What we urgently need besides a vaccine
By Martina Merten, Susann Roth
With millions of confirmed COVID-19 infections worldwide and hundreds of thousands of deaths, the search for solutions to end the impacts of COVID-19 is overpowering. Finding a safe and effective vaccine is one crucial answer to the crisis. But there is more to it.
For months, the focus of discussion about how to quickly solve the current crisis has been on finding an effective COVID-19 vaccine. Without a doubt, vaccines are among public health’s best buys, since they save millions of lives every year all over the world. Immunization is key for avoiding deaths from several infectious diseases. Solving the current crisis through providing the worldwide population with a COVID-19 vaccine is a major step we need to take – and can hopefully take soon.
But we should not forget about other measures. We now know that investments in the social determinants of health – in particular, education, income, physical environment, access to health services and paid sick leave – have a major influence on health outcomes. Social inequalities in health have been proven to impact COVID-19 morbidity and mortality, according to The Lancet Respiratory Medicine journal in its July edition.
Families from lower income groups are at higher risk of viral transmission because of crowded living spaces and lack of access to testing facilities and treatment. Infection rates are significantly higher in the urban areas of lower income groups and people with pre-existing conditions are more prone to develop severe forms of COVID-19.
We also know that health facilities and elderly homes can become infection hotspots if infection prevention and control is not in place, and that hygiene measures are significant to prevent infection in daily life. We know that not everybody who is infected is equally infectious, nor do they have the same risk to get severely ill or die.
Research shows that the unequal impact of COVID-19 goes beyond infections but also includes collateral secondary damage. A global survey done by Save the Children revealed that COVID-19 has widened the gap between rich and poor children. In the six months since the pandemic was announced, the most vulnerable children have disproportionately missed out on access to education, healthcare, food, and suffered the greatest protection risks, the survey found.
The take home message is this: Lockdowns cannot be the answer in future, especially because they undermine what has been achieved already, in terms of progress made to date on determinants of health. They also widen the social gap. Moreover, people have even less access to open spaces and fresh air, let alone the implications on mental health and substance use – be it in India, the United States, or elsewhere.
Development organizations, together with countries, need to weigh which investments have long-term impacts on improving health systems and determinants of health to be better prepared and better respond to pandemics.
This includes investments in urban infrastructure to create healthier cities, especially in middle- and low-income settings where quality of housing can be extremely poor and where public spaces are missing. Density, pollution and noise are factors that add to the stress of any pandemic. Investments in digital technology solutions can help keep people informed who otherwise couldn’t afford to go to a doctor or are living too far away from a health center.
Lockdowns cannot be the answer in the future, especially because they undermine what has been achieved already, in terms of progress made to date on determinants of health.
This also includes guaranteed access to health infrastructure during times of pandemics, especially for those living below the poverty line. Nobody should face difficulties seeing and paying for a doctor, getting tested and treated because they have lost their jobs and have no income due to lockdown restrictions.
Finally, this calls for more patient-centric approaches, which help to understand individual and community risks and health care needs. Addressing underlying health conditions like diabetes, and obesity is important since they affect the immune response and make people more susceptible to infectious diseases like COVID-19. So does gender. Men’s first line immune response is slightly different from women’s and makes them more vulnerable to more severe COVID-19 infections.
We have learned that the foundations for successfully handling crisis situations are trust, good information and knowledge management, and evidence-based decision making. If the population will not trust its government and institutions, restlessness and uncertainty arise. Countries rank lowest in their perceived well-being where levels of trust in governance in handling the pandemic are low, according to a recent survey by The European Foundation for the Improvement of Living and Working Conditions.
Trust can be built by providing sufficient knowledge and reliable systems for evidence-based decision making. Learning from previous epidemics like MERS and SARS, the Republic of Korea had an excellent knowledge management system place that guided the decision-making process for COVID-19. Solid communication is key for preventing panic, avoiding misinformation, and providing perspectives. For solid communication we need unbiased information from institutions. And from the media. Ownership of media should not be influencing opinions. Censorship should be forbidden. Critical thinking should be fostered.
Against the backdrop of COVID-19, we need to remember that each year around three million people alone die from communicable diseases. An estimated 1.3 million people died from tuberculosis in 2016. HIV/AIDS killed 1 million people in 2016. The death rate from diarrheal diseases in the same year was 1.4 million. Nobody stops the world for people who die from these diseases.
There is more to it. The world had to fight severe outbreaks prior to COVID-19, with case fatality rates between 14% and 50% (SARS; MERS, Ebola). Lastly – even though it seems to be forgotten in many discussions on the current situation – the world constantly fights another “pandemic” of non-communicable diseases which kill 41 million people each year, equivalent to 71% of all deaths globally. Most of the premature deaths among those overall deaths occur in low- and middle-income countries.
We have known for a long time that we need to do more than providing the world with vaccines – as important as immunization undoubtedly is. The world needs, as also mentioned in WHO’s World in Disorder Report, integrated and complex public/global health solutions to be prepared for the next pandemic and all current ones. It needs investments in determinants of health, health systems, education, and good governance.