The <scp>COVID</scp> ‐19 pandemic: some lessons learned about crisis preparedness and management, and the need for international benchmarking to reduce deficits

Abstract

If, despite the explicit warning of the World Health Organization in 2011 that ‘The world is ill-prepared to respond to a severe influenza pandemic or to any similarly global, sustained and threatening public-health emergency’ (https://apps.who.int/gb/ebwha/pdf_files/WHA64/A64_10-en.pdf), it was not apparent to those in charge, and to the general public—i.e., those suffering from COVID-19 infections and the funders of health services (tax/insurance payers)—that existing health systems had inherent vulnerabilities which could prove to be devastating when seriously stressed, the SARS-CoV-2 pandemic (e.g., see Brüssow, 2020) has brutally exposed it now. In some countries, preparedness, despite being officially considered to be of strong operational readiness against health emergencies (Kandel et al., 2020), was inadequate at multiple levels (e.g., Horton, 2020). Similarly, a fundamental lack of preparedness is the case for a number of impending non-health crises (e.g., global warming, poverty, the soil crisis, etc.). Once we are over the COVID-19 pandemic, important questions will be: what have we learned/can we learn and how can we improve our systems? Below, we argue for the necessity for major realignment of crisis responsiveness, and indeed of health system operationality, based on international benchmarking and adequately funded preparedness. International benchmarking is mandatory, because it has become clear that there is a wide range of effectiveness in the ability of different countries with developed economies to respond to this crisis (and probably others), and the tax-paying public has no compelling reason to tolerate perpetuation of factors underlying poor responses to crises. It may seem so trivially obvious to say, but obviously needs saying because it was not apparent from the health system responses of a number of countries: those most at risk of infection are those in contact with the infected, i.e., front-line doctors and nurses. And as they become infected, the numbers of available health professionals left to treat patients goes down as patient numbers go up. And, of course, infected health professionals become transmitters of infection among one another, and to uninfected patients, since in the hectic reality of emergencies, they may not always be able to practice adequate physical distancing. This obviously means that the greatest protection from infection must be accorded the front-line professionals. However, there were substantive differences between countries in terms of the availability and use of best practice protective clothing (personal protective equipment, PPE) in the early days of the COVID-19 crisis; these differences were mainly in different degrees of deficiencies. The incomplete protection of front-line health professionals that occurred in a number of countries in the early days of the crisis, and that resulted in many infections and some deaths, is an unacceptable deficit in their health systems, particularly since the COVID-19 outbreak was, from end of January 2020, a predictable disaster of international magnitude. Then there are those one might designate accessory front-line professionals: those who transport infected individuals, like ambulance drivers, non-medical workers in hospitals, and so forth, carers ministering to people in care homes or in private homes, and others like some pharmacy and supermarket staff who, because of the nature of their work, come into physical contact with many people and cannot always achieve prescribed physical distancing. These are also particularly vulnerable to infection and to becoming infection transmitters. Since the people they care for are, because of their ages and underlying morbidities, often themselves particularly vulnerable to severe outcomes, infected carers may, unknowingly and unwillingly, become ‘angels of death’. Accessory front-line professionals thus also require best PPE. There are wide regional and occupational differences in the availability and use of such clothing by these professionals. It is well known that experts have been warning of impending deadly epi/pandemics, including coronavirus outbreaks, for a long time (e.g., Turinici and Danchin, 2007; Ge et al., 2013; Menachery et al., 2015; https://www.ted.com/talks/bill_gates_the_next_outbreak_we_re_not_ready?language=en; Editorial (2016) Predicting pandemics, Lancet DOI: https://doi.org/10.1016/S0140-6736(16)32578-8 ; https://apps.who.int/gpmb/assets/annual_report/GPMB_annualreport_2019.pdf; https://www.weforum.org/agenda/2020/03/a-visual-history-of-pandemics/). Now while the nature, evolution, timing and source of novel emerging infectious agents is uncertain, pandemics are always counteracted by the same time-honoured strategy: interruption of infection chains and anticipation of a surge in need for treatment of acute disease (here, we are nearly in the same situation as in the world confronted by Spanish flu in 1918). We, therefore, only need one epidemic preparedness. Despite this, the SARS-CoV-2 outbreak has clearly exposed how unprepared we were. There are multiple reasons for this, including. It is human nature that, once this crisis is over, people, except those who lost loved ones, employment, and so forth, will generally want to forget it as quickly as possible and get back to normal. The number of individuals who try to keep it in the forefront of memory, in order to institute new measures that adequately protect us from the next crisis, and there will undoubtedly be new crises (see above), will be few and far between. Some, not all, leading politicians who now (often for the first time) insist that their responses are being guided by the best scientific evidence and advice, as though it were the most natural thing in the world, will quietly shed themselves of their scientific credentials and revert to business as usual, even when unpleasant issues like global warming, the antibiotic resistance crisis, our vulnerability to terrorist and cyber-attacks,4 again come to the fore. In order that our collective memory retains the crucial need for crisis preparedness, it is essential that each year governments publish updated and independently audited contingency plans. And the public—the central stakeholders in, and funders of, government policy/actions—must be able to understand the issues and personally evaluate the sometimes vague policy statements they hear. To do this, society must become knowledgeable about/literate in such things. In the case of infectious disease crises, such as the one currently ravaging humanity, and the contingency plans necessary for these, literacy in relevant microbiology topics is, as we have previously argued, essential (Timmis et al., 2019). Interrupting the transmission chain in a pandemic may require lock-down, which imposes major personal sacrifices on the public, including confinement: loss of freedom of movement/social activities/family visits; closure of workplaces/loss of employment and income, resulting in economic hardship/increases in debt; closure of schools/places of worship/hospitality venues/fitness studios/clubs of all sorts; restrictions on shopping; and elevated stress/worsening of psychiatric conditions. It is, therefore, crucial that such measures are accepted and supported by the public. For this, people must be engaged and presented with coherent lock-down plans that are convincingly justified, in order to solicit compliance, solidarity and sharing of responsibilities. Federal structures, like those in the USA, Germany and Switzerland may lead to uncoordinated actions in different parts of the country that are unsettling and unconvincing, because the public perceives them as arbitrary. Such countries require coherent national plans that are consistent for the entire country. Of course, all people in lock-down want an exit as soon as possible, and it is essential for governments to develop and communicate as soon as possible their exit strategy, and the determining parameters and assumptions upon which it is based. Interestingly, some members of the public favour staggered exit plans, which implies a willingness to accept an infection risk. It will, therefore, be important for the government to have a public discussion on different risk scenarios, to obtain, present and discuss human/economic cost:benefit estimates (e.g., human lives against cost in loss of income /economic prosperity underlying the lock-down versus herd immunity approach—how much unemployment averts how many deaths or years of productive life when considering the age structure of death). And this discussion needs to take place in the context of the probabilities of loss of life through other adverse causes, such as annual influenza epidemics. It is the responsibility of government to protect its citizens and the role of industry to innovate and create commercial products and services. These two goals are not always aligned for current clinical exigences. But to provide a vital health system, government and industry must align and form alliances that create synergies. There are, of course, many successful examples of such beneficial alliances. However, there is sometimes an unrealistic perception of the role of industry, particularly by some governments when confronted with a crisis for which they are not prepared, as articulated in the generic cry: why do not we have a vaccine for this, why do not we have a drug for that? For example, regulatory and payment hurdles incentivize industry to develop cancer drugs rather than antimicrobials, so it is irrational and unwarranted to complain about the poor state of pipelines for new antivirals in the time of COVID-19, of antimicrobials in the time of the antimicrobial resistance crisis. If industry is to realign its research priorities towards current clinical priorities, it needs incentives to do so, e.g., through adequately funded creative government–industry–academia–clinical-regulatory strategic alliances. We have previously proposed a mechanism to create novel pipelines for accelerated discovery of new drugs and diagnostics (Timmis et al., 2014; and, simultaneously, to promote long-term revival of struggling economies, interestingly in response to a financial crisis—that of 2008—which the SARS-CoV-2 pandemic will again unleash with considerable severity). This proposal calls for the use of infrastructure budgets (not overstretched research-education-health budgets) to be targeted to the creation of new strategic national/regional alliances between (i) cell biology and microbial diversity research groups, to discover and develop new diagnostics, drug targets and assays, and new drug leads from new microbes, (ii) biochemical engineers, chemists and pharma, to produce, evaluate and develop drug candidates, (iii) pharma, clinical research and regulatory agencies to assess clinical efficacy and safety of, and develop new drug candidates. In the context of the SARS-CoV-2 pandemic, an alliance between virology, cell biology, microbial diversity, and synthetic microbiology groups in upstream discovery would accelerate new antiviral discovery and populate antiviral drug pipelines, but also pipelines of new antimicrobials urgently needed for the treatment of bacterial superinfections responsible for some of the COVID-19 mortalities. And: while advanced age, underlying co-morbidities and infection dose are identified as predisposing factors for development of severe COVID-19 disease, deaths among young healthy individuals also occur for reasons currently unknown. Once predisposing factors for this group have been elucidated, diagnostics to identify young people at risk, especially those most exposed to SARS-CoV-2, will be needed in order to reduce their exposure. There is great diversity in stress resilience (e.g., the ability to deal with peaks of illness) of different health systems, with some being at least regionally overwhelmed during the winter influenza season. The less resilient systems will generally be the first to become overwhelmed in a health crisis. While there are numerous parameters involved in health system resilience, and experts know most of the pinch points and solutions that can deal with these (but also what is uncertain and what needs to be understood before effective ‘solutions’ can be formulated), three elements worth consideration in efforts to increase health system resilience are discussed here. Healthcare systems are by and large extremely large, complex, heavily bureaucratic and fragmented. The often system-wide, multi-level consultations, decisions and responses needed in times of emergencies are challenging and often slow, usually slower than crisis development, which means that healthcare systems follow and react to events, rather than managing them. Crises are in some ways analogous to wars, and bureaucracies are not designed to manage wars, which is the job of the military. In crises, we need crisis strategy-tactics specialists, a taskforce with short, well defined and effective chains of command, tasked with overriding normal procedures and taking charge of supply chains and requisitioning of assets, (re)deployment of personnel, organization and prioritization of allocation of infrastructure, managing logistics, and so forth. These could be specially trained taskforces of existing staff within healthcare systems, external taskforces or combinations of both. An important aspect of the SARS-CoV-2 outbreak is that, in most countries, it has become more difficult to obtain consultations with primary healthcare clinics/physicians, because of social distancing practices, illness or involvement in crisis management (e.g., see Keesara et al., 2020). As time goes on, the inability to access many primary healthcare services leads to progressive worsening of existing and new conditions in some individuals. Access to primary healthcare, which in some countries was already unsatisfactory before Covid-19, is becoming a new crisis. This has resulted in the ‘flight to the web’ for information (sometimes obtaining disinformation in the process): the web is becoming a substitute for clinical consultations, in terms of obtaining information relating to symptoms experienced. This will ultimately have a significant impact on how the public views the computer as a facilitator-mediator of primary healthcare. While classical telemedicine—the ad hoc consultation of a remote, unknown physician who can advise on the symptoms presented—may be helpful in times of inadequate access to regular primary healthcare facilities, it cannot replace clinical advice informed by patient case histories and personal knowledge of the patient. The current SARS-CoV-2 outbreak has brutally exposed the current vulnerability of society to pandemics, even those that have been long predicted and anticipated (Ge et al., 2013; Menachery et al., 2015). Most healthcare systems have not evolved for resilience in times of catastrophe, nor for effective rapid responses to pandemics. A key principle steering evolution has been value-for-money within a fixed budget; contingency planning within this framework (outlays for materials that may never be used) may be considered to be a nuisance that diminishes what can otherwise be done with limited funds, and so to a greater or lesser extent may be postponed. For this reason, it is crucial that budgets for contingency planning are separate from health system budgets. Equally important, it has emphasized the fact that some healthcare systems have for a long time been on the edge of the cliff, just waiting for an event to push them over. Their adaptation to changing needs has often been through a ‘sticking plaster’ response. Evolution has been ad hoc, via responses to new developments and challenges, and often led to fragmentation rather than coherence. The lessons to be learned are thus not only to take scientifically-founded pandemic predictions seriously into account in policy elaboration, but also to streamline and institute changes in healthcare systems that impose an evolutionary trajectory that increases coherence, efficiency and preparedness, and the necessary mechanisms to maintain these as new exigencies arise (e.g., see Timmis and Timmis, 2017). And, especially because this crisis has revealed enormous disparities in responsiveness, effectiveness and the quality of responses in different countries, both preparedness for pandemics and the general improvement of healthcare mandate international benchmarking for contingency planning and the evolution of healthcare systems. Comparisons/benchmarking within countries—within single systems—is no longer acceptable. Many healthcare systems need substantive improvements through strategic investments, in most cases targeted to system changes, not just extra funding of existing services. And above all, they need crisis taskforces embedded in them that can prepare for, and take charge in times of, impending catastrophes. Another lesson learned is that the SARS-CoV-2 outbreak has revealed new synergy potentials, such as the manufacture of ventilators by engineering companies not normally active in the manufacture of medical devices. It is not unreasonable to assume that new innovations can and will emerge from new interactions between creative engineers and clinicians. For example, best practice for breathing difficulty and poor blood oxygenation is intubation and ventilation. The paucity of ventilators is a ‘critical control point’ for best treatment practice in some hospitals, which has been discussed above. Anecdotal evidence suggests that, of those individuals who die, despite best treatment practice involving intubation, the cause of death is often due to superinfection by antibiotic resistant bacteria (Vincent et al., 2020). The cause of this may indeed be intubation, causing perturbation of normal lung physiology and creating susceptibility to superinfection. There are, however, less invasive means of increasing blood oxygen levels. Perhaps engineers, together with clinicians, will devise new or improved non-invasive approaches to blood oxygenation. And once creative engineers from the non-medical field start to expertly scrutinize current medical devices, perhaps we will see new approaches and new designs that significantly advance medical practice. But perhaps the most important lesson learned is about our frontline health professionals ministering to COVID-19 patients, especially those with severe disease. These clinicians and nurses who willingly and selflessly work long, sometimes multiple shifts to the point of utter exhaustion, often not able to see their families for long periods because of the danger of infecting them, always under unbelievable stress working in what are essentially war zones with the accompanying horrors (e.g. see http://www.sixthtone.com/news/1005474/i-spent-seven-weeks-in-a-wuhan-icu.-heres-what-i-learned?utm_source=sfmc&utm_medium=email&utm_campaign=2716680_Agenda_weekly-17April2020&utm_term=&emailType=Newsletter), sometimes without adequate protective clothing and always in danger of contracting COVID-19, sometimes becoming infected, and sometimes paying the ultimate price. These are the heroes of the pandemic, the faces of resilience of COVID-19 healthcare, citizens personal and they are our role of the

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