Month: July 2021

In the wake of the Covid-19 pandemic, everybody now knows that:

• Warnings about pandemic disease had been touted for decades
• Myriad organisations had called for increased health security funding
• The world ignored all these warnings
• SARS-CoV-2 emerged in 2019 with dire consequences

The fact that all these warnings were known, yet action was scant, remains difficult to comprehend. Although somewhat perversely, we even knew we would ignore the warnings. Psychological research has shown that these kinds of rare but devastating events are exactly the ones humans tend to overlook. As if to drive this point home, I noted in the news today that a resident of Westport (a New Zealand town flooded by a ‘1 in 100 year event’) even stated that he knew the area had flooded, but thought “the last one was it”.

The ‘unforeseen’ Covid-19 surprise

International organisations such as the UN, WHO, World Bank, and organisations such as the US National Academy of Sciences had made explicit warnings to governments across many years about pandemic and emerging infectious disease risk.

The human and economic impact of pandemic disease had been detailed, and estimated at half a trillion dollars per year (Fan 2017). The measures the world needed to take to detect, prevent and respond to infectious disease had been widely circulated and all the States Parties to the International Health Regulations had committed to implementing them (few contributed substantial resources and few had succeeded by the time Covid-19 struck).

No country was adequately prepared for Covid-19 (Dalglish 2021). The risk of coronaviruses had not been appropriately understood by governments, and many pandemic action plans (New Zealand’s included) focused solely on influenza.

A coronavirus pandemic simply wasn’t foreseen many would cry. We were struck by a black swan.

Covid-19 was no black swan

Black swans, are outlier events that comes as a surprise, have a major effect, and are inappropriately rationalised after the fact (Taleb, 2007).

However, coronavirus pandemics had been identified as a ‘time bomb’ after SARS 2003, and had been specifically workshopped in 2019 at the ‘Event 201’ pandemic exercise. This exercise involved leaders from a number of public and private global organisations contemplating how to deal with a coronavirus pandemic that kills 65 million people.

This table-top exercise took place in New York on 18 October 2019, when plausibly the first cases of Covid-19 were emerging half a world away. Within six weeks a handful of concerning cases were being discussed with alarm by experts on the ProMED bulletin board.

None of this fits the ‘surprise’ aspect of a black swan.

In the face of Covid-19 New Zealand lacked public health infrastructure (Baker, Wilson, & Woodward, 2017), lacked surge capacity (Skegg, 2021), and decision-makers had not previously contemplated the most effective measures ultimately deployed. These turned out to be border closure and comprehensive managed isolation.

In fact, as far back as 2017 two New Zealand academics (the author included) had started modelling the threshold criteria for when border closure for pandemics might be economically rational (Boyd 2017, 2018, 2019, 2020). We approached individuals at the Ministry of Health with a research proposal only to be told that border closure in a pandemic would never be a policy option and as such no funding could be provided to explore the policy in more detail.

Had these ‘left field’ organisms (coronaviruses!) and mitigation approaches (border closure) been pre-contemplated, then ‘off the shelf’ solutions, or at least solution outlines, might have been available at the time the pandemic struck. Appropriate border policies enacted in time might have prevented the mind-bogglingly expensive lockdowns New Zealand endured, and appropriate MIQ protocols might have prevented the second Auckland lock-down.

Historical myopia slowed New Zealand’s border control action leading to a troubled and porous approach amid inadequate legislation and the deficient public health infrastructure (Skegg, 2021).

Shortcomings were not unique to New Zealand and structural and textual failures in guiding regulations and processes at the international level, namely the International Health Regulations, and the World Health Organization generally, had been criticised, and continue to be criticised (Boyd & Wilson, 2021).

We knew the threat and we knew there would be a striking lack of global coordination. Covid-19, and its global ramifications, was no surprise, and therefore no black swan.

The black elephant

Indeed, the Covid-19 pandemic was a paradigmatic black elephant, a catastrophe that was extremely likely and widely predicted by experts, but ignored or simply unspoken (Asayama 2021).

Gupta describes a black elephant as:

‘an event which is extremely likely and widely predicted by experts, but people attempt to pass it off as a Black Swan when it finally happens. Usually the experts who had predicted the event – from the economic crisis to pandemic flu—go from being marginalized to being lionized when the problem finally rears its head’ (Gupta, 2009).

Knowledge about human cognitive biases explains why we ignore these kinds of risks (Gluckman 2021).

Overall, and painfully, not only was the threat of Covid-19 known, but we also knew that we would ignore it. There existed a myopic focus on day-to-day health needs, health policy that considers only the health sector, a reactive, response-focused approach, and lack of attention to future welfare. In general, a reluctance to address catastrophic risks, yet these kinds of risks harbour almost all the harm.

Escaping black elephants

By definition, information about black elephants is widely understood. To properly prepare for them governments must look both outwardly and inwardly.

Governments must engage experts not just policy wonks

Looking outward, we need to see crowd-sourced solutions, the power of superforecasters must be harnessed, and governments need to enlist assistance engaging in problem-finding, rather than mere problem-solving activities. These tasks will require close engagement with:

• experts in academia
• industry leaders & technical experts
• non-government sectors
• creative sectors

Although sensible plans might already be in place, there is always the possibility (or in the case of coronaviruses, probability) that reality will fall beyond the scope of established plans. Red-teaming approaches are needed, experts should be engaged to try to break existing plans. This requires openness and cooperation.

A percentage of preparatory investment should go to diversifying approaches to outlier events, especially when they are inevitable, as is the case with many black elephants. These days a few tens of millions of dollars thrown at understanding these problems, in order to draw the possibility space of mitigation measures, now looks trivial.

Public sector departments must self-critique

Perhaps more important than looking outward is looking inward. Governments must engage in institutional self-reflexivity and this is a process that must be supported from the outside.

Some of the greatest threats are the processes of governance themselves. These processes can become stuck through entrenchment, inertia, historical myopia, status quo, lack of imagination, ignorance, adherence to ‘best-practice’ and corruption by vested interest.

There must be a continual process of self-evaluation and self-critique. In a world of rapidly accelerating technology and human impact, the days of government departments simply justifying post-hoc their pre-formulated plans must end. A radical revision of risk and responsibility is needed, with diverse inputs and ‘crazy ideas’ articulated in detail and held on file for when they are needed.

National and global catastrophic risks must be the purvey of the population not merely the secret notebooks of Cabinet and DPMC spooks.

References

Asayama, S., Emori, S., Sugiyama, M., Kasuga, F., & Watanabe, C. (2021). Are we ignoring a black elephant in the Anthropocene? Climate change and global pandemic as the crisis in health and equality. Sustainability Science, 16(2), 695-701. doi:10.1007/s11625-020-00879-7

Baker, M., Wilson, N., & Woodward, A. (2017). The Havelock North drinking water inquiry: A wake-up call to rebuild public health in New Zealand.  Retrieved from https://blogs.otago.ac.nz/pubhealthexpert/2017/12/20/the-havelock-north-drinking-water-inquiry-a-wake-up-call-to-rebuild-public-health-in-new-zealand/

Boyd, M., & Wilson, N. (2021). Failures with COVID-19 at the international level must not be repeated in an era facing global catastrophic biological risks. Aust N Z J Public Health, Feb 23. doi:doi: 10.1111/1753-6405.13082

Boyd, M., Baker, M. G., & Wilson, N. (2020). Border closure for island nations? Analysis of pandemic and bioweapon-related threats suggests some scenarios warrant drastic action. Aust N Z J Public Health, 44(2), 89–91. doi:10.1111/1753-6405.12991

Boyd, M., & Wilson, N. (2019). The Prioritization of Island Nations as Refuges from Extreme Pandemics. Risk Analysis, 40(2), 227–239. doi:10.1111/risa.13398

Boyd, M., Mansoor, O., Baker, M., & Wilson, N. (2018). Economic evaluation of border closure for a generic severe pandemic threat using New Zealand Treasury methods. Aust NZ J Public Health, 42(5), 444–446.

Boyd, M., Baker, M., Mansoor, O., Kvizhinadze, G., & Wilson, N. (2017). Protecting an island nation from extreme pandemic threats: Proof-of-concept around border closure as an intervention. PLoS ONE, 12(6), e0178732. doi:10.1371/journal.pone.0178732. eCollection 2017.

Dalglish, S. L. (2020). COVID-19 gives the lie to global health expertise. Lancet. doi:10.1016/s0140-6736(20)30739-x

Fan, V. Y., Jamison, D. T., & Summers, L. H. (2017). The Loss from Pandemic Influenza Risk. In D. T. Jamison, H. Gelband, S. Horton, P. Jha, R. Laxminarayan, C. N. Mock, & R. Nugent (Eds.), Disease Control Priorities: Improving Health and Reducing Poverty. Washington DC: The World Bank.

Gluckman, P., & Bardsley, A. (2021). Uncertain but Inevitable: the expert-policy-political nexus and high-impact risks. Retrieved from: https://informedfutures.org/high-impact-risks/

Skegg, D. (2021). The Covid-19 Pandemic: lessons for our future. Policy Quarterly, 17(1), 3–10.

Taleb, N. (2007). The Black Swan: Random House.

G20 report shows global pandemic resilience is within reach, but developed countries like New Zealand need to pay our fair share

The G20 Independent Panel’s report ‘A Global Deal for Our Pandemic Age’ finds that US$15 billion per annum could provide some pandemic resilience through interconnected global measures. Our findings suggest another $31 billion is needed annually to support country-specific measures. However, New Zealand’s contribution would be trivial considering it is yet to contribute the expected 0.7% GDP in overseas development assistance.

The world has long known that health security investment is needed

Prior to the Covid-19 pandemic several international organisations provided estimates of how much the world needed to invest in capability and capacity to prevent, detect and respond to biological threats and attain a minimum level of global health security.

These estimates ranged from the very low ($1.9 billion, the World Bank’s lowest estimate) to reasonably substantial ($100 billion for just 67 low- and middle-income countries, by the World Health Organization). Progress had been made through initiatives such as the Global Health Security Agenda (GHSA), via which the USA provided nearly $1 billion in support to 31 low-income countries.

Health security internationally was known to be poor

However, the countries of the world were still nowhere near attaining a minimum level of health security capability or capacity by the time of Covid-19. This was demonstrated by the average global country score of 40.2/100 on the Global Health Security Index (2019), which identified major persisting health security weaknesses, particularly in the domain of ‘health system’ and also with regard to biosecurity and biosafety.

Health security scores did not predict Covid-19 response

Unexpectedly, the distribution of impact of Covid-19 across countries was not explained by GHSI scores. Countries such as the USA and UK suffered greatly yet exhibited the highest health security scores. Other countries, such as Niue, with low scores, remained Covid-free.

Figure source: Baum et al 2021 (BMJ, 29 Jan)

Health security scores are correlated with fewer deaths from communicable disease

That said, our research found a correlation between the proportion of a country’s population dying from communicable diseases, and the GSHI score. This suggests an association with increased health security scores and the ability to deal with internal disease threats.

Figure source: Boyd et al. 2020 (BMJ Global Health).

Global coordination was lacking prior to Covid-19

However, the world as a whole clearly failed to coordinate with respect to Covid-19. There was a lack of integrated disease surveillance, which might have raised the alarm early, there were equipment shortages globally, coordinating global institutions lacked resources to adequately manage a response, and financing to rapidly deploy countermeasures where they were needed was absent.  

At least $15 billion per annum is needed for inter-country measures against pandemic disease

In the wake of Covid-19 the G20 commissioned an Independent Panel to report on financing needs that would adequately ensure preparation to meet future emerging disease threats. The Panel identified that the missing pieces of the puzzle are not internal measures by individual countries, but rather coordinating measures and global public goods. Notably, these inter-jurisdiction factors are not assessed by health security metrics such as the GHSI that score individual countries, and it is logically possible (and indeed was the case for many countries) that isolated high scores for GHSI mask a complete lack of international integration across countries’ preparedness measures. It is not surprising, with hindsight, that GHSI failed to track Covid response.

In broad strokes, the G20 Report found that the following measures should be financed:

• Global coordination through high-level global governance systems
• Global institutions that have adequate and secured funding fit for purpose
• Global surveillance systems that are interconnected
• Global public goods and financing mechanisms to ensure availability and distribution

The G20 Independent Panel estimates the cost of these measures (and some others) at US$75 billion across five years, or US$15 billion per year. They note that the cost of an event such as Covid-19 is 300-700x this investment. The implication is that the ROI is vast. However, this statistic muddies the picture because the cost of Covid-19 is per event, not per year. If we’re aiming to estimate the cost-effectiveness of an annual investment of $15 billion, we really want to know the annualised cost of (all) biothreats.

Health security investment is associated with increased health security scores and might further reduce death from communicable diseases

In previous research we performed two extrapolations. Firstly, we compared the GHSI scores of countries that had received a share of the United States’ contribution to the GHSA programme. We found that countries receiving this funding scored +6 points higher than matched controls on the 100-point scale. These additional points came at an average cost of US$4.6 million per point. If we aimed to raise all countries to a score of 75/100 this would cost $31 billion and given the relationship between internal communicable disease deaths and GHSI scores (the scatterplot above), this might reduce ordinary communicable disease deaths by 16.7%. Assuming 50% annual ongoing maintenance costs, this programme might cost US$90 billion over five years. We note that this figure is in the same ballpark as the WHO estimates prior to Covid-19.

Global coordination is still needed, and country-specific plus international measures could cost US$33 billion per annum

However, what we’ve learned from Covid-19, and I discussed above, is that the missing piece of the puzzle appears to be global coordinating mechanisms and systems for providing global public goods that can be deployed anywhere and everywhere they are needed, rather than leaving it up to each country to ensure self-contained preparations. This is where the G20’s estimate of a further $75 billion comes in. This requirement must be added to the costs of bringing each country’s internal preparations up to a minimum standard. The total cost might therefore be US$75 billion PLUS US$90 billion, which is US$165 billion over five years, or $33 billion per year.

The return on these investments in health security is likely very good

We can calculate the return on these investments as follows. Our research estimates the annualised cost of all biothreats (including pandemic influenza, SARS, MERS, Zika, Ebola) at US$622 billion. This is excluding Covid-19, which is estimated to cost tens of trillions of dollars, but the inter-covid interval is not clear, so it is hard to annualise the costs across, say a couple of decades. Other estimates have put the costs of biothreats at $1 trillion annually. If we assume even just a 10% reduction in the impact of biothreats due to the measures outlined (eg 1 in 10 pandemics is avoided, or the number of deaths from each is reduced by 10%, thereby saving $62 billion in annual harms) then the ROI is as follows:

(US$62 billion – US$33 billion) / US$33 billion = 88% ROI

If we reduce harms from biothreats by 50% then the ROI is:

(US$311 billion – US$33 billion) / US$33 billion = 842% ROI

The cost of a minimum standard of international health security measures is relatively trivial for developed nations

To put this in perspective, if only the richest billion people on the planet were tasked with paying for this, then New Zealand’s contribution would be $US165 million. Or 0.08% of GDP. Given that the UN recommends that developed nations contribute 0.7% of GDP in development assistance, and given that NZ (in 2019) contributed only 0.28% of GDP, adding this additional contribution is still well within the expectations of New Zealand as a global citizen.

Another way to look at this is at the level of individuals. $33 billion per annum globally is $33 per person for the world’s 1 billion wealthiest people. Health security measures are well within reach for an almost trivial investment.

What New Zealand can do

• Advocate for global Heads of States meetings to agree to action on biothreats.
• Act to commit the recommended 0.7% of aid internationally by at least doubling present ODA investments and add an additional 0.08% for pandemic preparedness measures, thereby supporting the G20 recommendations.
• Enhance our local domestic capabilities and capacities to increase NZ’s and our Pacific neighbours GHSI scores.
• Stop the endemic habit of public sector departments justifying status quo preparations, and instead cultivate a norm of engaging in continual problem and risk finding and solutions. Ask (of MIQ, health system, pandemic preparedness, vaccine programmes, public goods, global agreements) how can we make this better? Rather than constantly saying ‘our measures are in line with global best practice’. It should simply be obvious that ‘current best practice’ was inadequate.
• Appropriately incorporate biothreat risk into our National Risk Register and publicly communicate the risks and problems to seek additional innovative crowd-sourced solutions.  

A minimum level of health security is well within reach globally and developed nations must rapidly finance the measures required. The next pandemic could begin at any time.