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Coronavirus

What We Haven’t Learned from the Pandemic

COVID-19 is no longer a public health emergency of international concern. Where does that leave us?

Crawford Kilian 11 May 2023TheTyee.ca

Tyee contributing editor Crawford Kilian blogs about the pandemic here.

On May 5 the World Health Organization declared COVID-19 is no longer a public health emergency of international concern. WHO has already published a recommendation on “long-term COVID-19 disease management.”

The pandemic itself, however, continues. Particular countries or demographic groups may still be at risk of high rates of illness and mortality due to COVID-19. But the world at large seems eager to forget about it with a clear conscience.

Ordinarily after a disaster, the appropriate level of government orders an independent commission of inquiry into its causes, with the hope of preventing future disasters.

We don’t seem likely to get such a commission in Canada. And that’s a shame. To paraphrase Oscar Wilde, to lose 52,000 Canadians (so far) to COVID-19 may be considered a misfortune; failing to learn how and why they died begins to look like carelessness.

The Canadian Parliament at least thought about the pandemic, establishing a special committee on the COVID-19 pandemic “to conduct hearings to examine the government’s response to the COVID-19 pandemic.” It seems to have been inactive since June 18, 2020, without having issued so much as a press release.

That’s a true misfortune, because a serious inquiry into this ongoing pandemic could greatly help in mitigating or even preventing the next one. A commission’s findings and recommendations might even reduce the cases and deaths we continue to suffer from COVID-19. (As of May 2, Canada reported 4,659,971 COVID-19 cases and 52,037 deaths since the pandemic began.)

The U.S., meanwhile, has lost at least a million lives. Millions of COVID-19 survivors are dealing with long COVID and perhaps other post-infection conditions. And the European Union reported over 275 million cases and over two million deaths as of late April.

Worldwide, the WHO COVID-19 dashboard listed over 765 million cases and 6.9 million deaths as of May 3.

The true numbers, WHO director general Dr. Tedros Adhanom Ghebreyesus has said, are likely three times higher.

Reluctant to self-criticize

If governments are reluctant to examine their own pandemic performance, others are trying to fill the gap. It’s enlightening to see what they have found.

Here in Canada, we’ve seen many “lessons learned” reports, usually focused on the pandemic’s effects on a single province or industry or profession. One, from the Public Health Physicians of Canada, appeared in early 2022. Its criticism of the Canadian pandemic response is implied in its recommendations: public health was underfunded, physicians without public health expertise were still treated as experts, health workers burned out, communications were terrible and marginalized communities endured systemic discrimination.

All doubtless true, but the report could be easily dismissed as just more advocacy from an interest group.

The B.C. government also commissioned a COVID-19 Lessons Learned Review, which was dated Sept. 23, 2022 but not made public until December, when I discussed it here. The BC Centre for Disease Control has buried its COVID-19 update page, and will henceforth publish updates only once a month.

The U.S. has likely had plenty of such specialized lessons, but it does have at least an attempt at a book-length overall examination of the country’s response to COVID-19: Lessons from the COVID War: An Investigative Report. Its authors are the COVID Crisis Group, which was originally intended to design a commission to look into the pandemic. When it became clear no such commission would be created, the group’s 34 members studied the pandemic and listened to almost 300 people who had been engaged with the pandemic in one way or another.

None, however, seem to have been major figures in the Trump or Biden administrations.

‘Amnesia can kill’

The group explicitly set out to fight the amnesia that so many already experience: “This disorder, this amnesia, can kill.” And the group deliberately adopted the metaphor of a war, though many in public health think it’s inappropriate. “Conceiving of this struggle as a ‘war’ does help people think about how to organize collective action against a terrifying danger.”

Their book, however, demonstrates that the American response to COVID-19 was anything but collective. The U.S. public health “system” is an anarchic bureaucracy, most of it underfunded and understaffed, from the federal to the county level. Lacking any effective guidance from Washington, some state governors and mayors managed to improvise mini-systems that “linked health departments, health-care providers, emergency managers, business and community leaders.… Governors issued executive orders to force hospitals to co-ordinate how they handled surges and underserved towns.”

In an effort to be non-partisan, the group points to Democrat failures and Republican successes. Former president Barack Obama’s pandemic plan was rejected by the Trump administration, and deserved to be, the group says. The plan described the “what” of a national response pandemic, but not the “how.” The Operation Warp Speed program did develop vaccines in record time, partly because Trump’s son-in-law Jared Kushner protected it from meddling by other Trump officials, but largely because it was effectively run by the U.S. Department of Defense.

One member of the group dismissed Trump as a “co-morbidity,” which is funny but minimizes the president’s destructive role. Later on, the group concludes that “Trump essentially detached himself from his own government. He moved toward questioning and challenging what other government officials were doing.… The administration abdicated its wartime responsibility to lead. It left the battlefield, and the war strategy, to state militias (led by the governors) and ad hocism at the local level.”

Collective national incompetence

It is hard to argue with a key finding: “The COVID war revealed a collective national incompetence in governance.” The group alludes to the wars in Iraq and Afghanistan (and could have gone all the way back to Vietnam) as examples of such incompetence undercutting American advantages in science and technology.

That collective incompetence was not uniquely American. Most countries eventually found it impossible to sustain lockdowns (however locally defined) in the face of public resistance. Even China finally eased its zero-COVID policy, suffered a predictable surge in cases and deaths, and then set to work rebuilding its economy.

American and Canadian incompetence seem to have had a lot in common. The group describes how the task force led by then-vice-president Mike Pence created a $2.3 trillion stimulus package: “Economists sometimes refer to such blanket stimulus as ‘helicopter money,’ since the theory is not far from the idea of just throwing money out of a helicopter flying over a city.”

Canada’s stimulus plan was similar; admittedly, such spending kept countless Americans and Canadians from impoverishment and protected their national economies from collapse. But it also legitimized the decoupling of income from work. Had it continued, the dangerous idea of a universal basic income could have become thinkable. Who knows what mischief that would have meant for a recovering economy?

Incompetence, the group argues, “produced bad outcomes, flying blind and resorting to blunt instruments. Those failures and tensions fed toxic politics that further divided the country in a crisis rather than bringing it together.” The same could be said for Canada, where conflict between anti-vaxers and governments were part of the reason for the “Freedom Convoy” in Ottawa and similar blockades at border crossings.

The group concludes by saying, “There is a core lesson. The United States and other countries must consider how to make a profound shift, a paradigm shift, what a recent CEPI [Coalition for Epidemic Preparedness Innovations] report rightly calls ‘a fundamental shift towards preparedness.’”

For the group, preparedness means biomedical surveillance long before we think we might need it, and policies that equip and train public health to do what needs doing. That would be disruptive and costly, imposing order on bureaucratic anarchy.

As the group observes, we will have to spend billions to save trillions.

A no-fault assessment of the pandemic

The European Centre for Disease Control, based in Stockholm, co-ordinates the activities of health ministries in the European Union’s 27 member states. Through much of the pandemic, ECDC studied the lessons learned by its members and other countries (including Canada and the U.S.) and did further research and consultation. The result, recently published, is Lessons from the COVID-19 Pandemic.

Strikingly, the ECDC report begins with instructions on how to conduct reviews both during and after a public-health incident.

“A review should not aim to put blame on teams or individuals,” the report says, “but rather it should provide evidence for changes needed in processes, legislation or guidelines. The lessons identified and any subsequent recommendations should be documented, prioritized, implemented and re-evaluated at regular intervals.”

This “no fault” approach must seem very alien to Canadians and Americans alike; we tend to heap the blame on Trump, or our provincial chief medical health officer, or some other supposed evildoers, rather than on the public health systems that couldn’t deal with the pandemic.

Lesson 1: invest in the public-health workforce

The first of ECDC’s four lessons is investment in the public health workforce. This means recruiting and retaining skilled workers, and keeping them current with constant professional development.

It also means designing built-in surge capacity so that young professionals, experts in other countries, and even retirees could be called upon. And it means training workers in preparedness.

Investment would also mean keeping public health budgets high, to avoid what cycle of what the Americans call “panic and neglect.”

ECDC warns that “Lack of resources at all administrative levels was reported by the countries, and this will have an impact on future planning activities.”

Lesson 2: prepare for the worst

The second lesson is preparing for the next crisis. This would involve sharing national preparedness plans and lessons learned, working with experts outside public health, communicating the results of literature reviews on non-pharmaceutical interventions like masking and physical distancing, and assessing EU member states’ prevention, preparedness and response plans every three years.

Preparedness plans, ECDC says, would include various scenarios, including the worst case. They would deal with several pathogens, not just COVID-19 or influenza, and would be scalable, so even a long and severe outbreak could be manageable.

Every government ministry and agency would have a clear role to play in the response. And public health agencies would have a clearly defined role “in giving evidence-based advice and avoiding politicization of this advice or the overall response to health threats.”

Lesson 3: communicate risk and engage communities

ECDC’s third lesson is on risk communication and community engagement — subjects scarcely mentioned by the American COVID Crisis Group. Public health professionals would be trained in risk communication, and could draw upon social and behavioural research both in preparedness planning and in response to an outbreak.

Lack of such social awareness was a severe hindrance to outside health workers during the West African Ebola outbreak of 2013-16. Outside health workers didn’t understand, for example, the cultural importance of funerals, so communities hid their infected members rather than let them be buried in mass graves without ceremony. They also attacked both local and foreign health-care workers.

ECDC’s report also says that some EU countries wanted guidance “on the management of mis- and dis-information.” The COVID Emergency Group scarcely mentions the subject, but online lies clearly aggravated the pandemic and continue to do so. Failing to prepare for future disinformation means preparing to fail yet again.

Lesson 4: support better data collection and analysis

ECDC’s fourth lesson, on collection and analysis of data and evidence, calls for more surveillance, especially “for diseases with the highest impact and degree of preventability.”

This would involve upgrading and integration of member states’ information technology, and automating surveillance data collection. Labs’ ability to do genomic sequencing would be sustained, and lab personnel would be trained in sequence analysis and applied genomic epidemiology. Both ECDC and member states found themselves without resources to do operational research.

This lesson could be politically sensitive, since so many nations including Canada have largely abandoned COVID-19 data collection and analysis.

A road map to nowhere

One lessons-learned report is on a global scale. "A Road Map for a World Protected from Pandemic Threats" was published in early May by the Independent Panel for Pandemic Preparedness and Response, a group led by Ellen Johnson Sirleaf, former president of Liberia, and Helen Clark, former prime minister of New Zealand.

The road map looks like a set of goals, not an operational guidance. They are certainly good goals — revising the International Health Regulations to emphasize surveillance and alert systems, and creating a new pandemic agreement that would be binding on signatories. But few countries would sign such an agreement unless it offered an escape hatch.

Independent monitoring, the road map says, would be needed to ensure that signatory nations lived up to their pandemic-preparation promises, but the monitors would be subject to pressure from their home countries and perhaps from others. If China, for example, were found to be neglecting preparation measures, the monitors representing China would almost certainly protest that this was not the case.

The road map accurately observes that “Throughout the COVID-19 pandemic, access has been inequitable — constituting a moral, financial and public health failure.” Low- and middle-income countries have been the last to receive vaccines and treatments, while the rich nations bought up such products and hoarded them (or rejected them). It is hard to imagine that Canada or the U.S. would develop a new vaccine, for example, and generously distribute it in necessary quantities to countries like Haiti and Venezuela before ensuring their own citizens had enough.

The rich countries would also have to finance preparedness and response in the low- and middle-income countries. The road map estimates at least $10.5 billion a year to support preparedness, and $50-$100 billion in “surge financing” for the early days of a serious outbreak. The idea that rich nations would park that much money in a rainy-day fund is simply implausible.

The road map also calls for “an independent, well-functioning and authoritative WHO.” But it’s long been understood that WHO is no more independent than its member states (and billionaire donors like Bill Gates) allow it to be. The same would be true of the road map’s proposed “high-level political council for pandemic threats.” The report says, “it should be seen as a diplomatic facilitator and motivator” — that is, a talk shop and lobby group, not an agency with powers of enforcement.

Of the lessons-learned reports I’ve read, ECDC’s seems the most pragmatic and likely to be adopted by EU member states. Each country has the promise of support from the others, with ECDC co-ordinating and unifying the member states’ preparation and response. ECDC’s goals could be met up with operational expertise, not aspirational rhetoric, if the member states see the benefit to themselves.

The ECDC approach would surely fail in the U.S., where every public health office is part of someone else’s power base and many states are now clearly opposed to the idea of public health itself as a threat to “freedom.” In Canada, an ECDC approach might work between Ottawa and the provinces, but it would likely require giving the provinces more money and power with little or no obedience to federal policies.

We should also bear in mind that lessons-learned reports rarely if ever suggest serious effort to reduce the inequality and racism that pandemics both exploit and aggravate.

The real lessons governments have learned

What the world’s governments have really learned from the pandemic is that they can ignore it. Many have simply stopped testing, stopped counting cases and deaths; after all, if you don’t count it, it doesn’t count. Dropping non-pharmaceutical measures like masking may enhance the spread of COVID-19, but who will know without surveillance?

Dr. Patricia Daly, chief medical officer of health for Vancouver Coastal Health, was on CBC Radio on May 5, the day WHO declared the end of the emergency. She encouraged listeners to think of SARS-CoV-2 “like other respiratory viruses,” especially the coronaviruses that can cause common colds.

Evidence suggests that SARS-CoV-2 is not just a respiratory virus. It can spread through the vascular system, forming blood clots, and the nervous system, dulling the senses of smell and taste as well as inflicting other kinds of brain damage. Unlike its cold-causing relatives, SARS-CoV-2 can cause long-lasting harm as well as death.

But governments have learned that long COVID and other after-effects can be largely ignored, just like the fact that SARS-CoV-2 is airborne.

Some health workers in some countries may well improvise effective preparation and response measures for the next pandemic, because they will have learned the true lessons of this one.

But we can’t expect to see such measures on a global or even national scale unless ordinary citizens demand them. They are unlikely to do that while our present authorities mislead us about the nature of the virus and urge us to get back to living our lives.  [Tyee]

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