The Covid-19 pandemic, emerging in the aftermath of the recent global financial crisis, could potentially further shake the confidence that Europeans have in their institutions. Rigid and slow decision-making processes and an excessive institutional reliance on super-specialisation and protocol-driven scientific evidence can at least partly explain why Europe finds it so difficult to predict disruptions and why it adapts its institutional machineries so slowly. Greater flexibility, including space for experimentation and improvisation, can help Europe to adapt more quickly to future contingencies, write Saradindu Bhaduri and Peter Knorringa.

Europe has offered a historically unprecedented degree of stability, prosperity, comfort and reliability to most of its citizens in recent decades. Many of its citizens have grown to take these benefits for granted, even when all this makes Europe a very high-cost economic system. Two recent disruptions, the earlier financial crisis and the Covid-19 pandemic, are unprecedented in the history of Europe, at least since World War II. The pandemic has caused more than 150,000 deaths so far, with a mortality rate in Europe far exceeding that of countries outside the continent. Potentially, these two events could shake the faith of people in the institutional mechanisms of the continent developed brick by brick over the last half a century, especially if such disruptions are expected to recur more frequently in the future.

Understanding the European system

Few would disagree that the present European production and innovation system, inter-country variations notwithstanding, relies extensively on the super-specialisation of work and an overwhelming reliance on strongly protocolised ‘hard scientific evidence’. Together, they are supposed to uphold quality and transparency in economic decision making, even at the cost of being expensive and sticky, i.e. slow in its ability to adapt to changing circumstances. While specialisation and protocols are in themselves indispensable and desirable elements in a modern economy, too much of it creates its own challenges.

In this blog we argue that the excessive institutional reliance on super-specialisation and protocol-driven scientific evidence in all its decision-making processes can, at least partly, explain why Europe finds it so difficult to predict disruptions and is not able to quickly adapt its institutional machineries in the face of a crisis¹. A remedy in our view lies in reducing over-formalisation in its decision-making processes and creating more space for experimentation and judicious improvisation. These steps can help Europe to adapt quicker to future contingencies².

A discourse which has begun highlighting the importance of such experimentations and judicious improvisations is the one on frugality and frugal innovations. They suggest ways to re-introduce such experimentations and improvisations in innovation processes to reduce ‘over-engineering’ and costs while maintaining basic functionality and affordability³. A concurrently emerging discourse on frugality in policy making emphasises the need for improvised decision making based on seasoned, practical, context-specific experience and the importance of ‘experimenting while deciding’⁴.

Does Covid-19 challenge protocolised hard evidence-driven decision-making?

Indeed, the pandemic struck, and struck hard while the system often continued to wait for a ‘formal go-ahead’ informed by ‘hard evidence’ to be gathered by ‘super-specialised’ actors and processes, to take policy decisions on (i) whether to test ‘asymptomatic patients’, (ii) whether ‘to wear a mask’, (iii) whether it is okay ‘to use hydroxychloroquine’, or (iv) whether ‘to impose a lockdown’. Waiting for ‘hard evidence’ has often been given a priority over also making clever use of readily available ‘soft evidence’ by seasoned practitioners, presumably also not to disturb the comfort of its citizens ^5,6,7,8. Moreover, this denial to act upon soft evidence is not specific to the context of the current pandemic; it is rather the routine. Incidentally, later more systematic studies seem to validate the soft evidence of wearing masks, and practising social distance⁹.

Is the system adapting?

Going beyond ‘super-specialised actors?’

While Europe initially responded slowly to the arrival of Covid-19, we do now observe quite a few deviations from the routine reliance on ‘super-specialisation’ and formal protocols surrounding innovation, production, and validation. Such improvisations are particularly visible in products and services related to public health deliveries, arguably to ensure their timely and affordable access at the time of the pandemic. Examples include the open-source development of a ventilator, where so-called lay persons can also contribute and participate. Similarly, many informal organisations have sprung up across the continent to produce open-source medical equipment and protection gear for patients and healthcare workers¹⁰. These organisations are not taking the routine protocolised path of regulatory approval. Instead, in order to ensure timely affordable access, they are relying on the viewpoints of physicians and clinical administrators on ‘whether it works’ in the ‘actual’ environment of their use¹¹.

Going beyond ‘protocolised’ hard evidence?

A sizeable section of physicians and clinical researchers of repute have vouched for including hydroxychloroquine (HCQ) in the treatment protocol of Covid-19 based, once again, only on soft evidence of clinical acumen, ‘prudent observations’, and targeted, non-randomised, small-sample clinical studies^12, 13, 14. While the opposition to rely on such soft evidence may be rational, the issue remains that we need fast decisions and therapies to deal with the pandemic, and ‘hard evidence’ of randomised controlled trials does not come fast, nor do they come cheap. Indeed, more than four months into the pandemic, we have conflicting evidence of its (non-) efficacy for advanced-stage treatment. While the WHO has stopped its randomised controlled clinical trial (RCT) citing ‘no benefit’[20], a recent ‘retrospective study’ by the Henry Ford Health System reports significant benefits.[21] For early-stage treatment or as a prophylactic, we are still guided by softer evidence of ‘clinical observations’ and ‘retrospective studies’¹⁵.

The evidence of low rates of mortality in places and countries using this therapy have triggered a diverse set of responses from scientists, politicians, and regulatory authorities^16,17. Some of them have rejected it outright due to non-availability of ‘gold standard’ evidence from RCTs. Other responses have ranged from agreeing to conduct more elaborate studies (RCTs or otherwise), to continuing with the therapy based on ‘prudent clinical acumen’. Indeed, an emerging view in this context invites us to explore ‘doing while learning’ by integrating the urge of clinical practitioners to use untested therapies, while designing, if necessary, full-fledged protocolised clinical trials to evaluate efficacy of the therapy better¹⁸. These propositions challenge the sharp division of super-specialisations between clinical research and clinical practice: “clinical practice and clinical research are addressed by separate institutions, procedures, and funding”¹⁹. The crisis has underlined the necessity to adapt this structure.

So, is a new pattern emerging?

Many of the presently successful experiments can be defined as frugal innovations: they are affordable, retain basic functionalities, and are developed through extensive polycentric interactions, involving super-specialised experts as well as seasoned lay practitioners. Similarly, in line with the arguments of the frugality discourse in policy making, decisions are being made by localised, practical experiences of people in the field, focusing more on ‘what works’ rather than ‘what ought to work’, to ensure faster access to protective gear, medical equipment, as well as medicine therapies. Such a process of decision making arguably gives priority to arriving at ‘good-enough’, faster decisions, rather than waiting for a zero-error solution. Of course, we need to be careful here; most of these experiments show that results are contextual, local in their scope and feasibility, and difficult to scale up.

Still, an exclusive reliance on super-specialisation and protocols would hold fort only in an environment where lives and livelihoods are stable, prosperous, comfortable, and reliable. But now that the illusion of a zero-risk and fully controllable society is fading, we propose a more nuanced future orientation that creates space for experimentation and improvisation based on localised knowledges. Recent EU efforts to pay more attention to citizen science and frugal innovation, for example in a Horizon 2020 call, are promising stepping stones in this direction, i.e. to develop rigorous science that is also built on the bottom-up knowledge, practices, and the creativity of EU citizens. This will help make the society more resilient to future contingencies.

1. See for an elaborated account of Europe’s early response to COVID -19 ‘Coronavirus Europe failed the test’, Politico.^{Last accessed on 1 June 2020.}
2. See ‘Better luck next time? How the EU can move faster when disaster strikes’,Sciencebusiness
_{Last accessed on 10 June 2020.}
3. Knorringa, P., Peša, I., Leliveld, A. et al. Frugal Innovation and Development: Aides or Adversaries?. Eur J Dev Res 28, 143–153 (2016). https://doi.org/10.1057/ejdr.2016.3 . _{Last accessed on 1 June 2020.}
4. Patil, K., Bhaduri, S. ‘Zero-error’ versus ‘good-enough’: towards a ‘frugality’ narrative for defence procurement policy. Mind Soc 19, 43–59 (2020). https://doi.org/10.1007/s11299-020-00223-7 _{Last accessed on 1 June 2020.}
5. ‘Italy, Pandemic’s New Epicenter, Has Lessons for the World’, New York TImes, especially the section on local experiments. _{Last accessed on 1 June 2020.}
6. ‘Report on face masks’ effectiveness for Covid-19 divides scientists’, The Guardian _{Last accessed on 6 June 2020.}
7. ‘In one Italian town, we showed mass testing could eradicate the coronavirus’, The Guardian _{Last accessed on 6 June 2020.}
8. ‘Up to 30% of coronavirus cases asymptomatic’, DW _{Last accessed on 6 June 2020.}
9. ‘Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis’  _{Last accessed on 6 June 2020.}
10. Digital Response to COVID-19. _{Last accessed on 3 June 2020}.
11. ‘Open-Source Medical Hardware: What You Should Know and What You Can Do’, Creative Commons
12. ‘Hydroxychloroquine for COVID-19: What’s the Evidence?’, Medscape _{Last accessed on 1 June 2020.}
13. ‘Hydroxychloroquine prophylaxis for high-risk COVID-19 contacts in India: a prudent approach, The Lancet’. _{Last accessed on 1 June 2020.}
14. See ‘He Was a Science Star. Then He Promoted a Questionable Cure for Covid-19’, The New York Times. _{Last accessed on 1 June 2020.}
15. ‘Preventive use of HCQ in frontline healthcare workers: ICMR study’, The Indian Express. _{Last accessed on 10 June 2020.}
16. ‘A Look at COVID Mortality in Paris, Marseille, New York and Montreal’, Covexit.com
_{Last accessed on 10 June 2020.}
17. ‘Coronavirus: How Turkey took control of Covid-19 emergency,’ BBC. _{Last accessed on 10 June 2020.}
18. ‘Chloroquine and hydroxychloroquine in covid-19′, the BMJ. _{Last accessed on 1 June 2020.}
19. _‘Optimizing the Trade-off Between Learning and Doing in a Pandemic’, JAMA network. _{Last accessed on 1 June 2020.}

20. https://www.who.int/news-room/detail/04-07-2020-who-discontinues-hydroxychloroquine-and-lopinavir-ritonavir-treatment-arms-for-covid-19

22. https://www.henryford.com/news/2020/07/hydro-treatment-study

This article was originally published by the Centre for Frugal Innovation in Africa (CFIA). This article is part of a series about the coronavirus crisis. Read all articles of this series here.