By RICHARD SKOLNIK
Los Alamos

(Based on remarks given to the Honors Program of the Erasmus Medical College, Rotterdam, The Netherlands)

Global Health Challenges in the Age of COVID

The Key Issues

The present pandemic is the quintessential global health problem. Yet, it is not the only global health challenge that we face. I comment below both on the pandemic and on other critical issues in global health.

Getting COVID under Control

“The health of anyone, anywhere, is the health of everyone, everywhere”. COVID highlights the importance of this, since no country can be safe, as long as the virus is circulating anywhere else.

In addition, only by controlling the virus can we stop social, economic, and educational hemorrhaging. Thus, the first challenge is getting COVID under control – everywhere

Some countries, such as New Zealand, South Korea, and Taiwan, will, hopefully, continue to suppress the virus, especially with the help of vaccines. In most countries, however, the only hope for reducing infections is very fast and very widespread vaccination.  

Some of the challenges to achieving this will include:

• Population fatigue of public health measures
• New more transmissible variants of the virus
• Variants that make the virus less susceptible to the existing vaccines
• Problems of manufacturing, storing, and distributing vaccines
• Vaccine hesitancy
• The inability to vaccinate young children
• The difficulties of addressing the virus in low- and middle-income countries (LMICs)

Overcoming COVID-induced Losses

Another challenge will be dealing with the indirect losses caused by COVID. This will be true everywhere but may be especially true in low- and middle-income countries. The indirect costs of COVID include, among others:

• Dead healthcare personnel
• Hospitals in deficit and attendant closings, staff losses, etc.
• Postponed patient visits
• Mental health
• Oral health
• Lack of future financing for health

Mental Health

The substantial mental health costs associated with COVID are likely to be around for a long time. These relate to losses of loved ones; job and income losses; being isolated; school closings; and, kids not being able to be kids. There are very few countries that can handle mental health issues under the best of circumstances. What will happen now?

Preparing for the Next Pandemic

Just before this pandemic broke out, two reports came out that suggested that countries and the global cooperative were NOT prepared to deal with a pandemic. How true this turned out to be. Even with all that has happened, it is not clear that ether individual countries or the world as a whole is ready for the next pandemic. Yet, it could be around the corner. 

Happily, the measures taken to address this pandemic appear to have dramatically reduced the spread of seasonal influenza. Yet, there is every likelihood that a novel influenza virus, among other viruses, will appear that can wreak the same kind of havoc on the world as this coronavirus. Countries have always gone from complacency to panic over the emergence of a disease. Can we do better in the future?

Anti-Microbial Resistance (AMR)

Anti-microbial resistance is an enormous and continuing threat. A few, mostly European countries, have improved the stewardship of their antibiotics. Yet, other countries have done little on this matter. The health and economic consequences of AMR are staggering. Yet, few governments and firms are investing what is needed to fight resistant strains of bacteria. You should especially worry about the lack antibiotics to fight some forms of infection and how long we will continue to have drugs that work against malaria. If you watch the Frontline documentary on this, you won’t sleep for quite some time afterwards.

Inequality

Concern for inequality is central to global health. Some of this is across countries. Women in low-income countries have a risk of dying in childbirth that is more than 40 times that of a woman in high-income countries. A child in a low-income country has a risk of dying in her first year of life that is about 12 times that of a child in high-income countries.

There are also enormous inequalities within countries. We have cities in the US in which there is a 15-year gap in life expectancy between well-off white men and poor African-American men. Rich women in Karachi don’t die in childbirth. Poor women in the rural areas do.

COVID has highlighted inequality in major ways. Minority groups in the US, for example, have rates of infection and death that are multiples of the rates for white Americans. Those who can work from home have rates of infection and death much lower than those working with others.

Enhancing health is central to reducing inequality. However, enhancing health will require a health-in-all focus by governments, that is multi-sectoral and addresses, as fast as possible, the underlying social determinants of health.

Climate Change

Climate change might produce some “winners”. Our friends in Canada, for example, might be able in the future to grow summer vegetables for many months. However, climate change will also produce losers. I don’t know what will happen to Bangladesh if the sea level rises. In addition, we can easily imagine places in which there will be more insect borne disease and enteric infections, related to more rain, warmer temperatures, and continuing poor sanitation.

Even as we battle a range of other global health issues, we need to continue to fight this one. Failure to do so will put continuing stresses on a range of communities globally.

Enhancing International Cooperation

As COVID has highlighted, there are a range of global health issues that require global cooperation. These include, among other things; the development of diagnostics, vaccines, and drugs; disease surveillance; pandemic response; the development of standards and protocols based on the best available global evidence; and the financing of efforts in countries which lack the resources to finance themselves what is needed.

Such cooperation has produced some exceptional health gains for the world, from smallpox eradication to the near eradication of polio, to dramatic reductions in other vaccine preventable diseases in children worldwide.

Yet, global cooperation has often worked imperfectly, as manifest by delays in the world’s learning about SARS and similar delays in the world’s understanding of this coronavirus. Delays in launching global efforts on Ebola in West Africa and with this coronavirus have also been hurtful. To make matters worse, the US in the last four years has attacked a number of global health efforts and many countries have opted for vaccine nationalism over global cooperation.

Overcoming these constraints to cooperation will take many years and good will on the part of many countries. It will also have to overcome the structural constraints to the work of the World Health Organization (WHO). These are largely its lack of power, its difficulty in dealing with sovereignty, and its inadequate budget, much of which is tied up in specific funds.

Editor’s note: Richard Skolnik is the former regional director for health for South Asia at the World Bank. He was the director of an AIDS treatment program for Harvard and taught Global Health at the George Washington University and Yale. He is the author of Global Health 101 and the instructor for Yale/Coursera’s Essentials of Global Health.