The editorial in the LANCET Journal, July 2020, provides the paradox of why it may not be feasible to return to “normal” after COVID-19. It reminds us that globally, before the pandemic, 734 million people lived in extreme poverty, 690 million people went hungry, 79·5 million people were forcibly displaced and billions of people, were not working. These trends are generally reflected in various regions as we illustrated in last week's blog, in the case for the Caribbean. Yet some advocates tell us that before COVID 19, the world has never been in a better state. So why shouldn’t we want to return to normal, even if we could. The sanguine explanation in the Lancet editorial is: “While COVID-19 is a human catastrophe, …it gives the health community an opportunity to rethink the purpose of society in a fractured world and to redefine what we want normal to mean”. In a nutshell: is the answer- placing emphasis on Health Security?
Why Health Security as a Focus
First, is the need for building a resilient health system with surge capacity, a commitment to quality improvements and effective responses to health emergencies. According to the Lancet editorial “resilient health systems would not plan for an influenza pandemic and then follow that plan when a coronavirus outbreak occurs”.
Second, since pandemics impact economies almost instantaneously, emphasizing the interrelations between planning for health and economic resilience simultaneously is essential. The compounding factors of natural disasters and climate change make it necessary to reorder priorities for both health and economics. And when climate and other natural disasters are added to the mix, Jonathan Alfred writing in the London Guardian (July 20,2020), reflected the opinion by the 2019 Economic Laureates, Abhijit Banerjie and Esther Dufflo, Changing the Culture of Economics, that the focus of orthodox economics on efficiency needs to be reconsidered. The argument is that “pandemics, climate disasters, and financial meltdowns might feel exceptional, but they are not unexpected”.
Third, Health Economics offers the prospects for placing priorities on resilience for coping with the exceptional consequences of a pandemic like coronavirus since its templates force a dual focus on both health and economic. Last week’s blog referred the costing tool of the UWI Health Economics Unit (HEU) with built in formulas for projecting from the available epidemiological data, the trends that go beyond cost-benefits to an examination of the social determinants of health. These determinants, more than quantification, help us to comprehend the basis for coping with inequality and poverty, the pervasive conditions in an uncertain future. Some readers expressed difficulty down loading the HEU Biannual Report (2020) last week. It is reposted here. https://drive.google.com/file/d/1zotei_mcc7vHMPvsqekbk9MiXgZlZLSy/view?usp=sharing
Fourth, mainstream economics has taught us that the only rational way to deal with an uncertain future is to quantify it by assigning a probability to every possibility. At the same time, The WHO Commission on Macroeconomics on Health chaired by Prof Jeffrey Sacks as early as 2000, argued that the traditional yardstick to prevent costs outweighing benefits is the oldest excuse for not taking precautions. The persistent high rates of the COVID pandemic caused by a rush to reopen businesses in the USA, for example, is perhaps the clearest recipe for disaster when the benefits, or the costs of inaction, are vastly undervalued. Now we also see that even with the best expertise in the world, knowledge often falls far short of predicting futures like COVID-19 which was unimaginable.
Fifth, the COVID-19 pandemic has created awareness of resources required by individual small island developing states to improve their capacity to prepare for, and respond to, acute environmental and health emergencies. This has been illustrated by the Global Health Security Index , a standard for measuring the national capacity to prevent, detect, and respond to public health emergencies. It shows that the Caribbean with a score at 32 with averages ranging between 24–38, is lower than the global average of 40·2 and an average among high-income nations of 51·9. How to improve the ranking on the GHS index is a concern. Since 2000, 12 years of tracking climate change, averages in temperatures have been classified above normal, and in 2017 and 2019 hurricanes Irma, Maria, and Dorian devastated national infrastructures across ten Caribbean islands. Three of the 10 countries most affected by extreme weather events over the past 20 years are in the Caribbean (Puerto Rico, Haiti, Dominica).
Some Positive Indications from the Caribbean for Coping with the Future
Major steps have been taken to strengthen health security in the Caribbean. From September 2016 through May 2017 a regional self-assessment adopting the GHSA was conducted in the Caribbean from which a Caribbean Health Security Assessment (CHSA) Roadmap was developed. This has led to reinvigorating the Regional Coordinating Mechanism for Health Security (RCM-HS). An important initiative is that of developing and endorsing the Roadmap into the current iteration of the Caribbean Cooperation in Health (CCH-IV) by focusing on improved communications, coordination and cooperation as a multi-sectoral, and collaborative process.
While The GHSA Roadmap now serves as a central tool for coordinating health policies and programs among countries and regional agencies, the baseline revolves around the international health regulations (IHR) established by WHO in 2005. These regulations represent an agreement between 196 countries to work together for global health security with specific measures at seaports, airports and ground crossings to limit the spread of health risks while keeping unwarranted trade and travel restrictions to a minimum. The Caribbean Public Health Agency (CARPHA) now works more closely with the Caribbean Disaster and Emergency Management Agency (CDEMA) , the Caribbean Community Implementation Agency for Crime and Security (IMPACS) , and others to track passenger movements on cruise liners and flights. This is a key step to coordinated regional prevention and tracking the spread of disease. At the same time , PAHO/WHO plays a valuable role in guidance provision, capacity building, information sharing, and bilateral tracking, while CARPHA coordinates security and health actors and others in the CARICOM system.
In addition he RCM-HS, chaired by CARPHA, is the inclusive platform sharing information between CARICOM and the independent, UK, US, French and Dutch interests to improve response to health threats. Using the Roadmap as tangible evidence of the interconnected nature of health security, the national councils on security and law enforcement are now encouraged to take on more health issues such as vector control, chemical hazards, and surveillance. In addition, the RCM-HS has established standard operating procedures for the harmonized management of illness in tourism establishments and on cruise ships and airlines. It outlines roles and responsibilities under different circumstances.
Conclusion: redefining and reconfiguring 'normal'
The economic impact has been quite severe for the emerging market economies like those the Caribbean which have been buffeted by multiple shocks. The IMF Report ( August 2020) confirms the effects of domestic containment measures on the decline in external demand. Particularly hard hit are tourism-dependent countries in the Caribbean due to a decline in travel. With global trade and oil prices projected to drop by more than 10 percent and 40 percent respectively, the adverse effect on all Caribbean countries and in the case of the oil prices, Guyana and Surname, could be severe.
The COVID-19 pandemic has heightened interest in creating separate institutions dedicated to health security as a way of both addressing the current crisis and preparing for the next outbreak. The Caribbean is in a fortunate position to have established RSM-HS - Chaired by CARPHA . However a critical component for ensuring resilience with the application of health economics requires that the UWI Health Economics Unit must feature prominently the RCM-HS It could help to establish the balance in health and economic resilience. It could make equity, resilience, and sustainability the priorities for our future. It could, in effect, help to redefine and reconfigure what we want ‘normal’ to mean.
Edward and Auriol Greene Directors, GOFAD.