Lessons not learnt from Covid-19

As heads of government from around the world gather at the UN in New York in coming days, they are unlikely to make any significant progress in tackling a pressing problem that so recently dominated their attention.

While conflict, climate change and economic growth are set to be prominent in their discussions, the existential threat of communicable disease has largely fallen off the international diplomatic agenda — despite its lingering legacy and certainty of recurrence.

Covid-19 is a reminder that infectious disease remains a fundamental threat. The pandemic has killed tens of millions of people, wreaked long-term harm on the health of many more, and triggered global economic disruption that has cost the world trillions of dollars.

Yet, despite prominent inquiries and ambitious proposals to enhance pandemic prevention and preparedness, much of the momentum has faded — even as new variants of coronavirus spread, mutate and claim lives.

Policymakers’ attention is elsewhere. Bold ideas to earmark funding, distribute vaccines more equitably, and increase government accountability — which appeared in pandemic treaty drafts — have been sharply diluted.

“The urgency that gripped nations to be better prepared in future has been replaced by complacency and compromise,” says Nina Schwalbe, a health consultant and adjunct faculty member at Columbia University’s Mailman School of Public Health. “If we squander the political will to fix our broken system in the wake of a pandemic, when will we ever do it?”

For years, economic growth backed by investment in public health — from improved sanitation to effective vaccines — seemed to be vanquishing once prominent infectious diseases, such as typhoid, polio and smallpox. Even in lower income countries, efforts sharply reduced the burden of former scourges, from HIV to malaria. Shifting lifestyles have made cardiovascular disease, cancer and other non-communicable threats the primary focus for health systems in richer and poorer populations.

But the pandemic has highlighted the tight connections between communicable and non-communicable disease, and the need for “surge” healthcare capacity to handle infections. People with underlying conditions were more vulnerable to Covid-19, and many who survived have developed “long Covid”.

While the previous pandemic on the scale of Covid-19 began more than a century ago, newly emerging infections continue to spread. Aside from periodic epidemic threats — such as Mers, Sars and H5N1 “bird flu” — some serious conditions never went away, including tuberculosis (TB), which continues to claim more than 1.5mn lives each year.

The complex, costly, and frequently ineffective treatments for TB are one example of the broader and growing threat of antimicrobial resistance (AMR), which already kills 1.3mn people annually. “It’s the huge risk,” says Tom Frieden, former head of the US Centers for Disease Control and Prevention. “We could soon be in a post-antibiotic era. We’re losing them faster than we’re developing them.”

Frieden now runs the organisation Resolve to Save Lives, which is working on an improved future pandemic response, alongside efforts to tackle cardiovascular disease. “We need sustained investment in preparedness rather than the panic and neglect cycle,” he says. He argues for a new “7-1-7” framework: a target of seven days to detect a suspected infectious disease outbreak; one day to notify public health authorities to start an investigation; and seven days to complete an initial response.

But economic pressures and populist politics have combined to squeeze foreign aid budgets in countries such as the UK, undermining momentum for fresh pandemic initiatives, as well as support for neglected tropical diseases such as bilharzia and trachoma.

While such conditions are largely confined to rural poor regions, climate change is bringing fresh threats to urban and richer areas, too. Florida this year reported the first cases of locally transmitted malaria in two decades. Other infections continue to spread, from Lyme disease to Chagas.

Funding to combat these infections, diverted by the pandemic, has yet to recover. That is one reason UNAids, the UN’s HIV/Aids programme, over the summer launched a Global Council on Inequality, Aids and Pandemics, to rekindle the focus on the burden, the interconnection of diseases, and the need for more co-ordinated responses.

There is growing support for universal health coverage to provide basic medical services to all and increase the focus on prevention. At a time of widespread burnout, early retirement and shortages in training and recruiting doctors and nurses, that may require greater “task shifting” to community health workers.

“Primary healthcare is the foundation and, globally, we don’t have enough people,” says Dr Shambhu Prasad Acharya, a director of the World Health Organization. “We have to develop a sufficient workforce, and then think about how it can be utilised in a much more effective way.”

Tim Evans, director of the School of Population and Global Health at McGill University, calls for the development of more “entrepreneurial spirit” in public health. “We don’t need another sub specialist in neurology or a top-notch biostatistician. The fundamental type of work we’re missing is someone who says ‘I love a challenge like how to mobilise people within 24 hours to secure supply chains for personal protective equipment’.”

Tackling future pandemics and other communicable diseases more effectively will require stronger and more integrated approaches to improving wellness and health systems. But it will also need continued progress on other UN challenges, including tackling climate change and inequalities in economic growth.

Letter in response to this article:

Top-notch biostatisticians are exactly what we need / From Tim Evans, Director, School of Population and Global Health, McGill University, Montreal, QC, Canada