Updated: Oct 17, 2020
How We Got Here
December 31st, 2019. January 25th, 2020. March 11th, 2020. These were three critical dates in Canada’s COVID-19 timeline.
Yet, it was not until the most recent date that serious work has been committed to slowing the spread and flattening the curve. December 31st was when the virus was officially announced in China, 25 days later, on January 25th the first case was reported in Canada, and 46 days later on March 11th, cases reported reached 100 and exponential growth began.
During the 71 days between the first reporting and when exponential growth began was policymakers’ opportunity to increase healthcare capacity, build private-public partnerships, and prepare Canadians for what was to come. Instead, there was little substantive work being accomplished. This is partly because there is little existing infrastructure or systems to use in times of pandemics but also because of an underappreciation of the degree to which the virus was going to spread.
Now, Canada has surpassed 14 000 cases and there is no sign that the inflection point has been reached and likely will not be for another week or more. In light of this, there are lessons to be learned from Canada’s, the world’s, and non-state actors’ responses to COVID-19. This article goes beyond this pandemic and identifies how to prepare for the next one.
National Policy Changes
Understanding how countries, people, international organizations, and the scientific community have responded to COVID-19 will provide an immense amount of collective knowledge to be drawn from in preparation for the next pandemic. This knowledge will inform two new national structures that should be built going forward to mitigate the next novel disease:
1. A national preparedness organization with provincial/territorial branches, which has: a) strong bipartisan funding; b) improved surge capacity for healthcare infrastructure; c) improved surge capacity for healthcare labour and; d) committed private-public cooperation.
2. A rapid response system that can adapt to novel disease through: a) widespread and rapid testing capacity; b) a comprehensive contact tracing system; c) strict, enforceable isolation measures and; d) strong and committed public support.
Pandemic Preparedness Infrastructure
To ensure that there is a wealth of funds, knowledge, and infrastructure ready for the next pandemic, Canada should create a new branch of its healthcare system. The head of this new, pandemic preparedness organization can be run by civil experts at the national level with sister branches in each of the provinces and territories. An interconnected organization will provide easy communication between Ottawa and different healthcare systems. Regionality ensures each branch can focus on the needs of its people.
Beyond the structural make-up, there are four necessities for this new organization to be well-functioning: bipartisan funding, increased healthcare infrastructure capacity, increased healthcare labour capacity, and stronger, more efficient private-public cooperation.
As with all strong and effective organizations funding is a necessity, but not sufficient. In this circumstance, there needs to be continuous, bipartisan funding to guarantee the country will be well-equipped regardless of the governing party. This funding need not balloon national debt though, Canada could spend only a fraction of what it does preparing for war — $32 billion by 2027 — on preparing for a pandemic and it would be beyond well-equipped.
With this funding, there needs to be a dramatic increase in critical pandemic infrastructure. One of the most difficult elements of pandemic preparedness is the unpredictable genetic make-up of the next disease. Still, viruses are the most likely to evolve into pandemics due to their infectivity, and luckily, they share common features. One of those is usually respiratory issues. This highlights the importance of Canada’s low 14.9 ventilators per 100 000 people. In comparison, the United States has 48, Germany has 30, and Italy has 8.3. To compound this low number, only an approximate 10–25% of those are available for non-COVID-19 patients depending on the hospital.
The diagram below illustrates the maximum daily number of COVID-19 cases that can be managed by the Ontario healthcare system given the current number of resources available. To prevent such a shortage of infrastructure in the future, there needs to be a comprehensive calculation of the potential resources required and a surplus of these resources procured to enable an appropriate surge capacity.
Diagram: Giannakeas et al.
Not only is infrastructure required but labour as well. There have been two critical issues with labour in the healthcare system during this pandemic. Firstly, there are simply not enough health-care workers in the system to deal with this influx of cases. Retired nurses have been volunteering to come back to work. Yet, many of these nurses are in the vulnerable demographic and the process to bring them back into the system is long. Secondly, health-care workers are becoming an increasing percentage of the total number of cases. In Canada, they are now nearly 10% of all cases. There needs to be an existing system to efficiently process retired nurses and other healthcare workers so they can quickly be brought back into the system in times of need.
Moreover, there should be a process to bring healthcare students such as nursing and medical school students into the hospitals. Of course, strict precautions and a review of this process would be needed, but those who have sufficient training could provide sufficient assistance to improve labour capacity.
To aid surge capacity in both infrastructure and labour, the military is a key organ of the state that should be utilized to rapidly construct temporary hospitals, personnel can facilitate non-medical tasks, and trained medics can be brought into the healthcare system.
Lastly, stronger and more efficient private-public cooperation should improve the flow of critical medical equipment including personal protective equipment (PPE), which has been in short supply during this pandemic, from manufacturers to hospitals. To accelerate private-public cooperation, early communication between public health experts and the government is needed to inform them of projected needs for equipment. Domestic manufacturers can then begin producing equipment before an outbreak becomes severe.
The emphasis on domestic manufacturing is critical here. This pandemic has proven that if governments purchase foreign equipment it will cost more and there is no guaranteethat they will receive it. In the future, the government needs to start working with manufacturers or even mandating production long before cases began to spread rapidly. It is better to be prepared and an outbreak dissipates than be unprepared and an outbreak becomes nearly uncontrollable.
Rapid Response Systems
While those policies are meant to construct national infrastructure that creates broad preparedness for a pandemic, there must also be a rapid response system that adapts to a specific pandemic no matter the disease’s symptoms, reproductive rate or required treatment. This response system would be an organ of the new healthcare organization. It would be ready and waiting with pre-existing funding and four unique features.
The first would be the capacity for rapid and widespread testing. COVID-19 has taught us testing is critical to minimizing the spread and maintaining low fatality rates. With this understanding, there should be leaps forward in innovation in disease testing. The response system should have testing systems in place that can be adapted to the particular molecular make-up of the novel disease, dramatically reducing the time it takes for reliable testing kits to be produced. Once a test kit is produced, and in conjunction with the private-public cooperation mentioned above, testing should be easily scalable.
The next feature is the contact tracing. This has been overlooked or become too difficult for many countries as their numbers have exploded. Contact tracing retraces the steps by anyone who tests positive, identifying those who have come in contact with that infected person. When applied aggressively, it can dramatically reduce the spread as individuals are tested before they even know they may be infected.
This could require the use of GPS, Bluetooth and surveillance technology to fully trace the infected individuals’ past movements. South Korea developed an app early that advised people on where known cases are and have been. While Singapore has used Bluetooth technologythat appears to be more accurate and less invasive to privacy.
Once testing and contact tracing occurs, isolation can be implemented. Isolation can be utilized by quarantining the infected until they test positive and maintaining stay-at-home advisories. These need to be enforceable though. COVID-19 has exposed the lack of public buy-in to government advisories. There needs to be credible enforcement of these advisories, which could include alerts to officials based on tracking data for those who break quarantine as South Korea has done. Serious debates surrounding civil liberties are needed on this subject, but these debates should be resolved long before the next pandemic so this response system can function effectively.
Lastly, and perhaps most difficult, will be enrolling the public’s help through strong trust in the government. While this response system cannot directly ensure this occurs, it can prove to the public through strong messaging and results that they need to trust the system built to protect them. There appears to higher trust and cooperation in East Asian countries than in western ones. This could be the cultural differences between individualism and collectivism. Regardless, this is a necessity that cannot be neglected, and the government needs to work to ensure it exists when the next pandemic occurs.
Global Policy Changes
There are two streams of global cooperation that is required in times of global pandemics. Cooperation at the political level between national leaders and cooperation throughout the scientific community. Strong political cooperation and leadership ensure that decisions by one nation will not negatively affect others and that there can be effective assistance from those better off to those worse off. Strong cooperation in the scientific community necessitates national data on the spread, reproduction rate, symptoms, and treatments be shared broadly and made open for others to use.
Improving Global Cooperation
The current landscape of political cooperation is imperfect. The G7 ministers failed to release a joint statement because of the wording of COVID-19, wanting it to be called the ‘Wuhan virus’. Moreover, the leadership has shifted as the United States has spent weeks denying the potentiality of the virus and China has moved quickly to offer aid and shipments of PPE and ventilators to other countries. This was evident more in Italy than anywhere else. When Italy asked its EU allies to help no one answered, but China. In the future, this leadership needs to be widespread; it cannot only be China. Assistance also needs to be reciprocal and geopolitical conflicts set aside.
The scientific community has done much better. Broadly, there have been enormous amounts to share data and scores of models being created. There is multilateral assistance to test plasma transfusions, create therapeutic drugs, and vaccines. So far, these efforts have demonstrated immense promise. It will be important for the international community to keep these efforts up. What is particularly important is when a solution, be it a drug or vaccine, is developed, that it is shared equitably across the world not hoarded by one country.
Unfortunately, China has underreported numbers and concealed the size of the outbreak at the beginning. Russia, Iran, Indonesia, and North Korea have also underreported numbers. Both underreporting, but especially concealing the source and beginning of the outbreak creates considerable damage to the global community as it leaves less time for other nations to prepare. This cannot happen in the future.
Aiding Low-Income Countries
There is an immense need to assist not just to own people but to low-income countries. They do not have the government capacity, healthcare capacity, nor the economic capacity to deal with a pandemic in the same manner as rich countries. Despite the low number of infections in low-income countries currently, it is only a matter of time before they are infected at the same levels or worse than rich countries.
Governments cannot supply the massive stimulus packages to allow citizens to live without employment, their healthcare systems do not have close to the same capacity of infrastructure, equipment, nor labour, and people cannot self-isolate in the same capacity because of the higher number of people per household. Importantly, the IMF is ready to deploy a one-trillion dollar lending capacity for low-income countries, which is vitally important, but not enough.
Now and in the future, there needs to be further cooperation between rich countries to low-income countries. As rich countries tend to develop strategies, technology, and large sets of data first, these need to be shared with low-income countries rapidly. These will need to be modified for low-income countries as technology will need to be made cheaper and more accessible, strategies may not be as effective there, and data entered into models made specifically for individual countries.
How Do We Achieve This?
The cost to the global economy will be in the trillions, while spending to prepare for the next pandemic is only in the tens of billions. Money alone cannot prepare countries or the world though. Commitments by governments and the global community to cooperate despite pre-existing conflicts or nationalists’ policies to ensure rapid, and cost-minimizing flattening of the disease curve is needed. With funding, expert-driven innovations, new systems and structures, and public trust, the next pandemic can be largely controlled, while allowing life to continue close to normal.