Preventable: How a Pandemic Changed the World & How to Stop the Next One

by Devi Sridhar

As we compare our pre- and post-COVID-19 selves, perhaps the question is not how much the pandemic has changed us, but rather how it has shown us who we really are as people.

Part of the explanation is having better tracking systems to detect when they occur, but the larger trend is the increasingly closer contact of humans with wild animals, particularly bats, through deforestation and live animal markets (or wet markets), as well as intensive farming of animals in crowded conditions.

Richer countries made health services their front line instead of recognizing that infectious disease prevention is about all the steps put in place to stop someone becoming infected and arriving at hospital in the first place. Poorer countries knew they couldn’t rely on their health services so focused more on preventing infections in the community. In January 2020 estimates out of Wuhan were that 20 per cent of those infected would need hospital care, and a third of those would need an intensive care bed. The patient numbers become astronomical at a population level and far beyond the reach of any health care system.

The challenge is how to bridge the wellbeing of animals, usually the purview of vets, with human health, as well as with concerns about the environment and climate change. This approach is often referred to as ‘One Health’.

The New England Journal of Medicine, the flagship American medical journal, was also rapidly publishing key studies on COVID-19 that contained gold nuggets of information for scientific advisers to governments, who were peering through the fog and trying to assess how best to respond. On the 24th of January 2020 NEJM published a brief report on 3 adults (49, 61 and 32 years of age) hospitalized with severe pneumonia, looking at exactly how it affected their lungs. On the 29th of January it published a large study of 425 patients, the majority of whom (55 per cent) were linked to the Huanan market. Based on this sample, they estimated R0 to be 2.2 and the doubling rate of case numbers in Wuhan to be 7.4 days. Based on what they were seeing in this patient group, the authors estimated what an adequate quarantine and isolation period should be: ‘Our preliminary estimate of the incubation period distribution provides important evidence to support a fourteen-day medical observation or quarantine for exposed persons.’ Soon it would become standard across most countries for those who had tested positive for COVID-19 or been exposed to someone who had tested positive to go into isolation for fourteen days.

A series of online surveys conducted in the UK with over 30,000 participants found that only 18 per cent of those who were symptomatic complied with isolation and only 11 per cent of close contacts quarantined.

As already mentioned, it’s rare to see public health researchers on cruise-ship holidays, because they are perceived from an infectious disease perspective as floating germ factories.

In effect, Lombardy’s plan was to treat its way through the epidemic. While other factors might have been at play, as of the 15th of April 2020 the case fatality rate in Lombardy (18.3 per cent) was almost three times greater than in Veneto (6.4 per cent) and nearly twice as high as in the rest of Italy (10.6 per cent).

As there was a concerning number of imported cases, Iceland declared Ischgl a risk region, in the same grouping as Wuhan and Iran. Norway reported that 57.1 per cent of imported cases had been traced to the resort, while Denmark had a 50 per cent rate of imported cases from there. As a result of the continual rise in cases, on the 13th of March 2020 a shutdown was declared in Ischgl by the Austrian government, forcing the termination of the ski season, which then led to an independent investigation to establish the route of the virus.

Public health expenditure in Greece is 5 per cent of GDP, compared with the European average of 7.2 per cent. Out-of-pocket payments compromise 35 per cent of total health spending, over twice as high as the EU average of 15 per cent. Since 2010 the public health care system has been severely affected by the austerity measures driven by the Troika (a decision group composed of the European Commission, the European Central Bank and the International Monetary Fund), designed to reduce public spending in the wake of bailout loans.

In Greece hospitals were prepared for COVID-19 cases: they massively reorganized the existing infrastructure to separate COVID-free areas (green zones) and COVID-involved areas (red zones); they strictly defined and separated COVID-free and COVID-exposed staff; they quickly increased the pool of medical, nursing and paramedical staff by putting them through a fast-track training process, with awareness of how health worker shortages would affect care. And, finally, they minimized crowding in hospitals by moving administrative staff to ‘work at home’ settings and shutting down outpatient clinics and services except for emergency care.

What became clear around the world is that, in the face of incomplete information and when trying to assess a fast-moving situation, countries that reacted pre-emptively and in a cautious risk-averse way did better in their first waves in terms of fewer infections, fewer deaths and less economic contraction. By contrast, those that waited for all the information and had overly complicated and layered decision-making processes were late to react and thus suffered heavier losses. In a pandemic, once the data is clear that growth in the number of cases is exponential, it’s too late to intervene without harsh restrictions such as stay-at-home lockdowns and closing all non-essential businesses and without considerable infection having already occurred.

As we will see, part of this complacency came from their experience with swine flu, which many European governments later complained was overblown by WHO, and didn’t result in a devastating pandemic that killed tens of millions. Sadly, successful public health interventions seem to fade quickly from memory.

Unfortunately overreliance on modelling by SAGE led to major missteps and blind spots in the UK response. For example, early COVID-19 models did not factor in the effect of mass test/trace/isolate programmes, such as those implemented by South Korea, or potential staff shortages in hospital capacity due to illness. Including these might have led to an earlier focus on testing capacity and adequate PPE for frontline workers, both of which proved to be major problems in the UK’s early response. SAGE members didn’t seem to be tracking the policy responses of other countries in real time and learning from them. These omissions were a reflection of the composition of the group and the expertise present.

In short, UK experts were so used to telling poorer countries how to do global health that they completely forgot humility and to listen to what experts in those poorer countries were saying or doing. They tried to ‘outsmart’ the problem of the virus through complex models and maths, instead of doing the hard work of building the logistics of a response and using common sense to stop an infectious disease spreading. Sweden attempted something similar,

In some strange way the idea of shielding creates an Orwellian society in which only the young, healthy, white and fit can circulate and interact, while the rest of society must hide. It’s as if only those who would fit into the cast of the 1990s show Friends could stay part of mainstream society. This is unrealistic as well, given the numbers involved: one study estimated that upwards of 40 per cent of the population would have had to shield, including people working as NHS medical and support staff, cleaners, security staff, supermarket staff and other essential workers who were needed to keep basic services running.

Scotland is the only place I have lived where saying anything good about it, in this instance Edinburgh,

All these factors meant that, as of the 6th of March 2021, 178 per 100,000 Black or African Americans had died of COVID-19, in comparison with 172 American Indians or Alaska Natives, 154 Hispanic or Latino Americans and 124 white Americans. This is not just true for COVID-19. Overall Black Americans have substantially worse health and shorter life expectancies than white Americans.

The anger about George Floyd’s murder reflected the ongoing unfairness and daily racism faced by Black Americans, which COVID-19 put into high relief. The US handling of the virus tells us how interlinked public health issues are with issues of social and economic inequality, and how any public health strategy can’t afford to ignore these realities. This is true not only of the US but of every country across the world. For example, in the UK, risk factors for dying of COVID-19 included being from a deprived background and being from an ethnic minority group (such as Black or South Asian). The Times ran an article on the 12th of April 2020 titled ‘Ethnic minorities bear the brunt of Sweden’s coronavirus deaths’, highlighting the higher morbidity and mortality in certain racial and ethnic groups.

During the first wave of COVID-19 in the first quarter of 2020, many countries closed all schools, while some closed them only in specific places or for specific year groups. In total UNICEF estimates at least 1.5 billion schoolchildren were affected by closures, which prompted their Executive Director, Henrietta Fore, to note, ‘The sheer number of children whose education was completely disrupted for months on end is a global education emergency. The repercussions could be felt in economies and societies for decades to come.’

In January 2021 UNESCO reported that, globally, schools had been closed an average of 14 weeks since the start of the pandemic, and an average of 22 weeks when partial closures were taken into account. The duration of closure varied greatly by region: Latin America and Caribbean schools were fully closed for 20 weeks on average, European schools 10 weeks and only 4 weeks in Oceania. School closures have far-reaching and detrimental effects. Many children, especially in poorer countries, will never return to formal schooling again and instead must take up jobs to help support their families. Even before COVID-19 more than 50 per cent of children could not read by the age of ten. In Miami (where I grew up), state schools opened with 10,000 fewer students than in 2019. Despite sending out teams of social workers to locate students, by March 2021 a thousand students could still not be found.

In the US about two thirds of state-school students were in home learning. But this was inaccessible to the most disadvantaged: 14 per cent of children aged 3–18 don’t have the internet at home.

The US already had severe educational inequalities that the pandemic increased. A June 2020 analysis predicted that the average student would fall seven months behind because of COVID-19, with Hispanic students falling nine months behind and Black students ten months behind. Kayla Patrick of the Education Trust explained, ‘We already knew that Black and brown students weren’t getting the support that they need even before the pandemic. And then the pandemic made all of that worse.’ And there are clear gendered effects too, with school closures putting girls at risk. Globally, before the pandemic hit, the number of girls dropping out of primary school had almost been cut in half. In 2015 women and girls more than fifteen years old spent on average seven years in school, compared with five years in 1990. However, as a result of the school closures, these gains were reversed, with more girls dropping out of school – making them vulnerable to domestic violence, sexual abuse, child marriage and teen pregnancy, and pushing them into the labour force. UNESCO projected that 11 million girls may never return to school after the disruption from COVID-19.

This is what a ‘child first’ lens means, and it is one that was politically popular too. In Scotland this meant letting children under twelve play in groups outside from July 2020 onwards, even during the various lockdown measures. The benefit of children playing and interacting outweighed the risk of child-to-child transmission outdoors.

Led by the inspirational former Kerala Health Minister, Dr K. K. Shailaja, that state managed to keep deaths low. In May 2020 Kerala reported only 524 cases of COVID-19 and 4 deaths out of a population of 35 million and a GDP per capita of only £2,200. Compare this with the UK at the time, which had more than 40,000 deaths, and the US, with 82,000.

By the 18th of January 2021, 39 million doses had been given in high-income countries, while only 25, in total, doses were provided in low-income countries. A paltry 25 – which is outrageous.

But, as new variants arrived that challenged even the most advanced rollouts in Israel and the UK, the focus turned to boosters – that is a third shot of a vaccine to increase the immune response of those vaccinated.

Instead of being the great equalizer, COVID-19 pulled back the veil and revealed one set of rules for elites and another for essential workers, whether it was in housing (having enough rooms, windows, bathrooms, space in which to isolate), the ability to work from home, access to quality education for children, access to early testing and treatment, or involvement in key decisions over government policy.

What the examples above point to is that, when it comes to policy, scientific advice must not only rely on modelling but also ensure representation from diverse backgrounds and experiences, to help to flesh out multiple options that can be presented to political leaders. Also, mathematical models do not include value systems or morals. For example, a model might suggest that allowing 95 per cent of people to continue life as normal while 5 per cent become critically ill is a suitable path forward. This is when scientific advice is just that – advice – and leaders need to consider the values, needs and preferences of their population when deciding how to build a strategy going forward.