The importance of a strong pandemic readiness has perhaps never been clearer than during the ongoing COVID-19 outbreak. However, equally clear has been the inability of “strong health systems” to respond appropriately. In the Global Health Security Index (GHSI), the first comprehensive assessment of health security, 195 countries are ranked by their expected ability to respond to a global pandemic. In this index, the United States of America (USA) claims the gold medal, with the United Kingdom (U.K.) as a close second. Looking back at these numbers in the midst of the COVID-19 pandemic, this index seems like wishful thinking.
The COVID-19 pandemic, with more than 2.2 million confirmed cases and 153,000 deaths, is still far from over. At the time of writing, the USA, which accounts for only 4% of the world’s population, has 22% of the total number of deaths attributed to the new viral disease. And the U.K., which has less than 1% of the world population, has 10% of the total COVID-19-deaths. A full discussion of the factors that determine a successful response is complex and beyond the scope of this piece, but we want to highlight two glaring observations. First is that the strength of the health systems in high-income countries like the USA and the U.K. has been clearly overrated and, second, low-tech prevention strategies are underappreciated.
A strong health system is one of the pillars in the GHSI and a component in other health security indices. A strong health system is primarily defined as the ability to adequately care for patients. The USA, despite its disparities in healthcare provision for the poor or marginalized communities, has the infrastructure and human resources to deliver high-quality healthcare. Yet the USA, and specifically New York City, had become the epicenter of the COVID-19 outbreak by early April. In the past weeks, dystopian stories have emerged from New York about mass-graves being dug and healthcare workers using home-made face masks or aprons due to insufficient supplies of personal protective equipment (PPE). Supposedly strong health systems (according to the GHSI) in Europe, such as the U.K., Italy, Spain, and France, are also failing. In Italy alone, more than 100 doctors have died of the virus and in Spain, 14% of those infected are medical professionals. Why have these strong health systems been unable to handle this stress-test?
One reason may be that these countries are overconfident in their ability to treat and were consequently slow to enact aggressive non-medical countermeasures such as travel restrictions, social distancing, early testing, and contact-tracing. It is clear now that even the best health systems need effective early containment measures to “flatten the curve”. In fact, the countries that implemented proactive non-medical countermeasures fared better, a lot better.
Together with other sub-Saharan African countries, Rwanda ranked on the other end of the GHSI index, in place 117/195. In mid-February, more than one month before their first confirmed cases, Rwanda and Kenya both implemented rigorous airport screenings for all incoming air travelers. At this point in time, the U.S. continued to practice business as usual for several weeks. In the past weeks, Rwanda, a country of 12 million people (for reference, New York city’s population is 8.4 million), has implemented a contact tracing system and managed to keep the number of new cases at a stable level, with an average of 5.2 cases per day between March 23 and April 10 and 3.5 cases per day from April 10 to April 17, and zero deaths. Distribution of essential goods has been put in place for citizens who are unable to buy food or sanitary products due to lost income during the lock-down. On April 12th, the Rwanda National Police announced that they would commence the use of drones to deliver information on COVID-19 prevention to rural communities. These examples suggest that early implementation of comprehensive prevention strategies is most effective in minimizing the number of deaths from COVID-19. The Rwanda response may be explained by the recent experience with epidemic preparedness during the ongoing Ebola outbreaks in the Democratic Republic of Congo. The knowledge that the health system would not be capable of handling thousands of COVID-19 cases at the same time, may also have caused the country to take such strong preventative action in the hope of mitigating an epidemic surge.
The equation does not read as easily as a high rank in the GHSI equals a strong pandemic response. The COVID-19 pandemic is an occasion to reevaluate pandemic preparedness and recalibrate the concept of a “strong health system” and how we measure it. To be clear, we emphatically support health system strengthening in every country, especially in low- and middle-income countries. But that is just one block in the defense against pandemics. Countries like the U.S., U.K., Italy, and Spain, can learn from countries like Rwanda in how to effectively execute the implementation of non-medical countermeasures in scale and timing. As countries endeavor to strengthen pandemic readiness in the aftermath of the COVID-19 pandemic, we need to develop a readiness framework that incorporates the painful lessons from the current pandemic. If a pandemic strikes again, we can’t afford to repeat our mistakes.
Lotta Velin is a Research Associate at the Program in Global Surgery and Social Change at Harvard Medical School and a medical student at Lund University in Sweden. Follow her on Twitter @velinlotta
Jean W. Lartigue
Jean Wilguens Lartigue is a research associate at the Program in Global Surgery and Social Change at Harvard Medical School and a medical student at Faculté de Médecine et de Pharmacie de l’Université d’État d’Haïti. Follow him on Twitter @jwlartigue
Kee B. Park
Kee. B. Park, MD, MPH is a Lecturer on Global Health and Social Medicine and Senior Faculty at the Program in Global Surgery and Social Change at Harvard Medical School. Follow him on Twitter @keepark