Tedros Adhanom, head of the WHO, on the lessons from covid-19
EARLIER THIS month I declared an end to covid-19 as a global health emergency; a bookend to the most severe global health crisis since the influenza pandemic in 1918. Over the past three-and-a-half years, covid-19 has officially claimed almost 7m lives, although the World Health Organization (WHO) estimates the true toll to be closer to 20m. Millions more continue to struggle with the debilitating effects of post-covid-19 condition, or long covid, a syndrome we only partially understand. On top of the death and physical suffering it has caused, covid-19 has severely disrupted health systems, depriving millions of essential health services; roiled economies, erasing trillions of dollars from global GDP; and caused immense social upheaval, with borders closed, movement restricted and schools shut. Covid-19 has also exposed and exacerbated political fault lines, within and between nations. Vaccines, masks, lockdowns and other public-health measures have been heavily politicised. Some leaders have lost their jobs as a result of their handling of the pandemic. The quest to identify the origins of the pandemic has increased geopolitical tensions globally. One of the key lessons of covid-19, therefore, is that a pandemic is so much more than a health crisis. That means governments must not see health as a cost, but as an investment in social, economic and political stability and security. Countries spend vast amounts preparing for the threat of a terrorist attack, but relatively little preparing for the attack of a virus, which can be far more damaging and costly. This is true for all nations, at all income levels. No country was spared by covid-19, and some of the worlds biggest economies and highest-income societies were the hardest hit. Why? The answer is complex, but one reason is that many high-income countries were lulled into a false sense of security by their advanced medical systems, and caught out by their historic under-investment in public health. For decades, the worlds wealthiest countries have invested heavily in specialised and sophisticated hospitals, medical equipment and medicines. These investments have made a huge difference to preventing, diagnosing and treating diseases, giving millions of people extra years of life. However, as the burden of disease has shifted from communicable to non-communicable diseases, wealthier countries have typically invested less in the infrastructure needed to prepare for, detect, respond to or ideally prevent public-health emergencies. But epidemics and pandemics dont typically start in hospitals; they start in communities. While people in high-income countries were more able to get access to vaccines and high-quality care if they needed it, those countries were generally slower to introduce community-level public-health measures, on the mistaken assumption that it wont happen here, and that their advanced health-care systems would insulate them from covid-19, if and when it reached their shores. When it did, their health systems were quickly overwhelmed and they were forced to introduce more severe restrictions, including stay-at-home orders. By contrast, because of their previous experience with outbreaks and epidemics, many low- and middle-income countries, especially in South-East Asia, had the public-health know-how and the muscle memory to respond more effectively to covid-19 at the community level. The lesson is that while advanced medical care is vital for protecting the health of individuals, protecting the health of populations takes a different focus, and a different kind of investment: in disease surveillance, laboratory capacity and especially primary health care. As the eyes and ears of the health system, strong primary health care has a vital dual function, in helping to protect communities against both pandemics and everyday health threats. Many people think of primary health care as the first point of contact in the health system: local practitioners who diagnose and treat a range of problems and refer patients to specialists when needed. But primary health care also encompasses a range of actions outside clinics to address the underlying reasons people get sick. It recognises that health does not start in hospitals or clinics, but in homes, schools, streets and workplacesin the air people breathe, the food they eat and the conditions in which they live and work. Truly protecting and promoting health, therefore, means addressing determinants of health that lie mostly outside the health sector. Creating healthy populations is not solely the task of ministries of health, but requires health-promoting policy in trade, commerce, education, agriculture, urban planning, transport and more. As public goods, investments in public health and primary health care are also investments in addressing the inequities within and between nations that covid-19 exposed so brutally. Lower-income countries and communities had less access to vaccines, therapeutics and other tools; at the same time, those communities were often more at risk as a result of having higher rates of smoking, obesity and other risk factors than more privileged groups. At a time when economies are stagnating, governments are under pressure to tighten the purse strings. But now is exactly the right moment to make strategic investments in healthinvestments in human capitalthat will pay dividends for decades to come in more healthy, productive, equitable and sustainable societies. The WHO was forged in the aftermath of the second world war, as nations sought a new path forward after the bloodiest conflict in history. In the preamble to the WHO constitution they affirmed not only that health is a fundamental human right, but also that The health of all peoples is fundamental to the attainment of peace and security and is dependent on the fullest co-operation of individuals and States. The covid-19 pandemic has shown how right they were, on both counts. The lack of global co-operation to share information, data, vaccines and other tools prolonged and worsened the pandemic. As the world rebuilds from the most severe health crisis in a century, nations are once again coming together to negotiate a new pandemic accorda legally binding pact to meet shared global threats with a shared global response. They are also discussing amendments to the International Health Regulations, the instrument of international law that governs the global response to health emergencies. Covid-19 may be over as a global health emergency, but its effects will be with us for many years to come. Just as the collective trauma of war gave birth to the WHO, so the legacy of the pandemic must be a new recognition that investments in local health security are investments in global health security, and in healthier, safer, fairer and more peaceful societies. Dr Tedros Adhanom Ghebreyesus is the Director-General of the World Health Organization.