A new pandemic is inevitable but here's what we can do

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As Covid transitions from pandemic to endemic, the world must strengthen preparedness. It's inevitable that another disease – potentially even worse than Covid – will spread across the globe. Just how bad it will get depends largely on what we do today to better prevent, detect and respond to infectious disease threats. We must make progress in three areas: public health infrastructure, primary health care, and resilient individuals and communities.

First, we must strengthen our public health infrastructure. There must be sufficient and consistent funding, including at local levels, which are so often neglected despite their position on the front line. At least $5-10 billion a year of new funding will be required for at least a decade to substantially increase preparedness in low and middle-income countries.

In addition to increased financial support, the world’s public health infrastructure needs continuous improvement. The World Health Organisation is the anchor of our global health architecture and essential for data, guidance, global collaboration and country support – but it needs stronger authority and capacity as well as a larger, more flexible budget.

Regional and national public health agencies, such as the Africa Centres for Disease Control and Prevention and the Middle Eastern regional CDC currently being developed after approval by the Gulf Co-operation Council in January 2021, can contribute to more effective public health action but have important limitations. However, as we learned during the pandemic, no public health agency can succeed if the government doesn’t follow its guidance. Getting the balance right in public health organisations means making technically sound recommendations based on the best available data with clear and open communication, and effectively engaging societal leaders who can make policy decisions.

Two deadly cycles have plagued preparedness. The first is the panic-and-neglect cycle. Even now, the millions of global deaths from Covid seem to be quickly receding in the rear-view mirror, with lessons not being learned and opportunities for improvement lost. The second is a cycle of planning and more planning without action to improve systems and processes for preparedness. The first cycle can only be broken by political leadership.

To help break the second cycle, we have proposed, and many countries and organisations are adopting, a new global target of 7-1-7: every suspected outbreak identified within seven days of emergence, reported to the public health authorities within one day, and an effective response established – as defined by objective benchmarks – within seven days. Every potential or actual outbreak becomes a means of quickly improving performance. This “find-a-problem, fix-a-problem” approach enables rapid improvement and is a way to prioritise more complex issues for longer-term progress.

It will be especially important to reduce the risks posed by the interconnections among people, animals and the environment. Middle East respiratory syndrome, or Mers, remains a threat, antimicrobial resistance could make our life-saving medications ineffectual, and the risk of spillover events – which account for three fourths of emerging infectious diseases in recent decades – is increasing as humans encroach on forest areas and come into contact with wild animals, whether in wet markets or otherwise.

Second, we must improve primary healthcare systems – often defined as the first point of within the health system, providing comprehensive, accessible, community-based care that meets most health needs throughout a person's life. One of the most important lessons from the Covid pandemic is that primary health care should be central to healthcare systems. And yet, nearly half a century after 134 national government members of the WHO called for strong primary health care by signing the Alma Ata Declaration in what is now Kazakhstan, progress has been too little, too late and in too few places.

Most disease outbreaks that are stopped early are diagnosed by alert clinicians with strong connections to their local public health system. These are doctors who knew to suspect an unusual disease, arrange for testing and promptly report to the public health authorities. Epidemic-ready primary health care bridges the gap between clinical care and public health. In countries from the US to the UK to Uganda, primary healthcare workers need to be paid better.

Resilient health facilities can maintain core services, including preventive care, during pandemics, extreme weather, social unrest and other societal disruptions while also ensuring health worker and patient safety with effective infection prevention and control. Healthcare safety also means protecting healthcare workers from violence and the threat of violence. Tragically, the trend has been for healthcare facilities to increasingly become a target of rather than sanctuary from violence.

It is not a coincidence that primary health care is weak in most countries. Hospital and specialty care create aligned economic, political and social interests – even though this care isn’t the most effective or efficient way to protect and improve health. Learning from countries such as Norway, Thailand and Costa Rica, that invest in strong primary healthcare, we can transform systems and increase the health return on health spending.

The global epidemic of obesity, and, as a result, type 2 diabetes, is particularly severe in the Middle East. Primary health care has an essential role to play preventing the strokes, heart attacks and kidney failure for which people with diabetes are at particularly high risk. What is often not understood is that diabetes, though diagnosed because of high blood-sugar levels, isn’t a sugar disease but rather a systemic metabolic disease. For a person with diabetes, controlling their blood pressure will protect their health the most and taking a statin will be the easiest way to prevent health problems. Management of blood glucose, though very important – and life-saving in insulin-dependent diabetes, which accounts for about 5-10 per cent of all cases – will be the most difficult to achieve and result in less health benefit than controlling blood pressure and cholesterol.

Hypertension is the leading preventable risk factor for heart attacks and strokes worldwide, killing more people than any other condition – more than all infectious diseases combined and more than Covid at its peak. Only about 1 in 7 people with hypertension have controlled blood pressure globally, and only about one in 5 in many countries in the Middle East region, despite this being the single most effective clinical means of preventing the leading cause of death: cardiovascular disease. High-performing health systems can achieve blood pressure control rates of 80-90 per cent among all patients with diabetes on their panel. Effective hypertension management programmes both require and facilitate strong primary healthcare services.

Third, we must promote resilience so that individuals and communities can get and stay healthier and be better able to withstand health threats of all types. One reason Covid has been so deadly is that so many people were vulnerable because of their health status. More resilient individuals and communities are better able to withstand health threats of all types.

Although people make choices that can result in either good health or illness, many of these choices are largely determined by societal incentives and structures. Resilience is strengthened when environments are structured to make healthy behaviours the default choice and when communities are empowered to better understand and take control of their own health.

Tobacco control is one of the most successful, least recognised, yet still unfinished successes of public health. It is a good example of how effective societal action – through tobacco taxation, smoke-free public places, hard-hitting ads, and effective warnings and limitations on advertising, promotion and sponsorship – can make a huge difference. Tens of millions of people will not die early from cancer, heart disease, lung disease and other tobacco-related causes because governments have taken effective action. But much more needs to be done.

Programmes to prevent heart disease and stroke – the world’s leading killer – have a long way to go in most countries. Of all funds for development assistance in health, less than 1 per cent goes to stop cardiovascular disease even though it is readily preventable and causes more harm than any other health problem.

Many countries in the Gulf region are in a position to make bold investments that can change the course of history. Supporting public health infrastructure, making primary health care central to their own health systems and supporting focused action to do so in lower-income countries, and supporting better hypertension treatment globally can protect the health of hundreds of millions of people. The world is waiting for a country to spearhead national, regional and global efforts to curb the world’s leading killer: cardiovascular disease.

To prevent the next pandemic, faster and more effective public health action is needed, with real-time surveillance, better communication and community engagement, co-ordination and rapid response capacity. Improved primary health care can address symptomatic conditions and also the leading drivers of disability and death. Environments can be structured to make healthy options the default choices. The need, tools and effective models exist in all three areas. The world needs catalytic investment and governmental commitment to take action that can save lives today and in the future.