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Introduction

BACKGROUND

To take stock of lessons learned from responses to coronavirus disease 2019 (COVID-19) around the world and United States, the Forum on Microbial Threats held two virtual workshops during 2021. The first session, held in March, was an introduction that focused specifically on what it means to take a “syndemic” approach to COVID-19,¹ and what the implications would be for global recovery. Discussions centered on the multifactorial nature of COVID-19 as a syndemic, including its amplification of existing health threats and the socioeconomic risk factors that affect disease outcomes in different communities.²

The second workshop in the series focused more broadly on key lessons and emerging data from ongoing pandemic response efforts that can be incorporated into current health systems to improve resilience and preparedness for future outbreaks. This proceedings summarizes those discussions.³

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¹ The term syndemic refers to the synergistic health and social factors that intersect to mutually affect outcomes. See Singer, 1994. https://doi.org/10.1016/0277-9536(94)90205-4.

² A summary of the virtual meeting was released in July 2021 and can be found here: https://www.nap.edu/read/26259/chapter/1.

³ The full Statement of Task is available in Appendix A. The workshop agenda is available in Appendix B. A full list and biographies of workshop speakers and participants is in Appendix C.

Organization of Workshop

This second part of the workshop series was organized and held virtually over the course of 4 days in September 2021. The first day focused on the long-term effects of COVID-19 on health equity, including considerations for mental health and social determinants of health. The second day addressed uncertainties during a pandemic, such as trust, communication, and engagement. The third day focused on systematizing recovery efforts to improve the ongoing responses and prepare for the next pandemic, knowing it is a question of when, not if, one will occur. Finally, the fourth day featured possibilities for a post-pandemic world, using what has been learned from this current experience and using a hypothetical scenario to brainstorm a future response strategy for stakeholders that ensures sustained community partnerships and prioritization of health equity.

Organization of the Proceedings

This Proceedings of a Workshop is organized into five chapters following the flow of the workshop. Following this introductory chapter, which describes the two keynote addresses and following discussion, Chapter 2 focuses on existing inequalities amplified by the pandemic and the potential long-term effects of COVID-19. Chapter 3 addresses uncertainties in pandemic communication, including case studies focused on establishing and sustaining trust in the population. Chapter 4 discusses recovery efforts to mitigate the next pandemic through community engagement and other tools for capacity building. Finally, Chapter 5 features strategies for a post-COVID pandemic world by using the lessons that have been learned throughout 2020 and 2021 in biomedical research, public health policy responses, and community engagement and partnership.

LESSONS FOR THE FUTURE

This section features two keynote discussions from the workshop, sharing diverse global perspectives on the current state of affairs in many countries and an improved vision for the future.

Perspectives from the Independent Panel for Pandemic Preparedness and Response

Presented by Helen Clark,
World Health Organization
Independent Panel for Pandemic Preparedness and Response

Helen Clark, former prime minister of New Zealand and co-chair of the Independent Panel for Pandemic Preparedness and Response (IP), provided insight from the IP’s report. IP was established by the World Health Organization (WHO) Director General in May 2020, with the task of making recommendations to improve member states’ capacity for global pandemic prevention, preparedness, and response, including through strengthening relevant WHO programming.⁴ She shared the key message of its report, released in May 2021: every possible step should be taken to make this the last pandemic and stop repeating the cycle of panic and neglect. While there had been more than a quarter of a billion cases and 4.5 million reported deaths worldwide at the time of this workshop,⁵ there is further concern that the wide-ranging “impact of the pandemic could be felt for generations to come,” she said. Clark referred to studies conducted during the 1918 pandemic, showing that cohorts in utero during that time were found to have reduced educational attainment, increased rates of disability, and lower income and socioeconomic status (Almond, 2006). Clark advocated that actions be taken to avert these negative consequences, rather than passively accepting the fate of the current pandemic.

Clark underscored that the COVID-19 pandemic hit during a time of numerous intersecting global challenges, not the least of which are biodiversity loss, climate change, intractable conflicts, and entrenched poverty and insecurity. She added that each one becomes a mutually reinforcing threat multiplier to the others. Before the pandemic, the world also faced a growing burden of noncommunicable diseases (NCDs), which, together with COVID-19, could be seen to form a syndemic—a synergistic combination of multiple epidemics. COVID-19 has also driven much greater humanitarian need, she noted, with extreme poverty increasing for the first time this century, leading to clear negative health effects. Clark further noted that the United Nations’ Office of Humanitarian Affairs reported that more than a quarter of a billion people globally would need assistance in 2022,⁶ with an 82 percent increase in those who are acutely food insecure.

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⁴ For more on IP, see https://theindependentpanel.org (accessed January 24, 2022).

⁵ For current global COVID-19 statistics, see https://covid19.who.int (accessed February 11, 2022).

⁶ WHO, 2021. Global Humanitarian Overview 2022. https://gho.unocha.org (accessed January 24, 2022).

IP states that the pandemic is an issue of inequities and inequalities, with effects not equally felt across populations. Clark noted the large effects closely correlate with deprivation and gender disparities, leading to downstream consequences like increased maternal and neonatal death. The phenomenon of “long COVID” is also disproportionately felt, with women being 50 percent more likely to experience it than men.⁷ She also highlighted the effect on young people, with recent evidence pointing to more than one million children losing caregivers and being orphaned by the pandemic. Extrapolating based on the effects of human immunodeficiency virus, she said these children could be at a higher risk of developmental delays, experience mental health difficulties, and become vulnerable to abuse.

Health Inequities

Clark highlighted the increased likelihood of minority ethnic groups being harmed by the pandemic and said IP was convinced that existing inequalities increased opportunities for exposure and spread of the virus. “If there’s no safety net,” she said, “it’s impossible for the poorest in society to stay home from work and to follow social distancing guidelines when they need to work to feed their families.” She suggested that the best way to mitigate these long-term effects is to adopt a whole-of-government approach, controlling the pandemic in the short term while also addressing longer-term structural issues like the need for universal basic social protection.

Tackling these health inequities should be a very high priority following the experience of the last 18 months, Clark stated. Thinking about immediate steps, she emphasized the principle of vaccine equity. IP calculated that high-income countries ordered twice as many doses as they needed and could redistribute one billion doses to lower-income countries by September 2021, and another billion by the middle of the following year. But this is simply not happening, she reported. High-income countries could double dose all of their populations from 12 and up and still have enough supply for both boosters and the redistribution of one billion doses before the end of the year. This inequity is criminal, she exclaimed, with most low-income countries having been able to vaccinate barely two percent of their populations. The inequitable distribution will prolong the pandemic, “and further increase the risk of emergence of new variants,” she argued.

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⁷ Also recognized at the time of the workshop by the U.S. Centers for Disease Control and Prevention as post-COVID conditions or postacute COVID-19. See: https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects/index.html (accessed January 24, 2022).

Transforming the Global System

Regarding longer-term health architecture reform, Clark explained some of IP’s recommendations for the future, saying it recognized there had not been any shortage of advice from the international community on this topic over the years. Still, there has been a lack of action. IP was very clear that the global pandemic preparedness and response could not be left to health administrators and WHO alone, and that there is a need for a whole-of-government response and multisectoral efforts, both internationally and within national governments. IP called for new mechanisms and for a strengthened WHO with the “independence, funding, and authority it needs to play the role it must play.”

IP also strongly advocated for the establishment of a global health threats council composed of heads of state and government to ensure ongoing high-level political leadership and awareness around pandemic preparedness and response. Such leadership has been lacking in the current crisis. Future crises, recognizing that another pathogen with pandemic potential could emerge at any moment, should not repeat the experience of a worldwide scramble for such global public goods as personal protective equipment and other supplies, she said. Clark offered that a more robust supply chain with equitable focus and access to public goods is needed, along with dedicated financing mechanisms to enable all countries to be prepared and respond.

If the right steps are taken quickly enough, Clark said, then a more robust system can be built to avoid this level of pandemic disaster in the future. But it will require urgent and sustained political leadership to address social determinants of health (SDOH) and operationalize a “health in all policies” approach. She noted that though the current pandemic represents a collective failure where each stage of the response has room for improvement, the most vulnerable in society have been paying the highest price. To improve upon this, IP recommends “fundamental transformation designed to ensure commitment at the highest level,” with a functioning global pandemic preparedness and response system.⁸

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⁸ To read IP’s report COVID-19: Make It the Last Pandemic, visit https://theindependentpanel.org/mainreport (accessed February 11, 2022).

Blueprint for a Whole-of-Society Approach to Health Care

Presented by Her Excellency Hanan Al Kuwari,
Hamad Medical Corporation, and Ministry of Qatar

H. E. Hanan Al Kuwari, minister of public health in Qatar and managing director of Hamad Medical Corporation, shared her country’s experience throughout the pandemic and what it has learned. COVID-19 has demonstrated the role and effects of the social and economic inequalities of health, she reported, with this pandemic becoming a toxic interaction of biological and social causes.

Al Kuwari outlined four inequalities that were exacerbated by the pandemic:

1. Preexisting epidemics of NCDs, also associated with SDOH. She noted that people with low socioeconomic status have the highest risk of COVID-19 complications.
2. Digital divide—people with more education and skills can work from home and continue to get paid while others get left behind. There is a similar effect on children who are not able to continue schooling as easily online.
3. Resilience of high-rate vaccine countries—they can return to business as usual faster, while others have higher mortality rates.
4. Overcrowding seeding poor health—poor housing conditions that do not allow for distancing are powerful determinants of COVID-19.

Against all of these challenges, Al Kuwari asked, how can countries and health systems react? Qatar is a small country, with just 2.6 million people, that experienced two strong waves of COVID-19, with additional seasonal waves. But the mortality rate was one of the lowest globally, she reported. While the young demographic is partially responsible, she also attributed it to Qatar’s whole-of-government response and its health system. The country never locked down, and while it did introduce quarantine measures for incoming travelers early on, it never closed the airport or cancelled flights to certain destinations. As of September 2021, she said, Qatar had 80 percent of the population vaccinated and was testing 5 percent of the population each week. Al Kuwari believed that Qatar is managing the pandemic well, but because of global inequalities, she recognized it is still at risk from other countries and ongoing infection rates. She shared several of her country’s lessons learned throughout this process (see Box 1-1).

In conclusion, she offered thoughts on the inevitable implications of the current pandemic, first emphasizing the effects on mental health and

wellness for the general public, recovered patients, and the health care workforce. Second, she anticipated seeing more evidence of “long COVID.” There will also likely be unavoidable delays to accessing health care during acute outbreaks, resulting in a need to address a significant backlog. She emphasized the importance of focusing on physical activities, especially working to prevent physical and cognitive decline in elderly populations and those with chronic conditions after long periods of confinement. Al Kuwari also highlighted the enormous amounts of data collected throughout the pandemic, so harnessing this for public health and improved health

care is critically important. Finally, she said health systems will be pressured to safely reduce costs, and they need to recognize the challenges and opportunities present. In conclusion, she expressed confidence that health systems in countries can become stronger, but only by harnessing collective experiences can they ensure that systems will be well prepared to detect and respond to future crises.

Discussion

In terms of positive outcomes from the COVID-19 experience, Clark noted that it did get people thinking that perhaps there could be a recovery that was more inclusive and more equitable than the systems of the past. However, the longer it drags on, the more difficult it will be to capitalize on that momentum and take action on those issues. She emphasized that no one is safe until the system truly reaches society’s most underserved and vulnerable. Al Kuwari added that there have been positive experiences, such as working much more closely with other ministries within the government, allowing them to better know and understand the health sector. It has also resulted in more awareness and understanding of approaches such as the health-in-all policies, increased the value of health workers, and led to more students signing up for health and medical fields, she reported.

Given the dire effects of COVID-19 in many places, another question highlighted the possibility of still meeting the sustainable development goals (SDGs) by 2030. Clark replied that she does not anticipate the SDGs will be met, though they should be. Progress on goals of poverty, hunger, education, health, and others were already not on track before the pandemic, she said, but now things have gotten even worse. Al Kuwari agreed that globally they will be difficult to reach, but noted every country is seeking to make progress. Coupled with the effect of globalization on the spread of COVID-19, a participant asked how to reenergize this commitment and get back on track for the SDGs. Clark responded that IP felt the International Health Regulations (IHR), last negotiated in 2005, hindered WHO in its response. The world is much more interconnected now, she said, but the IHR downplayed it and call for undue restrictions on travel. However, she believed that if New Zealand did not close its borders when they did, they would have had a runaway pandemic. There is a big responsibility on every country to play its role in fully and rapidly stopping localized outbreaks that could lead to a pandemic, she said, and IP was critical of China for not being more forthcoming. Clark also stated that WHO did not take as precautionary an approach as it should have with a pathogen of pandemic potential, and that WHO’s stance against taking special measures on travel failed to account for the current state of global interconnectedness.

In summary, Clark shared that she would like to see a group of leading countries that will champion the process at the United Nations General Assembly. It has been done for HIV and for universal health care she said, and we need to lead the way forward for the world on this issue as well. She also suggested that political leaders should sensitize their populations to the new normal, highlighting the occurrence of breakthrough cases even in vaccinated populations. Al Kuwari added that there could not even be considerations of returning to normal until all countries have high vaccination rates. She also acknowledged that masks and social distancing have saved lives, and those interventions should be included in our understanding of “normal” until we reach a strong global vaccination rate. Al Kuwari suggested using this opportunity at all levels and addressing the key issues and challenges to make 2022 a positive year. She also called for the implementation of the IP report recommendations, as well as improving the financing of health care, developing a robust health care workforce, and encouraging health care workers to become advocates for patient safety.

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