Reckoning with the pandemic’s second-order impacts
The coronavirus pandemic is putting this question to the test, and the experience of the past year suggests that the answer is a qualified no.
Can the international community pay attention to multiple health crises at the same time? The coronavirus pandemic is putting this question to the test, and the experience of the past year suggests that the answer is a qualified no. If that is indeed the case, it means that the world will likely be living with the after-effects of COVID-19 for years to come. At the same time, the pandemic has spurred some changes in the world of public health that may create additional chances for improving access to health care in the long term.
COVID-19 itself has already had devastating consequences for the global community. In a little more than a year, this previously unknown disease has infected more than 140 million people in every country in the world. (The North Korean government claims that it has had no cases of the disease, but few give that assertion any credence.) It has killed more than 3 million people, caused widespread economic devastation, and stressed health care systems to their limits around the world.
These are only the direct effects of the pandemic. An outbreak of this magnitude also prompts leaders to make far-reaching policy decisions that have significant first-order impacts—the immediate consequences of their actions—as well as second-order impacts, which are the consequences of those consequences. Second-order impacts often play out in both positive and negative ways that are difficult to anticipate, and their outcomes can linger unexpectedly.
Take a policy like the universal basic income, or UBI, variations of which have been proposed, debated, and piloted in dozens of countries. The first-order effect of a UBI is that everyone receives a guaranteed amount of money from the government. Will that guaranteed income then alleviate poverty and distribute wealth more evenly across society? Or will it exacerbate poverty and deprive people of the motivation to seek employment? These are second-order effects, and they are harder to predict—but that does not make them any less real.
In the global health realm, we are starting to see the second-order effects of COVID-19, and many of them are cause for concern.
Losing progress in other areas: The COVID-19 crisis has shown that health care systems around the world have limited capacity to simultaneously address multiple issues, meaning that ongoing health problems or diseases that lack the same public awareness as COVID-19 are being deprioritized. This often means backsliding on the progress that has been made in recent years.
Consider the world’s ongoing efforts to decrease the prevalence of malaria. In 2000, there were 238 million cases of this life-threatening disease around the world. Fifteen years later, that number was down to 218 million cases. Since then, however, the number of Malaria cases has increased. While this problem predates the emergence of COVID, the pandemic has pushed malaria further down on the list of global priorities. The World Health Organization warns that 2020 is likely to be the first year in decades with an increase in malaria deaths, and it blames this on disruptions in medical supply chains and decreased access to health services due to COVID—even in regions like sub-Saharan Africa, where the number of malaria deaths far outstrips the number of COVID deaths.
Such a reversal is problematic on at least two levels. On one level, the increases in mortality and morbidity pose immediate problems due to the loss of life, increased medical costs, and societal disruptions. On a second level, though, this represents the reversal of positive momentum that will take a long time to recover. It took 15 years to bring the number of malaria cases down by 8.4 percent, but that progress is being wiped out. This puts the international community even further behind its targets, and it will take years just to get back to 2015 levels.
There is one bright spot, though. Thanks to increased mask-wearing, social distancing measures, and increased vigilance about handwashing, the number of cases of the common cold and influenza are down dramatically. This decrease may provide scientists with an opportunity to learn more about both these illnesses and develop new strategies to better combat them.
The international community needs to seize this moment to make meaningful, appropriate and beneficial reforms to the global health governance system.
Funding: COVID-19 is putting a financial squeeze on national health budgets. Even if governments are able to maintain their current health spending in the midst of an economic crisis, the increased needs associated with COVID mean that even a stable budget can’t keep up. This will make low- and middle-income countries even more reliant on development assistance to meet their health needs, but the Center for Global Development warned last year that the amount and destination of any such funds are “increasingly uncertain,” making it difficult for recipient states to make plans. In addition, if those COVID funds are coming due to a reallocation of existing global health funds for diseases like malaria and tuberculosis, the shift will thwart progress in other areas of global health.
Such shifts in resources could also hamper longer-term efforts to address COVID. A recent report from the OECD warns that budgetary reallocations could make it harder to implement multisectoral strategies to address the direct health effects of COVID, as well as the social issues that increase vulnerability to the disease in the first place. This same report also raises concerns that, while many donor states have pledged to maintain stable levels of official development assistance, it is unclear whether they can live up to these pledges in light of the pandemic’s economic effects.
Effects on Chronic Diseases: The novel coronavirus spreads person-to-person due to aerosol droplets expelled when an infected person coughs or sneezes. While infectious diseases like COVID-19 receive the bulk of attention and resources within the global community, the more dangerous and costly maladies are actually chronic and noncommunicable ones, like cancer, stroke, diabetes, and heart disease. These require long-term care and management.
COVID-19 interrupted to care for non-communicable diseases in many ways. In some instances, health care clinics closed to non-emergency appointments, meaning that those trying to manage chronic conditions lost out on access to their care regimens. In other instances, patients expressed reluctance to go to a medical facility out of an abundance of caution to decrease their likelihood of contracting COVID-19, even though doing so increased the chances of complications or more serious illness later.
The combination of rising COVID-19 infections and increased rates of chronic diseases threaten recent progress in improving life expectancy. In addition, chronic diseases can make a person more vulnerable to the coronavirus. All of this combines to create a “perfect storm” that will undermine global health and reverse hard-fought gains. We have been here before: The Ebola outbreak in West Africa, from 2014 to 2016, led to an increase in maternal mortality and morbidity, reversing the preceding years’ progress. The problem was not that pregnant women were contracting and dying of Ebola; rather, they had less access to health services that could have identified and prevented problems.
Increased Use of Telemedicine: One potentially positive second-order effect of the COVID-19 pandemic is the increased use and accessibility of telemedicine, in which patients and providers can meet in real-time through audio or video means to treat, diagnose and provide care even when they are not physically in the same location. This has allowed for continuing access to medical care when health care services were not open for drop-in services or patients did not feel comfortable traveling to a clinic. One study found that 30 percent of all medical appointments in the United States during the pandemic have occurred via telemedicine. Even after the pandemic ends, telemedicine services could provide an opportunity for expanding access to health care services—particularly for conditions and issues requiring specialized care that may not be readily available in a person’s home community.
While this could provide expanded access for some, there remains wide variation within individual countries and globally around the availability of the technological infrastructure necessary to make telemedicine broadly accessible. There is evidence that mobile applications can provide patients with care and information effectively, but there need to be greater investment from state, international and corporate actors to expand their reach.
Opportunities for Reform? On a global level, the COVID-19 pandemic has shone a bright light on the successes and failures of the existing system of global health governance. There has been far too little investment in pandemic preparedness, too little international cooperation, and too few resources to effectively combat an outbreak of this scale. Despite these obvious shortcomings, it is also unmistakably true that the global community will need to work together more coherently to stop this pandemic and lessen the effects of future outbreaks.
The international community needs to seize this moment to make meaningful, appropriate, and beneficial reforms to the global health governance system. The shortcomings are painfully clear, as is the need for a better system. We can bemoan the weakness of the World Health Organization, but it is the WHO’s 194 member states that have the power to make it more robust and responsive to transnational health concerns.
If ever there were a moment when widespread global health reforms might be possible, it is this one, when the entire world is paying attention to public health. While the evidence thus far suggests that the international system has a limited capacity to deal with multiple global health issues simultaneously, the pandemic may provide a catalyst for improving the system going forward.