On the role of academic journals during infectious disease outbreaks

Academic researchers, naturally, are keen to contribute productively to the biomedical as well as social challenges caused by the current outbreak of SARS-CoV-2. Some of us do this by talking to the overwhelmed editors of newsoutlets' opinion pages, who are currently drowning in COVID19 pitches. Others are sufficiently well-known to government bureaucracies that they receive invitations to contribute their competence in the development of any number of policies and guidance documents.

Most of us, though, given that we cannot quite escape COVID19 at the moment anyway, have begun producing COVID19 research outputs. Journal editors across disciplines face an unprecedented onslaught of article submissions, many of which written very recently, and typically they consist of results of biomedical or survey research, economic modelling, analyses of the experiences made in countries like China and Italy. In my own field people are concerned about normative aspects of triage policies, privacy aspects of prevention strategies, challenge trials, equity, and so on and so forth.

What many of these article submissions have in common is that the authors hope to contribute to working through the current outbreak. I wonder whether academic journals, and the peer review and production processes we currently have in place for them, make them suitable outlets for those sorts of activities.

Most global publishers have developed technological means that permit the digital, on-line first publication of accepted content. These publications precede print publication, oftentimes by months. Many smaller academic publishers, especially many smaller university presses do not possess that capability. Anything submitted to them will not be published until, realistically, the end of this year. By most accounts that would be too late to have any impact on the current outbreak.

Let's have a closer look at a typical submission-to-decision-to-publication situation with a global publisher. Say you submit on April 01 (I know, the joke is on me). If the editor of the journal moves quickly, they will decided within a day or two whether they will have the paper reviewed. So, they'd send out reviewer requests. Normally those invited would have a week or so to reply and decide on whether they're ok with doing the review. Takes us to April 10. Say, given the urgency, the first invitee agrees to review the content. They've anywhere between 2-4 weeks to submit their review. Some, with prodding, might be prepared to move faster on COVID19 papers, but given the deluge of papers submitted, their willingness might sooner rather than later wear thin.

We are now around the end of April. The reviews require that some changes are made before the paper is publishable. Let's assume that you're an efficient author, so you send the revised manuscript back to the editor. We're around May 10-15. The editor takes until May 20 to review the changes and accepts your manuscript. The paper is exported to the publisher's production people. After about 10 days you will see your proofs. You correct the proofs and return them to the publisher. Realistically, we're looking at the end of May. The publisher takes another week or so to make the necessary corrections and uploads your manuscript. So, in an ideal world, from submission to publication of your paper about 6 weeks would have passed. The odds are that you'd be looking at 8-12 weeks.

The pandemic you have been responding to will have moved on to a very different stage to what your paper aimed to respond to.

Some publisher offer to upload accepted manuscripts prior to copy editing and proof production, and replace them with the final version when it's ready. While this is faster, it also means that mistakes that would be caught during the copy editing process would be published and can even be cited, only to find that, in the actual published version, the mistake has been fixed.

The upshot of this is the following: With the exception of very few topflight biomedical journals the academic publishing process is too slow to respond meaningfully to ongoing infectious disease outbreaks. The fault for this lies not only in still fairly slow and cumbersome production processes of academic publishers, but also, and arguably more so, on the time it takes to maintain sound peer review.

What this suggests to me is this: If you plan on submitting content that is designed as an intervention in the currently ongoing outbreak, reconsider that. The pandemic will long have moved on from what was urgent at the time when you submitted your paper. Academic journals are not a sound target for your output. There might be alternative outlets, like, for instance the Journal of medical ethics blogs. I suspect in your field you might also have outlets for non-reviewed content, like SSRN, where you can upload your content while you wait for your paper to run through the peer review and production processes.

Focus on lessons that we can learn for future outbreaks.

COVID19 and the ethics of hospital triage decision-making

There is a lot of talk these days about the predicted coming wave of COVID19 patients needing ICU beds and ventilators in particular, and the inevitable need to prioritise in terms of access. Based on what I'm reading I am somewhat reassured that the right decision criteria will be deployed. Medicine, as always when it comes to the crunch, moves speedily from publicly professed deontological values and handwaving right to consequentialist, if not outright utilitarian, decision-making. That is a good thing. You want to use your limited available resource to maximise the number of life-years preserved. It'll mean, among many other things, that you need to prioritize looking after infected health care workers first (incidentally, that doesn't include clinical ethicists :). It'll also mean to remove people who would need long-term intensive care from beds that could otherwise be utilised by a larger number of patients with better odds of faster recovery. This will be a big challenge for health care professionals who put much store in the acts and omissions doctrine, thinking mistakenly that they're less responsible for the death of someone they omitted to admit to an ICU bed, even though they could have chosen to move a patient with worse odds out of that bed. You are responsible for the choices you make, an act of omission is still an act that you are morally responsible for. 

What makes this less straightforward in practice than it looks like is that what 'the odds' are will inevitably change over time, as health care professionals begin gathering information about what does and doesn't work. This is something we saw during the Ebola virus outbreak of 2014/15. Death rates were staggeringly high and went down considerably as a result of the experience and knowledge gained by the attending health care workers. A case in point, the limited currently available evidence suggests that the vast majority of people who get on ventilators die anyway (the two papers that I have seen peg the mortality rate between 86%-97%), so the current debate about lack of ventilators might be a lot of noise about nothing. I wouldn't be surprised, however, if that changed over time, so this is something that makes allocation decisions more difficult, as the decision-making needs to be continuously updated, based on the rapidly accumulating evidence. Now, while this may well lead to different practical decisions, the normative criteria used to evaluate that evidence should remain pretty stable.

The really important bit though is that hospitals, by now, should have transparent resource allocation decision frameworks in place. They should have communicated those to their staff and made clear that to them that those criteria are binding on everyone. They should also communicate those criteria to the public. Nothing breeds suspicion, conspiracy theories and panic better than non-transparent decision-making procedures in a time of crisis. People need to understand that there is not one rule for them and another one for others who are better connected, as it were. We are all in the same boat, really. 

Which takes me to my last point. This all strikes me as obvious. So I went (16 March 2020) to the COVID19 bits of the website of our local Kingston Health Science Centre (the new name for KGH/Hotel Dieu), to find out what their policies look like, and, to my surprise, there is no relevant information. There's invariably important information about restrictions, like how many visitors will be admitted, and it's all eminently sensible. However, the hospital communicates nothing about what will substantively drive its triage nurses' and clinicians' decision-making should the predicted wave of COVID19 hit the hospital, and you're unfortunate enough to end up there, as a patient. That is unacceptable. Patients and their loved ones have a right to know how life-and-death triage decisions will be made at the hospital where they or their loved ones will be admitted. Incidentally, if everyone knows the basis on which decisions will be made, patient expectations would be realistic from the outset, which can only help in such circumstances.