The ongoing novel coronavirus, or COVID-19, epidemic is challenging health systems, nations, and international organizations to define the scope and dynamics of viral transmission and implement control measures. Infectious disease pandemics, affecting multiple continents, are among the greatest threats facing humanity today.
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There is consensus among international experts that a severe influenza pandemic will occur but predicting the timing, the place or the severity is not possible. The lack of precision in predicting is reflected by the observations of the highly pathogenic “avian” influenza, or HPAI, Asian H5N1 that is especially deadly for poultry and has caused sporadic, serious disease outbreaks in humans over the past two decades.
The last pandemic declared by the World Health Organization was in 2009 for a new swine-origin H1N1 flu strain that caused a serious epidemic, but not nearly as severe as the 1918 Spanish flu pandemic, also due to an H1N1 strain, that led to an estimated 50 million deaths worldwide. The presence of large bird and animal reservoirs for flu viruses and the ability of the virus to adapt and change indicate that a severe human epidemic is inevitable; preparations have been made and flu vaccines are stockpiled.
Building on that preparation, it is essential that broader pandemic preparedness be implemented globally. Recent experiences with SARS, Ebola, and Zika demonstrated that an outbreak anywhere can lead to disease transmission everywhere, due to the great connectivity of all parts of the world by air, land, and sea transport networks.
The world in general, and Africa in particular, invests little in infectious disease pandemic preparedness. Such investments are often not viewed as a priority in the face of more pressing, evident needs. Political expediency does not favor long-range investment and planning.
Yet, a panicked approach to responding when an infectious disease outbreak occurs is expensive and inefficient. The cost of containing the West Africa Ebola crisis was over $4 billion and still, more than 11,000 lives were lost. Moreover, health systems were left considerably weakened through the loss of 513 lives among health care workers.
Now that humanity is facing yet another infectious disease threat with COVID-19, it is an opportune time to ask: Did we let the HIV, Ebola, SARS, MERS-CoV, Zika, and cholera crises go to waste?
We have expert reports with valuable lessons and recommendations to avoid mistakes in the future. What did countries do with those recommendations?
Siloed responses, one infectious disease outbreak at a time, are not likely to build a robust, sustainable global response to pandemic preparedness. Based on our experience in international development and consistent with the U.S. Agency for International Development’s vision of the journey to self-reliance, we suggest that an immediate response be built on recent and current investments.
The U.S. President’s Emergency Plan for AIDS Relief and the Global Fund to Fight AIDS, Tuberculosis and Malaria, for example, invest more than $9 billion per year in disease control programs targeting HIV, TB and malaria, implemented through national programs and NGOs. These investments have begun to strengthen health systems and communities in some countries such as Rwanda.
Additional investments are needed for a “whole-of-society” approach with the following seven desired outputs:
1. Government ownership — including national coordinating mechanisms, national guidelines, domestic resource mobilization, financial management expertise and accountability. Compared to previous outbreaks, the response to the recent, 10th Ebola outbreak in Democratic Republic of the Congo drew lessons from the West Africa crisis and was primarily led by the host country government.
2. Renovation of hospitals and clinics, like those that have supported the scale up of antiretroviral treatment and TB treatment; established networks of host-country-owned laboratories — including molecular test-capable laboratories — and functional sample referral systems — hub and spoke models — to increase access and testing coverage.
3. A reliable supply chain management for drugs, commodities, and supplies, including antiretroviral drugs, laboratory equipment, and reagents. South Africa, for example, increased domestic contribution over the years, reaching $ 2.2 billion in 2014/15, mostly for purchase of drugs.
4. Training of thousands of host-country national health care professionals and thousands of trusted community health workers living in the communities they serve so they may become critical facilitators of behavior change and stigma fighting. The successful community health extension program of Ethiopia illustrates how such investment can help improve health indicators in the long term across disease programs.
5. Functional referral linkages between communities and health facilities.
6. Strengthened national health management information systems — monitoring and evaluation, surveillance, and data for decision making.
7. Enhanced civil society participation among impacted individuals to combat stigma and create impactful social behavior change for prevention.
There is much work to be done. Let’s not waste this opportunity.
Siloed, panicked, reactive responses to COVID-19 in Africa would suggest lessons from past crises did, indeed, go to waste. Investments from the international community are needed to support host-country health systems, ownership, and accountability.