Public health: Fail to prepare, prepare to fail

In January this year, world leaders met in Davos at the World Economic Forum (WEF) to discuss the next pandemic – Disease X. An ominous placeholder name for what could be the future. 

As we mark the fourth anniversary of the first Covid lockdown, the question for the likes of Mark Woolhouse, professor of infectious disease epidemiology at the University of Edinburgh and an advisor to the Scottish Government on its Covid pandemic response, is not whether there could there be another pandemic in the next few decades, but that another one is “inevitable”. 

“Most of us will experience another pandemic in our lifetime,” he tells Holyrood. 

Instead, the question to ask is what type of illness will present, how will it be spread, and most importantly, is Scotland ready to respond to an unknown pandemic that’s probability is near-inescapable? 

Our recent pandemic timeline supports what Woolhouse says. Not including the Covid pandemic, there have been three pandemics since the turn of the millennium; swine flu, Ebola, and severe acute respiratory syndrome (Sars). Ultimately, pandemics are relatively common in an average lifespan. 

While the mortal and social impacts of the aforementioned pandemics this millennium were not felt in the same way as Covid was in Scotland, pandemics have killed millions of people in the last century. The UK’s National Risk Register 2023 places the likelihood of a future pandemic between five and 25 per cent – one level below the highest grade of likelihood. More concerningly, the register places a pandemic in the most severe category for impact. It classes it as “catastrophic” and is the most likely risk facing the country that carries the highest grade of severity.   

The register paints a reasonable worst-case scenario where an unmitigated respiratory pandemic with an unassumed transmission route would see four per cent of symptomatic infections requiring hospital care and a 2.5 per cent fatality rate. The UK would remain in a state of emergency for at least nine months, with response mechanisms likely required beyond that length of time. 

It assumes that 50 per cent of the UK’s population would fall ill, with 1.3 million people estimated to need hospital treatment and 840,000 deaths.  

As of March 2024, Covid has been listed on more than 232,000 death certificates in the UK – over three times less than the reasonable worst-case scenario suggested by the National Risk Register.  

Therefore, it seems pertinent that Scotland learns the lessons of the pandemic or risk a deepening public health crisis.   

One area to address is the allocation of health spending. Michel Demaré, chair of AstraZeneca, warned the WEF panel in January that many countries are not spending enough money on preparing their health systems for the next pandemic – noting that OECD countries spend on average only three per cent of their health systems’ budgets on prevention. 

“If you spend so little on prevention, you end up spending the majority of your budget on hospitalisation and only treatments,” Demaré said. 

The main lesson, Woolhouse argues, is improving the ability to respond quickly in the early months of a new pandemic. He says, “first we floundered, then we panicked” and the result of the panic – lockdown – was “a failure of public health response”. 

The Independent Panel for Pandemic Preparedness and Response (IPPPR), a body established by the World Health Organization (WHO) that identifies lessons from Covid and applies them to avert future ones, arrived at a stark conclusion in a report in May 2021 – February 2020, it found, was “a lost month”.  

Woolhouse suggests that the decision to lockdown was a result of the inaction in that lost month: “It is what you do when all the things you ought to have done haven’t worked or haven’t been implemented. I see lockdown as a failure.  

“To give an example of that, the Omicron variant that arose in December 2021 was highly, highly infectious and swept through the whole world. If the first wave of Covid was that variant, the lockdown measures that we put in place [in March 2020] wouldn’t have even come close to working. And what that tells you is you have got to have other plans and interventions available.

You can’t rely on lockdown; it won’t save you every time. 

“And we hadn’t planned to do lockdown, not in Scotland, the UK, any part of the world that I know of that did pandemic preparedness plans in January 2020. None of them even mentioned the idea of lockdown.”

Woolhouse argues we did have solutions, but they were not implemented “vigorously enough” in the early stages. He says he finds it “very strange” that Covid, which wasn’t “all that different” from a flu pandemic and was what had been prepared for in the UK, was suddenly seeing “advisors from all around the world saying we had no choice but to have a lockdown”.    

“That’s why I call it a failure of public health policy.” 

The IPPPR’s report echoes much of Woolhouse’s assertions, suggesting that the failure of most countries to respond during February was a combination of two things. One was that they did not sufficiently appreciate the threat and know how to respond. The second was that in the absence of certainty about how serious the consequences of this new pathogen would be, “wait and see” seemed a less costly and less consequential choice than concerted public health action.  

An example of the ‘wait and see’ approach in Scotland is illustrated by the first meeting of the Scottish Government’s Covid-19 Advisory Group, which advised the chief medical officer, taking place three days after the lockdown began. 

Woolhouse, who was a member of the advisory group, says “everyone is now in agreement” that there must be a mechanism of channelling information advice on the “rapidly changing, early stages of a pandemic”. 

The Scottish Government has now established the Standing Committee on Pandemic Preparedness, chaired by Andrew Morris, chief executive of HDR-UK (the national institute for health data science) and vice-principal of data science at the University of Edinburgh. It seeks to make recommendations that are useful, evidence-based and sustainable, and to focus on the opportunities to improve future performance using recent lessons and new technologies. 

A recommendation Woolhouse has made is the implementation of a similar centre for human diseases like Epic Scotland, an animal health consortium project at the forefront of research on animal disease outbreaks, with a specific focus on their impacts on Scotland’s livestock, and provides risk-based evidence, advice and analysis to policymakers. 

Woolhouse says it will “cost a bit of money” to set up but it “could pay for itself hundreds or thousands of times over” if it helps prevent an economic crash like the one that took place during Covid. 

As Scotland continues to learn the lessons of the recent pandemic, Covid is often blamed for the current severity of some longstanding public health issues, namely life expectancy, obesity, and mental health – all of which have moved in the wrong direction since 2020.  

Gerard McCartney, a professor of wellbeing economy at the University of Glasgow and an honorary consultant in public health, says Covid is not the ultimate answer for why we are seeing such poor public health outcomes.  

Instead, he says the pandemic has added to what has become a “perfect storm” of issues that began more than a decade ago and have compounded into “a physical, mortality, and mental health crisis”.  

“Life expectancy in Scotland had been improving for decades up until about 2012. From then onwards it flatlined and declined from the start of the pandemic and has continued to decline since then, on average.  

“We are now really clear on what has driven that. It was the austerity policies that were brought in from 2010 across the UK and that has been evidenced by a variety of research studies.  

“The important mechanisms have been around cuts to social security benefits and increased conditionality on those benefits – people already in poverty have lost the income that they need to sustain the important goods and services that they need to keep themselves healthy.” 

McCartney adds that further cuts to local government services have removed the parts of the “foundational economy” that kept “the social fabric of society together for decades”, describing the welfare safety nets as having been “cut threadbare”.  

The most recent poverty statistics released by the Scottish Government show that one in five Scots – more than one million people – live in poverty and face health inequality challenges, such as less access to foods with high nutritional value. 

And as life expectancy fell for the third year in a row in Scotland in 2023, McCartney says that it has been falling “for a decade in the poorest 30 or 40 per cent areas”.   

He notes the recent “constrained” budget, warning of “another wave of austerity”, and says “the terrible state we are in” will continue.  

McCartney believes that tackling economic inequalities and reversing austerity is the only route to the post-pandemic public health recovery. He has a long list of things that he believes need to happen, such as investment into public services, communities and housing, regulation of the labour market, increased active transport, and greater funding for local authorities.  

While it seems unlikely to him that the reversal of austerity will happen under the current UK Government or by a potential incumbent Labour government, the Scottish Government is halfway through its five-year plan to get NHS Scotland back on its feet.  

In August 2021, in response to the “profound impact” on the health service, then health secretary Humza Yousaf announced a £1bn Covid recovery plan to “drive the recovery of our NHS, not just to its pre-pandemic level but beyond”.    

But halfway into the five-year plan, the bleak outlook on health continues as the green shoots of recovery aren’t yet sprouting. Progress on key targets, such as cutting down growing waiting lists, and other pledges is unclear. Audit Scotland’s latest review of the NHS states that “a range of the ambitions are absent” from the Scottish Government’s 2023 recovery plan update, and adds others had either no mention of the progress made or improvement was unclear.   

With generally worsening public health in Scotland since 2020, McCartney issues a warning to the government if another pandemic is around the corner. “One of the biggest risks is if a pandemic with a severe infection rate begins circulating, the government may be too reluctant to implement the necessary control measures because they feel so burnt from Covid, and actually what may happen is governments may act too slowly. That can’t happen. 

“But all of the risks will be reduced when you have a strong social infrastructure and a social fabric to support people in times of crisis.”