Why was COVID-19 such a shock?

The Four Horsemen of the Apocalypse: War, Pestilence, Famine, and Death make quite the team.  Terrifying individually, and where one goes, the others always turn up sooner or later.  The image of the four horsemen resonates with us. It endures, perhaps, because it taps into a primal understanding that as soon as humans transitioned from hunter-gatherers to settled farmers, these were the biggest threats to our survival.

In the 21st century, little has changed. The primary causes of death are often similarly categorised as 1) injury (road accidents, conflict deaths, terrorism, accidents, natural disasters, and suicide); 2) Infectious Diseases; and 3) non-communicable diseases (NCDs) (heart attack, stroke, cancer, and diabetes, etc.). These NCDs are often related to malnutrition, particularly overnutrition.

Not only are we constantly encouraged to eat more through carefully crafted advertisements, but we are also misled about the significant risks to our health. 

A physician will have told most people in high-income countries at some time to lose some weight and exercise more.  However, we are also bombarded daily with different, contradictory messages in the media.  Not only are we constantly encouraged to eat more through carefully crafted advertisements, but we are also misled about the significant risks to our health.  For example, in 2016, heart disease and cancer received only 3% of media attention despite causing 60% of deaths in the USA. In that same year, violent deaths by terrorism, homicide, or suicide received 70% of the media attention. Still, they accounted for less than 3% of deaths.  This disconnect in media attention causes us to have skewed perceptions of what is going to killing us. Therefore, it is not surprising that we will happily sanction spending trillions of dollars fighting a war on terror but have spent nothing to protect us from the ‘large hamburger and fries’ that will actually kill us.

We also don’t believe that infectious diseases will kill us and under normal circumstances for a good reason.

We also don’t believe that infectious diseases will kill us and under normal circumstances for a good reason. In high and upper-middle-income countries, only 6% of deaths are caused by contagious diseases. Moreover, we have become so used to the protection afforded to us by sanitation and hygiene programs, antibiotics, good nutrition, and vaccines that we don’t think about them anymore.  Indeed, vaccines have been so successful in controlling fatal childhood diseases that we now have groups of people fighting to “protect their children” not just from vaccines but from vaccinated teachers.

In the lowest-income countries, the picture is very different infectious diseases account for almost 40% of mortalities, being the leading cause of death and an even greater cause of morbidity. The chief culprits are respiratory infections, diarrhoeal diseases, HIV/AIDS. Tuberculosis and malaria.  It is estimated that a full quarter of all the people currently alive are infected with TB.  Thirty-two million people have died in the global HIV/AIDS pandemic and 37.9 million more live with the disease. In 2017 an estimated 1.6 million people died of diarrhoeal disease, most of them under five years old.  In 2018, 2.94 million people died of respiratory infections like influenza and pneumonia.   It is also essential to understand that the global effort to improve vaccination, sanitation, and hygiene in these countries has significantly reduced infectious diseases deaths since 2000. Indeed, vaccination alone is credited with preventing 37 million deaths in the last 20 years. 

Even in the wealthiest countries, there is a constant threat from newly emerging infectious diseases and the spread of existing diseases that have acquired new capabilities.  Since 1940, an average of five emerging contagious disease events have occurred per year.  Sometimes these were entirely unknown diseases (to western science at least), such as Marburg virus (1967), Ebola virus (1976), Sin Nombre virus (1993), SARS (2003), H1N1 Influenza (2009), and MERS (2012).  Sometimes diseases moved into new locations, e.g., West Nile Virus appearing in North America in 1999.   Established bacteria also acquired new and dangerous capabilities such as Methicillin-resistance in Staphylococcus aureus (MRSA) in 1961, the emergence of extensively drug-resistant tuberculosis (XDR-TB) in 2006, or the emergence and spread of the NDM-1 gene identified in 2008.  NDM-1 renders bacteria resistant to a critically important family of antibiotics usually used to treat antibiotic-resistant bacterial infections.

...it should not have been a surprise that something like the COVID-19 Pandemic would happen.

In a world full of infections, most of which have no effective vaccine or treatment, new diseases constantly emerge, and known microbes acquire new, deadly capabilities, it should not have been a surprise that something like the COVID-19 Pandemic would happen.  In fact, it was not a surprise. The Pandemic was not only predicted. We planned for it extensively.  Historically, influenza pandemics tend to occur every 25 to 30 years. So influenza is often the primary threat considered in pandemic planning.  However, the emergence of SARS in 2003 and MERS in 2012 had placed Coronaviruses on the list of potential pandemic threats.

In Oct 2019, the Johns Hopkins Center for Health Security, in partnership with the World Economic Forum and the Bill and Melinda Gates Foundation, ran a somewhat prophetic tabletop exercise called “Event 201” featuring a coronavirus pandemic.  In 2016, the UK government ran a pandemic preparedness exercise called Exercise Cygnus that predicted many of the UK’s shortages during COVID-19.

In 2017 the UK Cabinet Office National Risk Register of Civil Emergencies again highlighted pandemic flu as the highest impact emergency the country was likely to face.  Unfortunately, by focusing on influenza as the critical threat, assumptions were made that were not helpful during the COVID-19 Pandemic. For example, it was assumed that there would be effective antivirals. The disease would spread rapidly but have low overall mortality (0.1%). There would be time to escalate a response, fill resource gaps, and a vaccine would quickly become available.  Whereas compared to the anticipated scenario, COVID-19 spread more rapidly.  Many people did not have symptoms but were contagious. Hospital stays were longer, and more intensive care was required.  Antiviral drugs were either not available or ineffective. A vaccine was not available for a year (under the circumstances, this was incredibly fast, and ten years ago would have likely been impossible). 

SARS and MERS provided an adequate warning that other pandemics needed to be considered. 

However, the fact that the disease did not meet our planning assumptions should not have been surprising.  SARS and MERS provided an adequate warning that other pandemics needed to be considered.  Indeed, the 2009 Influenza pandemic response was flawed in many ways because the prior planning assumptions a highly virulent disease possibly caused by H5N1 influenza. Consequently, many governments and the WHO were criticised for overreacting to the 2009 pandemic strain.

Despite the success of the vaccine rollout in the UK, the national and global response to this Pandemic has highlighted devastating flaws in our national and international pandemic response efforts.  Whether at the global level through WHO, nationally through health agencies, or locally in public health departments, public health activities are chronically underfunded and understaffed.  This situation is the result of government policy. Public health is very cost-effective, but it is challenging to demonstrate effectiveness convincingly and simply.  The reality is that public health exists to stop “Bad Things™” from happening to the population. Consequently, when public health works and “Bad Things™” don’t happen, the result is that funding is reduced because the “Bad Things™”  are not happening, and public health is a waste of money.  Conversely, when “Bad Things™” do happen, it is because of a failure of public health and evidence that it isn’t fit for purpose and a waste of money.

The reality, of course, is that lessons are rarely actually learned.  Whether derived from simulations and exercises or real-life experience, experience alone doesn’t change how we prepare for and respond to future threats.  To learn lessons, we must change our plans based on our experiences and think about how things might be different next time (rather than constantly fighting the last war). Most importantly, we must ensure that money and resources are there so that plans become capabilities.

All predictions about how this Pandemic will progress are worth the paper on which they are written.  But it is likely that at the global scale, this will last until 2024-25.  By that time, it will probably have cost around $28US trillion; this is enough money to pay for all preparedness and prevention activities for several hundred years. Moreover, the emergence of antibiotic-resistant bacteria could cost the global economy $120US trillion by 2050.  These are staggering costs matched only by the human suffering they represent.

If it was a flood, rather than a disease, that we knew is going to happen every 25 to 30 years; and on each occasion, we knew that it would kill or injure hundreds of thousands or even millions of our citizens, it is unthinkable that we would accept that our governments would fail to prepare for and prevent the worst of these impacts.  We were warned in 2003, 2009, 2012, 2014 by diseases that had a global impact. Yet, we accept that Pandemics can be so poorly managed by successive governments of all political parties.  But the public has been so poorly informed about the threat of infectious disease. Our political leaders seem to struggle planning beyond 4-5 years, and until this experience, businesses didn’t consider this a problem. They needed to think about very much at all.

I hope that the future is better and we are stronger: public health professionals learn how to engage the public; the public demand better from their elected leaders; that businesses step up and work to mitigate the impacts of Pandemics on the economy and their employees; that politicians learn that getting elected isn’t the only thing they need to worry about.  I wish that all of this comes to pass, but I think it will be precisely the same next time.