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Build back better. And here are some ways how…

What can we learn from the experiences of the COVID-19 pandemic so that, in the words of the oft-quoted maxim, we do not “let a good crisis go to waste”?

This is the question at the heart of an important new publication that offers many useful insights for governments across the globe, reports Melissa Sweet.


Melissa Sweet writes:

The COVID pandemic will “cast a shadow” over the world’s health and wellbeing for decades, and governments must explicitly focus on addressing inequalities and strive to “build back better”, according to global health experts.

A 147-page review of COVID-related evidence, produced for the Pan-European Commission on Health and Sustainable Development, makes wide-ranging recommendations for how countries can better respond to COVID and prepare for future pandemics.

The recommendations are directed at European governments, but the report provides many insights that have wider application, including in Australia.

The review, edited by Professor Martin McKee, Chair of the Commission’s Scientific Advisory Board and Professor of European Public Health at the London School of Hygiene and Tropical Medicine, urges governments to implement One Health approaches, so that the health of humans, other animals, plants and the environment are considered together by all agencies and in all policies.

It calls for action on inequalities in health and education, racism, and precarious working and living circumstances, and for efforts to address the disproportionate pandemic burden upon women. It also identifies the critical importance of wide-ranging digital determinants of health, from disinformation to digital exclusion.

The report calls for closer connections between health and legal/justice fields, and stresses the importance of trust as “an essential element of a comprehensive response to major health threats”.

“The challenge is that trust is difficult to build up and easy to lose,” it says.

“When trust is squandered or neglected, it creates a major fracture in societies that undermines responses to a health threat, leaving some groups inhabiting a different cognitive environment and placing them and others at risk.”

A key recommendation is for countries to improve their collection of data on COVID’s impact on inequalities. One of the pandemic’s lessons, the review says, is “a recognition of the importance of policies that enhance societal resilience, leaving no one behind”.

The report says that in many countries, longstanding and deep-seated inequalities are effectively invisible, as can be seen from inspection of reports on the progress of the pandemic.

The report says “all countries should have systems in place that can quantify the impact of disease, and the responses to it, on different groups within their population so that they can identify those who are most vulnerable and take actions to address their vulnerability.”

This is especially important as vaccine programs roll out “as the need to achieve population immunity means that no one is fully protected until everyone is”.

As well as helping to hold governments to account for their policies, this data helps inform international comparisons, which can serve to identify good practice that can be emulated elsewhere.

Invest in infrastructure and education

The review also urges investment in infrastructure, citing governments’ failure to invest in pandemic preparedness, and the importance of preparing for other challenges, such as climate change.

When it became clear that SARS-CoV-2 was spreading rapidly across the world, many countries realised that their systems for surveillance, outbreak investigation, and delivery of healthcare and social support were inadequate – and this was part of a much larger problem.

“Over the past decades, many governments have reduced their level of investment in all forms of infrastructure,” the report says. “This was already apparent in areas such as education, transport networks and digital access.”

The report also explores the importance of the built environment in responding to and preparing for pandemics.

Now that the important role of airborne transmission in the spread of COVID-19 is recognised, it is important to consider how to design new buildings going forward, in particular by incorporating efficient systems of ventilation, it says.

The report says governments will need to put in place measures to enable children to catch up with the education they have missed, with a particular focus on those who have been most disadvantaged during the pandemic.

The economic losses for individuals and societies at large resulting from school closures will have impacts that seep beyond the education system and will likely fall back to the health system eventually, the report predicts.

“It is also clear that the educational needs of children must be included in plans for any future pandemic,” it says.

Healthcare heroes

The report also calls for investment in “strong, resilient and inclusive” health systems and the health workforce, to improve working conditions for health workers, and to address real and perceived pay gaps between the health workforce and equivalent professionals in other sectors.

It describes health workers as “heroes” who have worked under enormous pressures throughout the pandemic.

“They have gone above and beyond the call of duty, working for long hours in arduous conditions. They have faced physical and mental discomfort, spending long hours in hot and uncomfortable PPE, with risks of overheating and dehydration, as well as the consequences of placing a physical barrier between themselves and their patients.

“In too many cases, health workers have given their lives in the service of others, although in many countries the scale of their sacrifice has been unrecorded.”

As health systems in NSW and Victoria face surging COVID demands, it is timely to consider the report’s findings of the wider health impacts of a massive diversion of resources away from non-urgent care, for example in affecting the diagnosis, care and outcomes for people with cancer.

The report also warns that when hospitals come under enormous pressures, quality of care suffers.

In the United Kingdom, research into the death rates among patients requiring ventilation found that case fatality rates were 20 percent higher in ICUs operating at 85 percent occupancy or higher compared with those at the more usual 45–85 percent, after adjusting for a large number of patient characteristics.

“The most important lesson to learn from this experience is that the practice, in some countries, of running health facilities at over 95 percent occupancy, with no mechanism to deliver surge capacity, is short sighted. While this may seem to be efficient in the short term, it brings a substantial cost in the long term.”

Digital determinants

The report describes many ways that the digital determinants of health can exacerbate health inequalities, including through digital exclusion with UK research showing how those at greatest risk of digital exclusion overlap substantially with those vulnerable to poorer health outcomes from COVID-19.

A key area to consider is the potential exclusion of certain groups in predominantly “digital access first” models of healthcare.

The main determinant of digital exclusion is age but often other significant factors – including disability, learning difficulties, ethnic origin, location, culture and language – are present, often combined with low income.

The report also says digital technology creates new ways in which those already disadvantaged can be further marginalised, for example through algorithms that discriminate against particular groups or genders.

It raises concerns about the potential for cyber attacks to affect pandemic responses. In May, the Irish health system was hit with distributed denial of service attacks by criminals seeking a ransom. This led to the cancellation of hospital appointments, inability to request COVID-19 tests online and delays in obtaining results, and a breakdown of the COVID-19 vaccine booking system.

“For these reasons, a comprehensive assessment of future threats to health cannot ignore those that exist within the digital realm, both in terms of their ability to undermine societal resilience and the potential to pose direct threats to health,” the report says.

It also explores the evidence around disinformation’s health impacts, through sowing division, promoting disengagement from and interference in democracy, economic harm, and risks to life.

The report also says that while social media has been the most important vehicle for spread of disinformation, it is important not to overlook the role of the mainstream media with some having played an important role in disseminating misleading messages.

“Finally, any examination of disinformation should also include a recognition of the challenges faced by those who work to provide accurate information,such as investigative journalists,” the report says.

Global governance

The report calls for action to improve global health governance, noting that existing global architecture for One Health is fragmented, and that the world needs an international legal framework for pandemics and mechanisms for scanning the horizon for emerging health threats.

It notes that current manufacturing and supply capacity is not equipped to deal with the global demand for COVID-19 vaccines. Only a handful of companies are producing and supplying COVID-19 vaccines around the world, and to date none have shared their IP or technology via the World Health Organization’s COVID-19 Technology Access Pool or any other mechanism.

“These companies claim they can scale-up production to meet demand themselves; but so far, they have systematically overpromised and underdelivered,” the report says.

While an IP waiver would be helpful, it should apply more widely than vaccine patents to include other technologies, such as diagnostics, respirators and even future treatments, that are also critical tools for preventing, treating and minimising the effects of COVID-19.

The Pan-European Commission on Health and Sustainable Development is an independent and interdisciplinary group of leaders convened by the WHO Regional Office for Europe to rethink policy priorities in the light of pandemics.

It includes former heads of state and government, distinguished life scientists and economists, heads of health and social care institutions, and leaders of the business community and financial institutions from across the European Region.

The Commission’s final report, which is based on the review of evidence cited above, calls for the establishment of a Global Health Board under the auspices of the G20 to ensure effective coordination of health, economic and financial policies within governments and in the international area.

Writing in the report, Commission Chair Professor Mario Monti said the world needs “a bold new strategy for health and sustainable development in the light of pandemics” integrating One Health policy into a wider and coherent policy framework, comprising in  particular economic and financial, technological, social and international policies.

Monti wrote:

The pandemic has submitted the globe to a real, not simulated, stress test. The test has exposed, with unprecedented clarity, a serious chronic disease of policy-making: short-sightedness.

This has two dimensions: short-sightedness over time, when policy-makers try to get consensus today by shifting burdens onto next  generations; and short-sightedness over space, when they try to solve nationally problems that are inherently  transnational.

Neither health nor sustainable development will be achieved unless these twin diseases, endemic to current  politics, are eradicated.”

Further reading

From the BMJ: Covid-19: “Health in all policies” will help protect world from future pandemics, says commission

From The Lancet: A new strategy for health and sustainable development in the light of the COVID-19 pandemic

From December 2020: We don’t want to go back to ‘normal’, when ‘normal’ wasn’t good for everyone, by Professor Bronwyn Fredericks and Abraham Bradfield


See here for Croakey’s archive of stories on global health.

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