Pandemic preparedness: What have we learned from COVID-19?
Prior to the outbreak of COVID-19, metrics of pandemic preparedness were largely unquestioned. The Global Health Security(GHS) Index, last produced in 2019 by a consortium of respected agencies, made a series of judgements about countries’ capacities to prevent the emergence of new diseases; detect and report on cases; mount a health system response; comply with international norms; and prevent risk borne of government ineffectiveness. The GHS Index identified a small group of countries, headed by the United States, the United Kingdom and the Netherlands, as those ‘most prepared’ to protect their citizens against global disease threat. Clearly, the experience of COVID-19 has failed to bear out the predicted overall effectiveness of measured capacities, as all three are among the 55 countries that have experienced more than 1 per 1000 of their population dying from the disease to date.
Most apparent in the underlying explanations of this failure, might be the excessive level of trust placed by this index in the effectiveness of government responses in these three high income countries. Perhaps this should be less of a surprise than it seems to have been. There has been considerable reference back to the 1919 influenza pandemic over the last 18 months, but only a little attention to the parallel government failures and politicisation of public health that occurred. In countries such as the USA there were demonstrations against mask mandates that may have been super-spreaders; in Italy, the rise of fascism has been linked to the experience of the 1919 pandemic. All this occurred long before TikTok and Facebook had facilitated the easy spread of conspiracy theories and other forms of misinformation.
The experience of the last 18 months has also clarified that health system capacity is a lot more than numbers of hospital beds and qualified health workers. Those are of course important, and absolute capacity constraints have hit in countries in which the GHS predicted they would. Hospitals from Jakarta to Papua in Indonesia, have been unable to cope with the current surge in COVID-19 cases, and three have been reports of ICU bed and oxygen shortages across other countries identified by the GHS as ‘least prepared’. Equally important have been public health capacities to effectively test, track and isolate infected individuals. In our State of Victoria (Australia), the initial failure to control the first wave of the virus was attributed to shortfalls in such capacity relative to the neighbouring state of New South Wales.
Just as significant, though less easily quantified, are the shortfalls in trust and confidence in health systems that have played out differently across the world. Vaccine hesitancy among populations that have experienced racism and abuse in the health care system is an excellent example and risks re-victimising populations that have good reason to distrust medical advice. In the US, long-standing problems of incomplete, or absence of, insurance cover, combined with the high price level of hospital care is leaving the bereaved and recovering with eyewatering health care debt. The costs associated with accessing COVID testing is likely to have deterred many. Even before the COVID 19 crisis, analysis of the explanation of growing mistrust in government highlighted the role played by health care costs. When society as a whole has been reduced to a free market, with little effective government intervention, as in India, it is easy to understand how a phenomenon like a black market in oxygen cylinders can emerge.
Do things go better in a highly governmentally controlled system like that of China in comparison to the market dominated systems of the US and India? Until recently China’s government, with capacities to marshal huge reserves of human resources at short notice to construct hospital capacity and perform public health functions; governance systems with Communist Party leadership installed at the micro level of small areas and housing blocks and a society and culture that is more collectivist than individualist, did well at containing the pandemic across the country. Equally though, the virus emerged in China and combinations of respect for hierarchy and fear of penalty led those who first became aware of its existence to cover it up rather than blow the whistle. Authoritarian government is at the root of the whole crisis. Current news from China suggests that even its ability to manage the virus may be better matched by the ability of the Delta variant to evade control.
Ultimately, pandemic preparedness is complex and not easy to measure in a simple index. It is not only about a series of technical capacities, but is an important component of good governance. The experience of the last 18 months highlights how far we are from achieving it almost everywhere across the world.
Pandemics are only one of a series of threats that societies need to prepare for. Climate change and other environmental catastrophes will need similar approaches. In its broadest sense, pandemic (and other catastrophe) preparedness needs substantial, and more importantly, intelligent investment if we are to avoid future years of tragedy and disruption such as the ones we are experiencing. Such substantive and strategic investments will require system change, not just additional funding of existing systems, and they will need to embed crisis capacities that are costly and that governments tend to prefer to defer.
The Nossal Institute is offering a new course in Pandemic Preparedness and Response, to address these issues. It is currently available to University of Melbourne registered students and through the University’s Community Access Program. We also aim to develop tailored versions for specific cohorts of learners and by doing so hope to contribute to such intelligent investment.
This article was written by Professor Barbara McPake and Clare Strachan
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Professor Barbara McPake, Director, Nossal Institute for Global Health