From the moment the SARS-CoV-2 virus first began to proliferate out of control in China and was subsequently recognised as a pandemic in official terms by the World Health Organization on 11th March 2020, it became one of the fastest-spreading and most significant pandemics in modern history.

It has been a once-in-a-century global pandemic that has so unexpectedly and irrevocably changed the world, in ways we could once have only imagined in big box office hits on the silver screen. But should we have left such imagination to great works of fiction? 

We are familiar with influenza or the ‘flu’ as we so often affectionately seem to refer to it, and we are also reluctantly accustomed to flu pandemics of different variations. Indeed, a June 2013 WHO guidance document clearly states that, “Influenza pandemics are unpredictable but recurring events that can have consequences on human health and economic wellbeing worldwide. Advance planning and preparedness are critical to help mitigate the impact of a pandemic.” 30  

That WHO guidance document, titled Pandemic Influenza Risk Management, both updated and replaced a previous such document published in 2009, with the revision intended to take into account the lessons learnt from the A(H1N1) 2009 influenza pandemic (so-called swine flu) and any other relevant developments. 

It clearly states that its guidance can only be used ‘to inform and harmonise’ national and international pandemic preparedness and response. Countries should consider reviewing and/or updating their own national influenza preparedness and response accordingly, it adds. In fact, whilst the roles and responsibilities of the WHO relevant to pandemic preparedness, in terms of global leadership and support to Member States, are also articulated, the document was not intended to replace national plans, which it made clear should be developed by each country. On the evidence of the Covid-19 pandemic and how it was initially dealt with, however, one might ask whether each country did have such plans or how robust they were. 

In Part 1 of this series, we explained how the WHO was informed of cases of pneumonia of an unknown cause in Wuhan City, China, on 31st December. A novel coronavirus was identified as the cause by Chinese authorities on 7th January 2020; by 30th January, the outbreak was declared a Public Health Emergency of International Concern by the WHO; by 11th March it was officially recognised as a pandemic; yet by the end of March and into the first weeks of April, Europe had become the new epicentre and tens of thousands of confirmed cases were being identified each day. Hundreds, soon thousands, of lives were being lost every single day as the virus continued to rip through communities, cities, countries and regions of the world with increasing ferocity.

With improving healthcare systems the world over prior to 2020 and the increasing prosperity of so many economies and national health departments as a result, a question to emerge from Part 2 of this series was, how pandemic-prepared were we? Had we been sleepwalking into a false sense of disease security, despite the best efforts of speeches from high-profile figures like WHO Director-General Dr. Tedros Adhanom Ghebreyesus to guard against such indifference and urge investment in immunisation programmes, public health communication, and strong primary care?31  

Perhaps a better question to take forward is, how pandemic-prepared could we be? 

The world is ill-prepared…

Cursory online research demonstrates the chequered history that the world collectively has with pandemics. In many respects, one might imagine that mankind would by now be much more agile, adept and experienced at dealing with the emergence of new viruses and/or diseases. There are many examples to learn from, and clearly medical science has advanced phenomenally in the last half-century alone. 

Others would argue that pandemics, like Mother Nature, are unpredictable. Assuming, of course, that we continue to follow theories of natural emergence. Indeed, as described earlier, WHO guidance clearly states that influenza pandemics are unpredictable but recurring events. Let’s look at some of these recurring events, then.

Turn the clock back just over a century; the 1918 influenza pandemic was the most severe pandemic in recent history. Though termed ‘Spanish flu’ there is no universal consensus regarding its place of origin, only the knowledge that it was caused by an H1N1 virus with genes of avian origin.

The virus spread worldwide in various waves throughout 1918-1919 and through to April 1920, during a period of major international conflict, most notably World War I, and it is estimated that around 500 million people – one-third of the world’s population at the time – became infected with it. The number of deaths was estimated to be at least 50 million worldwide, though interpretations vary considerably given dynamics such as misdiagnosis, the wars being fought at that time and a lack of accurate data compared to today. In fact, estimates range from a conservative 17 million to a possible high of 100 million32

And yet it has also been labelled ‘the forgotten pandemic’ in some quarters, largely due to the fact that it has no major markers, commemorative installations or reminders around the world. Another contributing factor to that tag is no doubt the fact that there had been that backdrop of World War I (which could have skewed fatality counts) and subsequently World War II, as well as a number of global recessions and comebacks, and various other diseases, epidemics and even pandemics since then. A century is a long and, in many ways, arduous time. The struggle is real for many a generation, through no less than 10 decades and across continents, so one could be forgiven for forgetting or overlooking the 1918 influenza pandemic. 

When Covid-19 struck just over a century later, it was suddenly far from forgotten as an eerily similar pattern of spread and destruction played out and we might well ask, had we really learned nothing from that pandemic? Did we think this wouldn’t or couldn’t happen again, on such a devastatingly worldwide stage, particularly given our current picture of globalisation? 

Clearly it would not be the last respiratory pandemic. Fast-forward to the early 2000s, and another example is the aforementioned swine flu pandemic of 2009, both the first of the 21st century and the first since the WHO had produced pandemic preparedness guidance. 

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Source: bear_productions / Shutterstock.com

Centers for Disease Control and Prevention (CDC) in Georgia, Atlanta (March 2020).

A novel influenza virus, it was detected first in the US and spread quickly across the US and the world. This new H1N1 virus contained a unique combination of influenza genes not previously identified in animals or people, and was very different from H1N1 viruses that were circulating at the time of the pandemic. According to the US Centre for Disease Control and Prevention (CDC), few young people had any existing immunity (as detected by antibody response) to the H1N1 virus, but nearly one-third of people over 60 years old had antibodies against this virus, likely from exposure to an older H1N1 virus earlier in their lives. Since it was very different from circulating H1N1 viruses, vaccination with seasonal flu vaccines offered little cross-protection against this novel new virus infection33.

The CDC continues to explain that while a monovalent (H1N1)pd09 vaccine was produced, it was not available in large quantities until late November that year and, therefore, after the peak of illness during the second wave had come and gone in the US, at least. In terms of its ferocity of infection, from 12th April 2009 to 10th April 2010, the CDC estimated there were 60.8 million cases, 274,304 hospitalisations and 12,469 deaths in the US alone34. Additionally, the CDC estimated that 151,700 – 575,400 people worldwide died from this new strain of H1N1 infection during the first year that the virus circulated35.  

The question may be, then, what did we learn from this most recent of influenza pandemics, just one decade prior to the first recorded onset on Covid-19? 

According to the WHO web archives, the experience of Member States during the pandemic varied, yet several common factors emerged. Member States had prepared for a pandemic of high severity and appeared unable to adapt their national and subnational responses adequately to a more moderate event. Communications were also demonstrated to be of immense importance: the need to provide clear risk assessments to decision-makers placed significant strain on ministries of health; and effective communication with the public was challenging. These, and other areas with improvement potential, were identified by the ‘Review Committee on the Functioning of the International Health Regulations (2005) in relation to Pandemic (H1N1) 2009’36

The report concluded, “The world is ill-prepared to respond to a severe influenza pandemic or to any similarly global, sustained and threatening public-health emergency.”37  

The Review Committee recommended that WHO should revise its pandemic preparedness guidance to support further efforts at the national and subnational level. Revisions recommended included simplification of the pandemic phases structure, emphasis on a risk-based approach to enable a more flexible response to different scenarios, reliance on multi-sectoral participation, and utilisation of lessons learnt at the country, regional and global level. A key point made was that previous pandemic planning guidance was overly rigid; Member States had prepared for a pandemic of high severity and appeared unable to adapt their responses adequately to a more moderate event. 

Given these findings, one might well question how, a decade later, the response to Covid-19 was arguably not so simple, wise, coordinated or ultimately effective. In fact, it could be observed that the response to the Covid-19 pandemic was overly rigid and slow out of the blocks, arguably not heeding the lessons learned of this prior pandemic or those before it. 

Shots across the bows of society

Those are just two examples of respiratory pandemics, almost a century apart. Both exuded relatively fearsome spread of infection, and both provide lessons to be learned in preparedness. 

This is without even discussing other types of epidemics/pandemics that have also provided warnings from very modern history and continue to do so. Think of the Ebola virus disease (EVD), a severe and often fatal illness affecting humans and other primates that has continued to evolve and resurface since its first discovery in 1976, or the Zika virus disease caused or transmitted by Aedes mosquitoes. 

Both have reoccurred through the decades and both have fired shots across the bows of society in the last 10 years in particular. The 2014–2016 Ebola outbreak in West Africa the largest and most complex Ebola outbreak since the virus was first discovered in 1976. There were more cases and deaths in this outbreak than all others combined. It also spread between countries, starting in Guinea then moving across land borders to Sierra Leone and Liberia38. Meanwhile the 2015 outbreak in Brazil of the Zika virus, itself first identified in Uganda in 1947 in monkeys, sent shockwaves around the world when its association with both Guillain-Barré syndrome and microcephaly were reported. According to the WHO, outbreaks and evidence of transmission soon appeared throughout the Americas, Africa, and other regions of the world. To date, a total of 86 countries and territories have reported evidence of mosquito-transmitted Zika infection39

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Zika virus aedes aegypti mosquito on human skin.

Are these two examples evidence of the increased rate of transmission of such diseases in the 21st century and further, the lessons still to be learned in how such scenarios are best handled by the international community? 

Let’s go even further back. Whilst not contextual nor necessarily relevant to today’s science and challenges in global healthcare, we must not forget, either, that there is a chequered history of pandemics across the world, dating back thousands of years. 

Basic search engine research will provide you with a comprehensive list stretching as far back as a prehistoric epidemic estimated at around 3,000 B.C which is said to have wiped out a village in China. The bodies of the dead were stuffed inside a house that was later burned down. No age group was spared, as the skeletons of juveniles, young adults and middle-age people were found inside the house. The archaeological site is now called ‘Hamin Mangha’ and is one of the best-preserved prehistoric sites in northeastern China40

It’s a list which includes The Black Death of circa 1346-1353; the Cocoliztli epidemic of 1545-1548 across Mexico and Central America; the Great Plague of London (the Black Death) of 1665-1666; similarly the Great Plague of Marseille from 1720-1723 and the Russian plague of 1770-1772; the flu pandemic of 1889-1890 that is thought to have started in Russia before moving swiftly through the rest of Europe and the world despite no emergence of air travel at that time; and the rapidly proliferating Asian Flu epidemic of 1957-1958 which appeared to have originated in China but quickly emerged in Singapore in February 1957, Hong Kong in April 1957, and the coastal cities of the US in the summer of 1957. The total death toll of that latter epidemic was estimated at more than 1.1 million worldwide, with 116,000 deaths occurring in the US41

The evidence (or in some instances lack of) from these epidemics may provide no learnings or bearing on today’s pandemic prevention, but they illustrate the sense of fragility that we consistently seem to have at the hands of various different diseases and viruses. There are clearly also recurrent themes to these epidemics: societal factors; demographic factors affecting fatalities; an uneasy simplicity with which diseases seem to enter the human ecosystem from animals; and as time advances, an increasing ability for these epidemics to spread further and faster with the rise of international travel.

Have we also witnessed another pattern emerge: have our healthcare systems tended to be set up to fight the last big pandemic and not the next? We have tackled HIV/AIDS and malaria to a lesser degree; we are alert to Ebola and even Zika for example; but did we ignore the threat of a future respiratory pandemic, despite the earlier warning shots?

Certain countries notably handled the onset of Covid-19 better than others during the pandemic’s early stages; many will recall the widespread commentary in 2020 of how Taiwan, Singapore and South Korea, for example, dealt with their first wave of Covid as a result of the lessons learned from relatively recent experience with both SARS and MERS. Measures were able to be planned for and implemented, it seemed, with these nations alert to the threat of the next pandemic. Why was this not the case globally? Did we lack collective cohesion in our pandemic preparedness?

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Globalisation

What various recent pandemics have demonstrated is arguably the effects of globalisation and how interconnected the world is, far quicker and easier than ever before. 

There are various theories around this topic and the impact of globalisation on health, with clear advantages and disadvantages to be argued. Two very balanced and salient approaches to this debate are provided by a 2004 report by the Medical Journal of Australia (MJA), titled Globalisation: what is it and how does it affect health?  

Citing AJ McMichael from his book Human frontiers, environments and disease (Cambridge: Cambridge University Press, 2001) 42, it begins by providing the context that, “Humans have lived with continual change since the migration of Homo erectus out of Africa a million years ago. Globalisation, in this sense, has gone hand in hand with the evolution of human societies. But our current phase of globalisation is distinctive in its unprecedented intensity and extent of change.” 

It continues to explain that it would be overly simplistic and inaccurate to describe globalisation as either ‘good’ or ‘bad’ for health. For example, spatial change is leading to increased migration of people throughout the world. For high-income countries, the debate surrounding globalisation and health tends to focus on the perceived threat, from low and middle-income countries, of acquiring certain acute and epidemic infections, such as HIV/AIDS, tuberculosis, plague and, more recently, severe acute respiratory syndrome (SARS). Richer countries also fear the potential financial burden of unhealthy populations migrating from the developing world43

Yet we must also consider many other, less appreciated ‘risks’ that high-income countries may export to other parts of the world, the report balances, from potentially harmful lifestyle products to macroeconomic policies and their associated effects. 

A ‘complex equation’ of pros and cons exists in the discussion of globalisation’s impact on health but the two simple, aforementioned arguments that perhaps relate most strikingly to the Covid-19 pandemic – in this author’s view – are the report’s assertion of how temporal change affects the spread of disease. On the one hand, the speed of modern transportation systems means that infections can potentially move around the world within a few hours (as illustrated by the SARS outbreak in 2002–03). On the other hand, modern technology potentially enables the health community to respond more quickly to such emergencies. For example, an international network of institutions coordinated by the WHO via global telecommunications can readily detect and rapidly respond to changes in the influenza virus44

Clearly, there can be no fixed conclusions nor a definitive argument about the impact of globalisation on pandemic preparedness. If the argument around a more interconnected world where viruses roam freely, however, is negated by a theory of more advanced and enabled communications that could enable us to mobilise the spread of information and response to a pandemic break out more rapidly, does one have to question why we did not see more positive reinforcement of this with the onset of Covid-19? 

Or is the question, conversely, whether our political climate and choices could be attributed to a discernible lack of clarity and cohesion in our response to the pandemic?