In October 2019, in those halcyon pre-Covid-19 days, a chart was published that ranked 195 countries according to their capacity to deal with outbreaks of infectious disease. Drawn up by the Washington DC-based Nuclear Threat Initiative and the Johns Hopkins Center for Health Security in Baltimore, Maryland, the 2019 Global Health Security Index (GHSI) placed the US and UK first and second, respectively. South Korea came ninth, New Zealand 35th and China 51st, while a number of African countries brought up the rear.
Well, that was droll. Either the authors of the chart got their colour key inside out or our definition of health security needs an overhaul – and given all the fancy data visualisation software available these days it’s unlikely to be the former. Of course, the pandemic is not over. But back in March, when the index was already looking about as accurate as a 2016 US election poll, Johns Hopkins health policy analyst Sarah Dalglish wrote in the Lancet: “The pandemic has given the lie to the notion that expertise is concentrated in, or at least best channelled by, legacy powers and historically rich states.” And she hasn’t changed her view.
Many factors contribute to good epidemic management, but perhaps what the sorry fate of the GHSI teaches us is that while many of them are measurable – disease surveillance arrangements, emergency response plans, intensive care unit capacity – some are more ephemeral, or hard to discern until the chips are down. And yet good leadership, public trust in government and experts, and a sense of solidarity also powerfully shape a population’s vulnerability to infectious disease.
You may also need a dose of luck, such that all these things align in the moment, but that’s no reason to stint on praise for the countries that have come through well. Each one took different weapons into the fight: Vietnam is relatively poor but learned lessons from the 2003 epidemic of Sars (severe acute respiratory syndrome) and now has a world-beating epidemiological workforce; Senegal is even poorer but, remembering Ebola in 2014, used travel restrictions and testing well; New Zealand was untouched by both Ebola and Sars (apart from a single probable case of the latter) but had the competent and charismatic Jacinda Ardern in charge.
One thing the leaders of all these countries have in common is that they know an outbreak can grow exponentially, and that their best hope of containing Covid-19 was therefore to act fast and in a coordinated, data-driven manner. In a sense, each government sacrificed its population’s present for its future, but only because it understood that the sooner the sacrifice was made, the smaller it would be. They spared themselves agonising dilemmas down the line, such as whether to let the elderly residents of care homes die of Covid-19 or loneliness, or what to do about the generation of young adults facing mass unemployment. The ones that did best knew that offering support to those hit hardest by the containment measures would require a much smaller investment than would be required to stimulate recovery if they didn’t put those measures in place.
In contrast, the wealthy countries that topped the GHSI sacrificed their future for their present, arguing as US president Donald Trump did that the cure must not be worse than the disease, or in UK prime minister Boris Johnson’s immortal phrase, that “Our country is a freedom-loving country” – to which the only possible response is this line from Albert Camus’ The Plague: “They fancied themselves free, and no one will ever be free so long as there are pestilences.”
Thinking back now on how these leaders failed, when according to a colourful chart they had so much going for them, it’s hard not to be reminded of the marshmallow experiment. If you aren’t familiar with this classic test of a child’s ability to delay gratification, watch this YouTube video posted by the Canadian newspaper the Globe and Mail. Four preschoolers do their best not to scoff a marshmallow left alone with them for 15 minutes, because they’ve been promised two if they pull it off. The marshmallows look pretty soggy and dog-eared by the end, but they survive the encounter and the children get their reward. Encouraged by their leaders, the US and UK chose instant gratification instead, and will now pay the price.
Luckily, societies have built-in counterweights to such present bias – ways of investing in the future that they call research and education. Though both have suffered this year, the fact that they have a long investment horizon means that previous generations’ efforts have tided us over. Hence a pandemic that for 11 long months has felt ancient, because our only shield against it was the age-old one of social distancing, suddenly slipped through a wormhole and became postmodern. The Covid-19 vaccines that have recently been approved mark a technological watershed – one from which the world is unlikely to look back.
Those vaccines offer us the possibility of herd immunity and a return to something approaching normality – but only if enough people take them. Unless governments make them compulsory for some or all of the population – which hopefully won’t be necessary – this will be an individual decision, which means our collective future lies in every individual’s hands. Getting in line for a dose seems like a no-brainer, given that our regulators have deemed the vaccines to be safe and effective, and not only our future but potentially that of the next generation is riding on them.
Once the pandemic has receded, there will be lessons to digest and implement. One of them is that experts should be treated once again with the respect they deserve. They are, after all, the dividend of our investment in research and education – our guides to the future. They should be allowed to disagree, to say they don’t know, to fail, as all human beings occasionally do. But we should keep them on their toes too, and point out their blindspots, because it’s not really droll that more than 300,000 Americans have died of Covid-19 to date, or that the UK has had the sixth highest number of deaths in the world at the time of writing. It’s a tragedy of dimensions that would have been literally inconceivable a little over a year ago, when the GHSI was published.
Key to preventing any recurrence is understanding why that coloured chart got it so wrong, because hindsight is all very well but it should at least sing for its supper. As Dalglish pointed out, 85% of global health organisations are headquartered in Europe or North America, and half of all global health leaders are UK or US nationals. The community of experts that seeks to protect us from future pandemics needs to open up to Vietnam, Senegal, China, New Zealand and all the other countries that learned from their diverse past experiences, and learned well – in many cases, with fewer resources. It may seem like another no-brainer, but global health should be truly global.