Learning lessons from the last pandemic

In this turbulent world, it’s tempting to move on and forget the difficult days of COVID-19. Although the impact of the COVID pandemic is far-reaching, and for many, ongoing, as priorities shift, people are thinking less about the last pandemic or the possibility of another one. We risk falling into yet another cycle of panic and neglect. 

In episode 6 of Not If, But When, we ask, what are the challenges for the public health experts trying to apply the lessons of the last pandemic, and working to strengthen the global systems for preventing future ones?

We speak to Catherine Smallwood, former WHO Regional Office for Europe’s Senior Emergency Officer and Programme Manager (Emergency Operations), about the systems in place that guide health emergency preparedness and response.

We hear from Mike Ryan, Executive Director of WHO's Health Emergencies Programme, about why, despite increasing and overlapping emergencies, he’s optimistic that the world will find ways to work together to combat global threats.

Transcript

Introductory music sound of school playground. 

Alice Allan: Today's teenagers spent the final years of their childhoods living through a pandemic. What was that experience like for them?

Montage of teenagers’ voices:

The COVID pandemic closed all schools, meaning that we got to take school in a different approach. We got to learn at home. 

It was definitely a big social difference for us because you went from seeing loads of people every day to like only three members of your family and it significantly impacted like also your mental health. 

I think that, um, teenagers, teenage students, um, kind of suffered a bit when it came to authentic human interactions. 

Yeah, during the pandemic, all over the world, millions of people got sick and died and even today, a lot of people still, you know, they have things like long COVID and struggle with the effects, for example, my dad had long COVID for nearly two years and it was a really difficult time for our entire family.

AA: While the impact of COVID-19 is far-reaching, and in some cases, ongoing, Catherine Smallwood, Senior Emergency Officer & Programme Manager for WHO/Europe, explains the challenges facing those who are trying to apply its lessons, and working to strengthen the global systems for preventing pandemics.

While the impact of COVID-19 is far reaching and in some cases on- going., Catherine Smallwood, senior emergency officer and program manager WHO Europe the challenges facing those who are trying to apply its lessons and working to strengthen the global systems, but preventing pandemics.

Catherine Smallwood:

 On the one hand, we've just come out of a really traumatic global event and we're suffering from this kind of post traumatic amnesia, right? Where none of us really want to go back to 2020 and 2021 and really remember and deal with all of that mess. It was horrible for everybody. And so there's a natural tendency for us to try and just move on and forget about it. On the other hand, we’re in a very difficult and turbulent world at the moment so the priorities have shifted, and in the public mind, people are thinking less about the next pandemic now. Partly because they've just come out of one and no thanks, we've been through that, we don't want to talk about it any longer, but also we've got bigger things, bigger fish to fry right now, than thinking about something that isn't yet happening. But we've also got this huge opportunity because we have learned so much and there was so much innovation and progress . Things that we would have taken decades to do, we were able to move forward.

AA: Mike Ryan executive director of WHO's Health Emergencies Programme explains why, when it comes to pandemics, the world falls into cycles of panic and neglect.

Mike Ryan:

I think it's part of human nature. We forgot the first world war and we fought the second world war and we always forget painful events. It's part of human nature to put aside pain and suffering so we could move on, sing individually and collectively. The problem with that process of amnesia is that it has benefits because you can function again and you don't remember the bad things, but it also has downsides, that you forget, and you don't learn from that experience. And what did Napoleon say? Those who do not learn from history are doomed to repeat it. It's totally consistent with human nature. It's just very, very dysfunctional and potentially dangerous when it comes to pandemics.

AA: Is there anything that gives you optimism about how countries and it collectively responding to the threat of future pandemics?

Yeah, I think it's mixed. I think what we saw in the in the Covid pandemic, many countries that had learned the lessons of SARS well, like the Koreas and Thailand and others and had follow up scares with the likes of MERS were much better prepared both in terms of public health and surveillance, clinical methods and in societal readiness and they did better. 

And if we're to take that lesson, then every country had a very harsh lesson in, I suppose, the consequences of a pandemic, which weren't the same in every country. In some countries, it was really long term care facilities that became the huge issue, in other countries it was migration centres or meat packing facilities or migrants, in other countries, there were different groups that were differentially affected by the pandemic. The pandemic came and went in different types of ways. The health system collapsed or came under pressure in different countries in different ways, depending on the public private mix, depending on the general level of access to health care on the scalability and integration of the health system itself.

So in countries that had good command and control on their health service delivery and had the ability to move staff around quickly, they did relatively well on the clinical side, but maybe did very badly on the public communication side. 

So when you look at the pillars of the response in terms of surveillance and monitoring or clinical care and triage and care, community engagement, education, risk communication, borders and airports, you know, the different elements of the response, I don't think any country came out with the 10 in each of those different categories. 

I do think we've all had those different lessons during the pandemic and many countries now are determined not to let the weaknesses that caused more suffering in the last pandemic be the weaknesses that cause suffering in the next. 

Now, we don't know what the bug will be. We don't know when it will come. So there's a lot of unknowns, but you know, if we look at it logically, yes, it's likely to be a respiratory pathogen. Our older population, our population with underlying conditions are likely to be very high risk or maybe very young children.That's been the case in previous pandemics. We know that our health system is going to come under pressure with the surge of cases. We know we want to reduce that surge. We won't be able to stop transmission, but how do we reduce the surging of cases that overwhelms our system? We know better how to do that now through public health and social measures, but to avoid lockdowns that are suffocating, that suffocate society, suffocate economic activities.

Do we know enough about public health and social measures and how they worked and how they didn't work? And how restrictions of movement versus closure of public facilities, what is the right mix of public health intervention that will reduce transmission enough to reduce the pressure in your health system without shutting down social and economic activity to the point where you create even more problems on the system?

That's where we need to learn. So we have learning to do both scientifically, and everyone talks about new vaccines and new research and diagnostics, and that's great. We need innovation in the scientific space, but we also need innovation in the decision making space and how we apply measures like public health, uh, social measures. How we manage our hospital systems, how we manage clinical pathways and clinical triage through the system. Did we deploy our primary healthcare well enough during the first stages of the pandemic to protect the tertiary healthcare system from a wave of cases? 

So I think that's where we will learn the lessons. There are I suppose lessons to be learned strategically, operationally, tactically and scientifically from this last pandemic. 

AA: Back to the teenagers, what do they think should be done differently if there were to be another pandemic?

Teenvoices montage: 

Well, I think just looking from sort of an equality perspective, we need to sort of try to even out the world, don't we? 

.Like the moment that a country hears about an epidemic going on, precautions should be set at that exact moment because any epidemic can turn into a pandemic that will then affect the world. And I feel like precautions are set a bit late when it came to COVID.

,I think maybe like more effective methods of, uh, cooperating on a global scale because countries didn't have their own ways of dealing with epidemics and pandemics, let alone working with other countries. And like working with other countries is imperative to stop something global.

I think if there is a framework in place, we could better tackle future pandemics and sort of future events alike. 

AA:

Fortunately, there are frameworks. One of them is called HEPR- it's the framework developed by WHO to tackle health emergency preparedness response and resilience. I asked Catherine Smallwood to introduce it.

CS:

It's not really a new set of ideas, but it's a new way of presenting what many of us who have been involved in emergency response for a very long time have always known, which is that when you're preparing and responding to emergencies, there's a set of things that you need to really think about that are completely interconnected. And if you don't have those systems in place, but also those connections between the systems, then your response is going to fail. And if you don't have some of these critical pieces of the jigsaw, then your response will never be as strong as it could be. 

AA: 

The HEPR framework brings together what WHO calls the five Cs: Collaborative Surveillance, Community Protection, Safe, Scalable Care, Access to Countermeasures and Emergency Coordination.

(AA- to teenagers): Okay, so each group has a piece of paper with one of the five C's described on it. I want you in your group to discuss why you think your C is particularly important, and then you're going to present back to the group. Okay? Good.

Montage from teens:

 Collaborative surveillance: to solve any crisis, you need to have the correct information on the crisis so you can know how many people you need to send and what scale the crisis is, 

 We believe that community protection is essential to the five C's, because one of the key things that it identifies is the way community communities work together in order to tackle issues such as medical emergencies 

Care is really important no matter what disaster it is, whether it's a natural disaster, whether it's a pandemic, it's really important that the hospitals get the resources they need.

We believe that access to countermeasures is one of the more important five C's is how are you going to solve an international health issue without the necessary equipment or solutions? 

So, um, when these large-scale global issues like the pandemic happen, they often come out of nowhere and we don't expect them. If they do come, we must be prepared so we can avoid a global crisis like what happened with the COVID 19 pandemic.

AA: Here's Catherine Smallwood again, to explain in more detail just what the 5 cs are all about, starting with...  Collaborative surveillance.

CS: So really, the ability to bring information together, to understand what is happening, pick it up, communicate it in a timely way. And that might be information coming from the health sector, but it might be information coming from the government, other sectors, so the animal health sector. It might be the security sector, it might be mobility for population movement, things like this. So collaborative surveillance is really about bringing different pieces of information together and that really kind of sets the framework to be able to act and brings the evidence base to act.

AA:Community protection.

CS: Then community protection is really about, well, protecting communities, but also engaging them. There's no point in having any response if the communities are not interested in accessing that response or not behind it. And we've figured that out very much in the European region during COVID 19. If a community don't want a vaccine, they just won't present to the healthcare workers to receive it, regardless of whether the vaccine is available or not. 

AA: Safe and scalable care 

CS: Clinical care. Of course, a requirement in the immediate response and consequences of any health emergency is that you need to quickly provide that access to clinical care.But that's also about sustaining all of the routine services that are already in place and then surging that with increasing, availability of technical expertise, perhaps for diseases that we don't have any previous experience in treating.

AA: Countermeasures 

CS: So that's all of the specific products that will be required during a response.

AA: And emergency coordination.

CS: And then last but not least, the coordination, the emergency coordination. So really bringing the other pieces together and making sure that information is shared, that decisions are taken, that there's a chain of command and some ability to manage the response at all levels. 

That's the gist of what the HEPR framework is, and it's bringing that together into one piece and not have this fragmented approach to emergency preparedness and response which is the big change. 

Clip of Dr Tedros congratulating member states on amendments to the IHR. “You've made history here today and approving a strong package of amendments to the international health regulations in strengthened the cornerstone of international health law in doing so you've made the world safer.”

AA: In response to the pandemic countries have engaged with new urgency to strengthen the way they collectively work on emergencies. Here's Mike Ryan.

MR: I'm very pleased with the process that the member states went through to amend the international health regulations. I mean, we've had the current version since 2005, well, came into force in 2007. They've served the world well, but clearly COVID and many other epidemics have illustrated areas in which they could have been improved.

So I do think, the IHR, the new amendments will give us a stronger mechanism for detection, for reporting, for verifying events, for doing joint risk assessments, and for building the capabilities to do all of that. So I do think it's a big step forward. But it's really amendments to an existing functioning instrument. So that's good. 

The other part of that, the treaty or the pandemic agreement that was being negotiated in parallel hasn't been agreed yet. And I think in terms of preparing for the next pandemic. In terms of workforce, in terms of vaccine, availability, vaccine, equity, research, transfer of technology, sample sharing and benefits sharing, one health approaches to prevention, there are the things that are all contained in the pandemic agreement. 

And that's not egregious, and you could argue that in a way we've made an existing instrument for detection and coordination and reporting and verification. We've made that stronger, and that's great. I'm really delighted, but to not have in parallel with that the pandemic agreement, which is fundamentally more focused on the next pandemic, that still remains a big gap.

So I'm really hopeful that the member states will get back to work in July and get us, over the finishing line, according to the World Health Assembly's request to have that finished and done before the World Health Assembly next year. Cause I think they can get it done. And I would really dearly like to see the IHR amendments and the pandemic agreement to be agreed in the same year by all our member states, sovereign member states who agree to come together and solve this problem, a huge problem for the world at a time where geopolitics is very disrupted, very divided. It will be a strong message for the world, both in terms of the next pandemic, but also in terms of international cooperation. Because there's so much info disinformation out there and misinformation around this whole process.

It's a shame to see in general, to see health being attacked, healthcare being attacked, health workers being attacked at every level. 

AA: So misinformation is one of the challenges to the negotiation of the pandemic agreement. What are the other reasons why it's so difficult to get countries around a table, acting in this global interests for pandemic preparedness? 

MR: First of all, they have to be commended, very much commended. I mean, they've spent, you know, a good two years or more, you know, at a task of doing two things, amending the IHR and coming to a pandemic agreement.

And, you know, it takes time for 194 countries to agree on anything. My God, if you were in my house, you know, trying to agree on what we're going to have for Sunday dinner. So I think we have to recognize that there are big issues on the table here. There's more experience with the IHR. We've lived experience with it.

So adjusting it means taking a trusted engine out of a car that we know works and making some adjustments and putting it back in. We have every expectation through the process that we get something better, because we know it works already. The pandemic agreement is slightly different. It breaks new ground.

It really tries to operationalize equity. It really tries to identify, you know, what prevention measures we should be putting in place as well with the One Health approach. So how do we prevent, reduce the risk of pandemics, but at the same time, how do we make sure that the protection we offer, it's more equitable to citizens.

They're big issues because that then begins to cut across some very big sort of political interests around national sovereignty, around the idea, around, well, serve our own first and that principle of whatever we have is ours, you know, what's mine's mine and what's yours is mine as well.

AA: Creating equitable access to countermeasures is one of the challenges that the 194 countries engaged in negotiating the pandemic agreement are trying to resolve:

CS: It's very, very difficult because, um, there are so many things that are tied up in developing countermeasures, especially if they're new countermeasures. Many of the countermeasures that we need to draw on for pandemics are not new. They're basic oxygen. There’s nothing new about oxygen. It's still critical and still posed a huge challenge during COVID 19, but new vaccines, that's a new countermeasure, new diagnostics.

If a country can't even access a diagnostic to diagnose a new disease, then how are they going to do all of the rest? So I think the focusing on the countermeasures is critical, particularly because inequity comes into play so quickly. And who gets it, who pays for it, who gets it first versus who gets it second.

Do you vaccinate the entire population in one country before you start in another, or are there more fair mechanisms for sharing countermeasures? And that really plays into the friction between decisions that national leaders need to make for their own populations versus decisions that we need to make as humanity for our one humanity across the world. 

MR:

I do think it gets into political areas very, very quickly particularly around the issue of vaccine sharing or sharing benefits on the principle that a country would give away some of its vaccine before serving all its own people. You know, this is something that politically, it's very hard to sell, but it's not really, because this isn't about charity, this is about collective security. We were very lucky in the last pandemic. Almost all the vaccines that were developed worked. That is not the normal. The normal course of vaccine development is most vaccines don't work. And you have to, it could take years to find sometimes a vaccine that works against a particular pathogen.

We don't know who's going to buy the golden ticket in the next pandemic. We don't know which country, which geography, which region is going to develop the effective vaccine in the next pandemic. What we're trying to say is, we do know from previous pandemics that a particular proportion of the population is always at higher risk.

Of dying or being hospitalized and that those individuals around the world deserve to be protected first, regardless of the ability to pay. And you may not be the country that gets the vaccine or develops the vaccine. So everyone needs some access. And who knows, the next vaccine may be developed in India, may be developed in Indonesia. So this isn't a North/South issue. This is about collective security and collective access to a minimum quantity of quantity of vaccine that allows every country to protect the people in it most at risk of dying.

And everyone agrees with that. And what's been fantastic in the process is the member states have really committed to that discussion and nobody disagrees with that principle.

But when I look at the overall document, what I see is a document that's mostly agreed. And now we need to get the final language. 

It'll be a huge gift to the world, to be honest, because if we have a pandemic agreement in which we've got principled agreement on one health and prevention, principled agreement on how to build a health workforce for the future, principled agreement on how we do beef up research and innovation, principled agreement on how we manage technology transfer.

Principled agreement on how we share specimens and information and benefits of that through the sharing of vaccines and principled agreement on how we coordinate financing for the next pandemic. If we have principled agreement on that between 194 member states, that's brilliant. It doesn't give us anything.

We have a huge amount of work to do after that. But it gives us a platform from which we can do better in the next pandemic. So I cannot overstate the importance of the pandemic agreement and nor the faith I have in our member states to agree it. But again, we as WHO, we make the tea, we carry the bags, right?

We're not parties to the negotiation. We will be obviously important players in implementing the will of the member states after, but it is 194 member states. I think it was at Winston Churchill said this, you know, democracy, he compared democracy to a sausage factory, you know, if you want to see how laws are made,  it's like going to a sausage factory. Maybe you shouldn't go to where they make the sausages. So, sometimes it looks boring and it looks fractious and the member states are, you know, arguing over the head of a pain and dotting eyes and crossing T's and putting in brackets and deletions and insertions.

And sometimes to us who work in the medical world or people who work in the non-governmental entities or general people in society, they look at that and go for God's sake, you know? But they are making a very important instrument. And I keep saying, this is not just a piece of paper. This is a lifesaving instrument and I've compared it before, I said, this is like a defibrillator for the world. This is a very important instrument. We have to be able to craft it properly so we can use it. To make us better prepared for pandemics.

CS:

 If, if the, if the pandemic treaty is a kind of defibrillator, bringing something back to life. The five Cs are those next steps that we can all use to make sure that we protect the world. If the world indeed is our sick patient. And they need to come in from all directions and they need to be targeted towards protecting the patient, i.e. our global territory.

That’s why if we forget certain parts of the world, the world as a whole is not going to be protected. And if we forget certain of the five C's, the patient is not going to get the protection that they need.

AA: A final question for Mike Ryan.

AA: You've worked in emergencies for most of your career. There seem to be more emergencies around than ever before. If you look at the news headlines, what keeps you going through all of this?

MR: Yeah, it's, it's not my fault, by the way. Yeah, we are seeing this convergence. It's not just more emergencies. It’s these permanent and overlapping crises that are placing societies around the world under extreme stress, extreme stress. And then you have the big ones like the pandemics that are going to affect us all. So we've got a very unstable geopolitical situation. We've got a very fractured global economy in which we have many haves and more have nots. We've got a fragile biome. 

I actually think that unfortunately the bad news gets the amplification. The bad news gets the news and the good news and the news about the good people who are doing that work rarely, rarely gets there. So do I think there's more good than bad in the world? Absolutely. 100%. And do I think that human ingenuity and human innovation can get us out of where we are?100%. Uh, we just need to be really focused. We need people to stand up. We need leaders at every level of society and every sector. We need leaders in every age group. We need people not to be afraid, not to be afraid of the conspiracy theories and not to be afraid of the disinformation jocks, not to be afraid of governments who don't want to support their own people, not to be afraid of making the world a better place.