more inclusive and multidisciplinary: the Covid-19 crisis is not simply a health problem but a societal one—it impacts every single person in society one way or another. Decision makers need to address more systematically the suffering from mental illness exacerbations, domestic violence, child abuse, child development delays, chronic diseases and so on, during lockdown. Introduction As SARS-COV-2 (severe acute respiratory syndrome coronavirus 2) ravages the globe, heads of state are making swift decisions to put large swathes of the world’s population under mass isolation in the race to heed off Covid-19’s lethality, particularly in certain population subgroups. How are these decisions—that affect each and every one of us, some groups disproportionately and regardless of Covid-19 status—made? How far have policy makers and politicians consulted those who have experience and expertise on the secondary effects of lockdowns, social isolation measures and movement restrictions? We attempted to address these questions with a rapid analysis of 24 countries’ Covid-19 task force compositions. The countries were selected to represent a range of geographies and income levels. As far as possible, we focused on governance bodies set up or activated to give scientific, or evidence-based, advice to national decision makers. In some countries, the advisory and decision-making bodies were one and the same, often taking the form of government-only interministerial committees. We excluded committees which were established to focus on a specific area, for example, research related to vaccination; rather, we examined committees whose explicit mandate (based on available information) was to provide advisory guidance on the overall national response. We scanned publicly available documentation from government websites, media articles, and in specific cases, contacted our networks in governments and health ministries for official documentation. We then researched the task force members’ backgrounds and triangulated from different sources to classify them based on their current professional role or area of specialisation. Experts were thus categorised based on the principal reason for their appointment to the task force. For example, a physician with a current public health role would be classified as a public health specialist and not a clinician, the assumption being that their current role is most relevant for the task force. The ‘government’ or ‘Ministry of Health’ category was allocated to career civil servants, that is, posts which are usually filled by generalists rather than specialists. Most other task force members, including public health institute staff, were categorised according to their expertise since the rationale for their task force membership is their specific skill set (mathematical modeller, virologist, etc) rather than their institutional affiliation. At least two coauthors independently categorised the task force members and crosschecked categorisations with each other. How inclusive and transparent is Covid-19 decicion-making? We highlight a number of key issues, some very worrying, made evident by table 1: Table 1 Covid-19 task forces set up to advise national governments Country Name of task force convened or activated for Covid-19 response Composition of task force by member expertise Gender distribution Argentina28 Expert Committee (El comité de expertos) 5 Government officials 2 Ministry of Health officials 6 Infectious disease specialists 1 Epidemiologist 1 Public health specialist 12 M; 3 F Belgium29 30 Scientific Committee Coronavirus (Comité scientifique Coronavirus) 3 Infectious disease specialists 1 Epidemiologist 1 Laboratory specialist 2 M; 3 F Burkina Faso31 Name unknown 1 Ministry of Health official 4 Infectious disease specialists 2 Epidemiologists 3 Public health specialists 2 Other medical specialists 1 Communication specialist 1 Private sector 4 Unknown 14 M; 5 F Chad32 Scientific Committee for Covid-19(Comité Scientifique Covid-19) 1 Ministry of Health official 7 Infectious disease specialists 1 Epidemiologist 1 Laboratory specialist 8 Public health specialists 2 Intensive Care specialists 12 Other medical specialists 1 Pharmacist 1 Nutrition specialist 1 Lawyer 1 Socioanthropologist 1 Historian 33 M; 4 F Chile33 Advisory Board of Ministry of Health for Covid-19(Consejo Asesor del MINSAL por Covid-19) 2 Ministry of Health officials 1 Infectious disease specialist 3 Public health specialists 1 Other medical specialist 3 M; 4 F China34 35 Central Leading Group on Responding to the Novel Coronavirus Disease Outbreak 9 Government officials 8 M; 1 F France36–39 Scientific council Covid-19(Conseil scientifique Covid-19) 4 Infectious disease specialists 1 Epidemiologist 1 Mathematical modelling specialist 1 Intensive Care specialist 1 Other medical specialist 1 Anthropologist 1 Sociologist 8 M; 2 F Analysis, research and expertise committee(Comité analyse, recherche et expertise (CARE)) 6 Infectious disease specialists 1 Mathematical modelling specialist 2 Laboratory specialists 2 Other medical specialists 1 Anthropologist 7 M; 5 F Germany40–42 Interministerial crisis unit(Krisenstab) Government officials from six different ministries Unknown Guinea43 44 Scientific council on pandemic response to coronavirus disease (Covid-19)(Conseil scientifique de riposte contre la pandémie de la maladie à coronavirus (Covid-19)) 2 Infectious disease specialists 1 Epidemiologist 1 Laboratory specialist 3 Public health specialists 3 Pharmacists 3 Other medical specialists 1 Psychologist 1 Economist 2 Socioanthropologist 14 M; 3 F Haiti45 Scientific committee to combat coronavirus(Cellule scientifique pour lutter contre le coronavirus) 1 Ministry of Health official 2 Infectious disease specialists 1 Epidemiologist 1 Laboratory specialist 2 Public health specialists 1 Intensive Care specialist 3 Other medical specialists 1 Mental health specialist 1 Sociologist 1 Civil society 12 M; 2 F Hungary46 Coronaviral Defence Operational Staff(Koronavírus-járvány Elleni Védekezésért Felelős Operatív Törzs) 11 Government officials 3 Ministry of Health officials 1 Infectious disease specialist 14 M; 1 F Italy47–49 Operational Committee on Coronavirus for Civil Protection(Comitato operativo sul Coronavirus alla Protezione Civile) 6 Government officials 1 Ministry of Health official 7 M; 0 F Scientific Technical Committee(Comitato Tecnico Scientifico) 4 Ministry of Health officials 2 Infectious disease specialists 1 Public health specialist 7 M; 0 F Task force tech anti Covid-19 2 Government officials 2 Ministry of Health officials 2 Infectious disease specialists 5 Epidemiologists 1 Mathematician 4 Public health specialists 1 Social scientist 12 Data management specialists 4 Statisticians 1 Physicist 1 Civil engineering expert 1 Digital health expert 1 Chemist 1 Information systems expert 13 Economists 3 Computer science experts 1 Communication technology expert 3 Digital transformation experts 2 Emergency management experts 11 Lawyers 1 Unknown 56 M; 18 F Kenya50 51 National Emergency Response Committee 17 Government officials 4 Ministry of Health officials 15 M; 6 F Mali52 53 Crisis Committee(Le Comité de crise) 2 Governmental officials 2 Ministry of Health officials 1 Infectious disease specialist 2 Laboratory specialists 4 Public health specialists 1 Other medical specialist 12 M; 0 F Scientific and Technical Committee of the National Public Health Institute(Comité Scientifique et Technique de l’Institut National de Santé Publique -INSP) 5 Infectious disease specialists 1 Public health specialist 1 Other medical specialist 1 Agronomist 1 Ecologist 1 Nutritionist 9 M; 1 F Philippines54 Inter-Agency task force 2 Government officials 2 Ministry of Health officials 4 M; 0 F National task force Covid-1919 (National Disaster Risk Reduction and Management Council - NDRRMC) 4 Government officials 4 M; 0 F Portugal55 56 Task force Covid-19 13 Infectious disease specialists 10 Epidemiologists 12 Public health specialists 1 Intensive Care specialist 5 Other medical specialists 1 Chemist 2 Communication specialists 25 Unknown 26 M; 42 F National Public Health Council(Conselho Nacional de Saúde Pública) 2 Government officials 2 Ministry of Health Officials 5 Infectious disease specialists 1 Epidemiologist 2 Public health specialists 1 Other medical specialist 1 Pharmacist 2 Lawyers 1 Private sector 2 CSO 14 M; 6 F Singapore57 Multi-Ministry Taskforce on Wuhan Coronavirus 10 Government officials 1 Ministry of Health official 10 M; 1 F South Korea58 59 Central Disease Control Headquarters (KCDC) Led by Jung Eun-Kyeong (Director) Other members unknown 1 F, unknown Central Disaster and Safety Countermeasures Headquarters Led by the Prime Minister (Chung Sye-kyun) Other members unknown 1 M, unknown Central Incidence Management System for Novel Coronavirus Infection Led by Minister of Health and Welfare (Park Neung-hoo) Other members unknown 1 M, unknown Central Disaster Management Headquarters Led by Ministry of Health and Welfare (Park Neung-hoo) Other members unknown 1 M, unknown Government-wide Support Centre Led by Minister of Public Administration and Security Other members unknown 1 M, unknown Local Disaster and Safety Countermeasures Headquarters (local municipal governments nationwide) Led by the head of the local government Other members unknown Unknown Local quarantine task force (local municipal governments nationwide) Led by the head of the local government Other members unknown Unknown Spain60 Scientific Technical Committee Covid-19(Comité Cientifico Técnico Covid-19 19) 3 Infectious disease specialists 3 Epidemiologists 3 M; 3 F Switzerland61 Science Task Force 6 Infectious disease specialists 2 Epidemiologists 1 Mathematical modelling specialist 1 Laboratory specialist 2 Public health specialists 1 Environmental engineering expert 1 Computer science expert 1 Economist 1 Bioethics expert 12 M; 4 F Thailand62 National committee for controlling the spread of Covid-19 26 Government officials 2 Ministry of Health officials 28 M; 0 F Vietnam63 Committee for Covid-19 Prevention and Control(Tiểu ban giám sát phòng, chống dịch bệnh Covid-19). 5 Government officials 9 Ministry of Health officials 13 M; 1 F United Kingdom64–66 New and Emerging Respiratory Virus Threats Advisory Group (NERVTAG) 9 Infectious diseases specialists 1 Epidemiologists 2 Mathematical modelling specialists 1 Public health specialist 1 Intensive Care specialist 1 Sociologist 1 Psychologist 14 M; 2 F Advisory Committee on Dangerous Pathogens (ACDP) 1 Government official 12 Infectious disease specialists 1 Mathematical modelling specialist 1 Public health specialist 1 Other medical specialist 13 M; 3 F Joint Committee on Vaccination and Immunisation (JCVI) 19 Infectious disease specialists 1 Other medical specialist 1 Lay member (unknown) 12 M; 9 F USA67 68 White House Coronavirus Task Force 19 Government officials 1 Ministry of Health official 3 Infectious disease specialists 21 M; 2 F 1.‘Evidence’ seems to be largely understood to mean research-based evidence, and not necessarily experiential, implementation-based evidence from the field The vast majority of Covid-19 response task force members are from reputed universities and government institutes where rigorous research is conducted in the classical sense, often under clinical trial or laboratory conditions. Information and evidence on the lived experiences and everyday challenges faced by the various groups in society who are (at times, severely) affected by isolation measures seem to be altogether overlooked in the urgency of the current situation. 2. Among researchers, mainly virologists and epidemiologists seem to be consulted, leaving out other health and also non-health experts Most countries acknowledge the need for government to work jointly with the medical (and public health) community in the national Covid-19 response. However, mainly virologists and epidemiologists seem to be consulted, largely leaving out specialists in areas such as mental health, child health, chronic diseases, preventive medicine, gerontology, not to mention experts in non-health spheres. Social isolation measures have enormous secondary effects1 beyond the primary aim of curbing viral spread. These effects go far beyond health (discussed below). But even within the health space, the consequences of not accessing, or inadequately accessing,2 basic essential services for a wide range of non-Covid-19-related conditions3 do not seem to have been sufficiently considered. 3. When the task force is government-only, more non-health sectors seem to be represented, but at the detriment of non-government expertise Still, some countries’ Covid-19 task forces are government-only. In those cases, there at least seems to be a stronger presence of non-health sectors, although to the detriment of non-government expertise. In a number of countries, Covid-19 task forces consist of high-level government cadres only, combining the advisory and decision-making elements into one. Medical and epidemiological expertise seems to come from government health institutions, but it is not always clear who is being consulted beyond government. A multiministry task force at least theoretically brings in concerns from other sectors such as education,4 economy, interior, and so on, potentially raising serious issues in terms of, for example, child development5 (relevant to decisions on school closures, for example),6 loss of livelihoods7 (particularly relevant in low-income countries8 and those with large social inequalities and no social safety net), and further marginalisation of migrants9 and illegal workers (who often have nowhere to isolate to). However, how far those concerns are actually taken into consideration is impossible to discern without more transparency with regard to the content of deliberations and potential consultations with external parties. 4. Civil society and community groups do not seem to be consulted at all In addition to civil society and community groups not being engaged in primary discussions, neither are social workers, child development specialists, human rights lawyers, and many other people whose experiential and vocational expertise are particularly relevant in terms of societal rights, and groups affected by isolation measures. The WHO weekly Covid-19 situation update from 15 April mentions that only 36% of member states reported having a Covid-19 community engagement plan.10 In addition, a majority of the 175 civil society respondents from 56 countries confirmed in a recent rapid survey of the UHC2030 Alliance’s Civil Society Engagement Mechanism that most of their Covid-19 response work was, indeed, independent of the government. Results and methodology of the survey can be found here. Vulnerable groups11 such as the disabled,12 those with serious mental health conditions,13 single mothers,14 people in abusive family relationships15 and the elderly16 bear the burden of the negative consequences of isolation and loneliness, potentially threatening the social fabric of society. Civil society organisations, community groups, social workers, nurse-caregivers and many other groups are at the front lines with this broad cross-section of society clearly affected by the far-reaching effects of mass isolation. Civil society can also raise awareness on existing social inequalities which are usually exacerbated in crisis situations, leaving many to feel that ‘self-isolation is a privilege for the rich’.17–20 If there is one thing that we should learn from another virus-based crisis (HIV), it is that the population, communities and civil society are an integral part of the crisis solution.21 5. Women are a minority in Covid-19 task forces, and are not represented at all in some The Women in Global Health movement has already lamented the abysmally low proportion of women represented in global Covid-19 response efforts.22 Besides some notable exceptions, the same low percentages of female experts are seen across the national task forces we rapidly reviewed, with some task forces even being all male. Women’s perspectives and expertise clearly seem to be heard less often than male colleagues, even while the majority of front-line health staff fighting the crisis is female.23 6. More transparency is needed on who is taking decisions and how We took great pains to scan a broad variety of websites, newspapers and government documents in several languages within a short amount of time. Still, information on (1) Who is making far-reaching decisions on an unprecedented global and national crisis? (2) How decision makers are reaching their conclusions (ie, who else are they reaching out to for advice)? (3) Which exact positions advisers had? was not always easy to come by. There are signs that some countries’ governments and/or Covid-19 task forces are indeed consulting with outside parties24 relevant to the secondary consequences of long-term isolation25 but this information is generally not clear and transparent. In addition, transparency on selection criteria for the task forces themselves is needed to better understand the weight given to the different aspects of the outbreak. Conclusion We acknowledge that the information may not be complete, nor completely up to date, given the extremely fast-paced dynamic of the Covid-19 outbreak as well as response measures. We also recognise that Covid-19 task force compositions are not the sole indication of whose voices are included in decision-making. Through the fairly broad range of (mostly) publicly available information analysed, we attempted to understand which groups the task forces were reaching out to within the scope of a rapid analysis. In general, protocols, reports, minutes of task force meetings and lists of externally consulted parties were simply not easily available. Nevertheless, we feel that the broad conclusions we take based on our rapid (but imperfect) analysis still hold based on the information we were able to access. The table above displays the list of countries and their available task force information. Governments must recognise the multidimensional effects and needs of society26 during this Covid-19 crisis and consult more broadly and across disciplines, within health and beyond health, based on a true multisectoral paradigm. More importantly, more transparency is needed regarding who decision-making bodies are listening to as a basis for their decisions. Now more than ever, the voices of those who are at risk of getting left behind need to be heard.27 In the end, we must ensure that we do not do more harm than good with the measures in place to protect our at-risk populations.
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                Author and article information

                Journal
                BMJ Glob Health
                BMJ Glob Health
                bmjgh
                bmjgh
                BMJ Global Health
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2059-7908
                2020
                11 June 2020
                : 5
                : 7
                Affiliations
                [1 ] departmentThe George Institute for Global Health , University of Oxford , Oxford, UK
                [2 ] departmentJulius Center for Health Sciences and Primary Care, University Medical Center Utrecht , Utrecht University , Utrecht, The Netherlands
                [3 ] departmentThe George Institute for Global Health , University of New South Wales , Sydney, New South Wales, Australia
                [4 ] departmentDepartment of Epidemiology , Johns Hopkins University , Baltimore MD, United States
                Author notes
                [Correspondence to ] Dr Ana-Catarina Pinho-Gomes; ana.pinho-gomes@ 123456georgeinstitute.ox.ac.uk
                Article
                bmjgh-2020-002922
                10.1136/bmjgh-2020-002922
                7298677
                32527733
                d16ecba8-da19-4013-b680-44824ae756cf
                © Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

                This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/.

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                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/501100001773, University of New South Wales;
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                public health,epidemiology
                public health, epidemiology

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