In May of this year, over three years after its international debut, the World Health Organization (WHO) announced that SARS-CoV-2 (COVID-19) was no longer a ‘public health emergency of international concern’. While acknowledging the continued severity of the risks associated with COVID-19, Dr. Tedros, WHO’s Director-General, stated that nations should now transition from emergency mode to managing COVID-19 much like any other infectious disease. While COVID-19’s formal recognition as a novel, immediate threat may have dissipated in the eyes of our global leaders, its role in exposing the frailty of government responses, healthcare systems, and international organisations as a whole remains at the forefront of public health discourse.
Future Pandemics:
The lack of robust institutional pandemic responses and plans is especially worrying in light of the growing concerns regarding future disease outbreaks. Contributors to the Proceedings of the National Academy of Sciences (PNAS) forecast that another global pandemic will occur within the next sixty years, with a twenty-five percent chance this outbreak will be in the next decade. Alongside this, PNAS estimates that the risk of new disease outbreaks, including the spread of pathogens from non-human species to humans, will rapidly grow over the next few decades, citing international travel/trade, human and agricultural antimicrobial resistance, and climate change as major drivers of this growth.
Public health experts remain divided regarding the most likely pathogen to be behind future outbreaks. Some are looking towards a global expansion of Ebola, while others are focusing on Crimean-Congo Haemorrhagic Fever, a virus with a staggeringly high mortality rate that is endemic to Africa, the Balkans, the Middle East and Asia, or even a resurgence of SARS, another coronavirus that caused a minor pandemic in 2003. However, most eyes are on Influenza, which GAVI (previously the Global Alliance for Vaccines and Immunization), a public-private vaccine alliance based in Geneva, notes as being one of the greatest pandemic risks in the following decades, with the WHO more definitively stating that Influenza is likely to be the cause of our next pandemic.
The Global Pandemic Response:
With the looming presence of further pandemics, one would expect that global pandemic responses were continuously being honed and improved; however, this is far from the case. Despite calls to increase the US $1.4 billion pledged to pandemic preparedness at the G20 summit last year, leaders are reluctant to open their pockets, and instead are dismantling pandemic infrastructure. One example of this is the actions of the United Kingdom’s (UK) government. Professor Teresa Lambe notes that the UK has failed to learn its lesson from COVID-19, citing the disbandment of viral tracking systems as an indication of the country’s reckless abandonment of its public health duties. Similarly, former government Chief Scientific Advisor, Sir David King, argues that both the NHS and the country’s pandemic responsiveness is worse, rather than better, than it was in 2020 due to the dismantling of laboratories, tracking systems, and collaborative consortiums. This position is mirrored on a global scale by the Global Health Security Index (GHSI) – whose international average value was almost exactly the same in 2021 as in 2019. This indicates that the COVID-19 pandemic failed to catalyse any significant improvement in international emergency preparedness.
Despite this abysmal GHSI figure, certain nations’ pandemic responses were much stronger than others. According to a Bloomberg opinion piece, New Zealand’s consistent leadership and relative geographical isolation helped it to avoid a significant COVID-19 death toll. Whereas the US’ politicisation of health saw high death tolls despite the nation’s wealth and significant vaccine supply. Similarly, Mexico, an advocate for maintaining economic stability despite health risks, ended up with both a high death toll and a struggling economy. While this evidences the role that government responses play in facilitating, or dissipating, pandemic risk, it also suggests that a nation’s political climate, and how strongly they synonymise public health interventions with autonomy infringements, can influence how they experience a pandemic.
Vaccine and Health Inequity:
The international variability in pandemic experiences was likely furthered by significant vaccine distribution inequities. As of January 2023, high-income countries had vaccination rates that were twofold higher than middle-income countries and twenty-fold higher than low-income countries. Infrastructure, GDP, and population education levels may be to blame here, as local vaccine manufacturing levels are strongly associated with vaccine coverage. When combined with the failure of global institutions to leverage equitable international vaccine distribution, nations began adopting isolationist approaches to vaccination. Such isolationism, and resulting vaccine hoarding, further exacerbated the COVID-19 burden experienced by low and middle income countries.
Vaccine distribution issues also persisted within countries, with demographic and social factors cited as significant influences on vaccine coverage. In particular, vaccine coverage was usually higher in women, the elderly, healthcare workers, and individuals with higher household incomes and education levels. Contrastingly, predictors of vaccine hesitancy included: young age, immigrant status, living in a rural area, larger household size, and lower education levels. Interestingly, having a religious conviction was associated with an increased likelihood of vaccine hesitancy, while liberal political ideals increased the likelihood of vaccine acceptance. This is relatively unsurprising considering the significant backing given to the anti-vaccination movement by conservative and religious populations, and highlights the dangerous role of political antagonism in fuelling vaccine hesitancy and increasing the disease burden of COVID-19.
There have been several strategies implemented with the aim to reduce inequalities in vaccine coverage. Probably the most infamous of these was COVAX, which promised to provide lower-income countries with the chance to vaccinate their populations. COVAX not only failed to meet its target of 2 billion vaccinations by 2021 but has only contributed to an abysmal 5% of all vaccines administered globally. Experts argue that part of this failure was due to an overestimation of higher income countries’ ‘charity’ by the WHO, GAVI, and the Coalition for Epidemic Preparedness Innovations (CEPI), when such countries instead adopted more isolationist vaccine and intellectual property policies.
From a vaccine hesitancy point of view, things are more promising. Multicomponent interventions have been cited as efficacious due to their ability to provide targeted approaches to multiple drivers of hesitancy. Such approaches often consist of: targeting specific under-vaccinated groups, increasing vaccine knowledge, awareness, and access, mandating vaccination or implementing sanctions against non-vaccination, engaging community/religious leaders, and consistently incorporating new evidence into vaccine policies and procedures.
Conclusion:
Despite COVID-19 rapidly falling off public, and political, radars, reflecting on institutional failures during the COVID-19 pandemic may be the key to ensuring we are prepared for the next one. With climate change and rapid agricultural expansion causing vast habitat loss, the encroachment of human settlements into previously unpopulated regions may accelerate the rate, and risk, of pathogen transmission between species. These pathogens, termed ‘zoonotic diseases’ have enormous pandemic potential due to the lack of knowledge surrounding their genome (and thus their infective properties), as well as the absence of targeted diagnostic, treatment, and prevention strategies. When paired with the ever growing market of international trade and travel, such pathogens have the potential to become global threats before scientific knowledge can catch up. Alongside this, we are still at threat from known, human-predominant pathogens, such as Influenza, whose mutation capacity and resulting treatment challenges render it a disease with strong pandemic potential.
Such a multitude of microbiological threats should dissuade governments from falling into complacency in the wake of the new so-called “COVID-normal” feeling. Instead, they should focus on disease monitoring, strengthening their healthcare systems, and adopting charitable policies focused on promoting the self-sufficiency of lower-income countries and their pandemic responses. Governments should also acknowledge the significant contribution that the COVID-19 pandemic has made to the politicisation of health and, by extension, vaccination. While multicomponent approaches have been touted for their efficacy in reducing vaccine hesitancy, if health and freedom continue to be seen as politically incompatible, then any uptakes in vaccination or preventive health behaviours are likely to be short lived.
Despite the significant global disturbance caused by COVID-19, the international community seems to have failed to learn from the pandemic. Poor future planning, accelerated globalisation, and political polarisation may mean that we are hit by an even deadlier pandemic sooner than we think.
