The pandemic is a hard teacher, but there are two things we can say we know with confidence. Since January 2020, we have had the genetic sequence for the SARS-CoV-2 novel coronavirus mapped out in its entirety. And one year on from its discovery, we know that at least 2 million lives have been cut short by the disease it causes, Covid-19.
Dealing with the pandemic is an unprecedented challenge that would test any administration. Nevertheless, it seems most governments systematically overestimated their ability to manage a complex and rapidly changing situation, and underestimated the breadth of risks posed by a highly infectious disease let loose in a highly globalised world.
With the prospect of mass vaccination now on the horizon it is tempting for policymakers to reassure themselves and each other that the worst is over, and that all we need to do is tread water until the required doses arrive in sufficient quantities.
This mindset is entirely understandable. Everyone is exhausted, our hearts are broken by grief and loss, and we all just want this nightmare to be over.
But it is a mindset we cannot afford to indulge.
It will be months before rich countries are administering vaccine doses in meaningful numbers – months in which the virus will continue to adapt, with an ever-increasing risk of new mutations rendering our current safety protocols, treatments and vaccines ineffective.
And it could be years before there are enough doses for everyone in the world. Vaccine nationalism has already begun to rear its ugly head, pitting the self-interest of countries where vaccines are being manufactured against our common humanity.
In the meantime the hard truth is this: If we carry on as we are, then either our economies will be pushed to breaking point as lockdown measures are escalated to match a more dangerous threat, or our health services will be overwhelmed by the sick and dying – both from Covid-19 and from all the other conditions we fail to treat early enough as a result.
There is only one route out of this dilemma: data, knowledge and understanding. If countries can gather a more complete picture of the threat the world faces and the environment they are operating in, and if leaders can use this knowledge to make decisions more quickly and coherently, then a faster escape from the crisis is still possible.
You Can’t Manage What You Can’t Measure
The first warning signs about a lack of data came early on in the crisis, when countries’ inability to test most of the people falling ill meant that official tallies of the number of people infected were a poor guide to how bad the situation really was.
The absence of comprehensive, real-time data has haunted the world ever since.
Governments struggle to make good estimates of how many people have had the disease, to measure excess deaths attributed to it, and to reliably compare case fatality rates and infection fatality rates across countries.
Clinicians have by necessity learned more about how to treat the disease – the survival rates for people admitted to intensive care is better now than it was nine months ago, for example – but health experts are still learning which therapeutics work best in different circumstances.
Most countries have struggled to break the chain of transmission, which has often resulted in cases surging again when restrictions are lifted. Mass testing remains the exception rather than the rule, leaving likely vast numbers of asymptomatic carriers at large around the world. Contact tracing has been shown to work when carried out quickly and thoroughly, but most countries do not have experience of doing this and have struggled to coordinate both manual and automated approaches.
Even the countries that acted early on with widespread use of face coverings, extensive testing, and robust isolation and contact tracing – enabled by data and often grounded in the experience of past outbreaks like SARS – may not be able to protect themselves from failures elsewhere. South Korea is a case in point: Lauded for its initial handling of the crisis, today it nevertheless finds itself exposed to more infectious variants originating overseas.
Identifying these new variants has, however, been a bright spot for some countries. The UK in particular has led the way on genomic sequencing, helping scientists to spot new variants early and increasing the time policymakers have to respond.
The power of modern science has also been evident in the pace of vaccine development. Advances in messenger RNA (mRNA) technology enabled the Moderna and Pfizer vaccines to be designed in a matter of days after the virus was sequenced. Viral vector alternatives, including the AstraZeneca vaccine, took longer but were nonetheless largely complete by the spring. The focus since then has been on conducting trials and seeking regulatory approvals around the world. That this has been done in record time should be applauded, but with so much at stake it is right to ask how things could go even faster in future.
Proper testing for safety and efficacy is of course essential, and there are limits to how quickly clinical trials can be completed. But greater pooling of trial data and agreed data standards could enable more widespread passporting of approvals from one country to another, and the potential for challenge trials as a faster route to obtaining data required for regulatory approvals merits further consideration.
With vaccines now being manufactured, the next challenge is rolling them out at global scale. With immediate demand for vaccines massively outstripping supply, decisions about allocation and distribution will be critical. With better international data on supply chains, absorptive capacity and the cost of delay in different scenarios, leaders might be better able to cut through disputes about which supplies go to which countries, in what order and at what times. Within countries, a more data-driven approach to prioritisation would help avoid doses sitting on shelves any longer than necessary.
And policymakers haven’t properly reckoned with the need for secure, portable health data as a precondition for getting life back to anything like normal. It seems likely that we will have to learn to live with Covid-19 and its variants rather than hope to eradicate it, and that new pandemic threats could emerge at any time. Being able to provide credible proof of test or vaccination status will in the end be a prerequisite for reopening our cities and restoring global travel.
This last point bears repeating. Before the pandemic shut down international travel, there were estimated to be around 1 million people in the air at any given time, and perhaps several times that number at sea. Knowing how destructive new disease outbreaks can be and how quickly they can spiral out of control, it is a significant risk for any country to fully reopen its borders unless the people entering can prove their test or vaccination status. The same will be true within countries for any setting where large numbers of people come into close contact: offices, schools, public transport, sports arenas, theatres, bars, restaurants and shopping centres, to name a few examples.
There is a legitimate debate to be had about the right way to implement new proof infrastructure for public health, and it will be critical to get the design, governance and protections right. But make no mistake, safely reopening countries and restoring freedoms will ultimately depend on it. We are used to showing proof of citizenship at passport control, being asked to show proof of age when buying drinks, and being vetted before working with children or vulnerable people; in a post-pandemic world a requirement for proof of test or vaccination status may be little different.
Situational Awareness
The world has been behind the curve on collecting data from the onset of the crisis, and for the most part has never really caught up.
Most countries that had health data infrastructure in place hoped that, with a little reinforcement, it could withstand the worst of the pandemic. Many other countries that did not have much by way of health data infrastructure also found themselves dealing with more immediate problems like shortages of hospital beds and equipment.
The net result has been many countries lurching from one crisis to the next, punctuated by unforced errors like aborted contact-tracing apps, premature easing of restrictions and test results getting lost in spreadsheet mix-ups. In other parts of the world it is hard to say exactly how bad the pandemic has been, because the data on tests and patients is missing. Without better data infrastructure, rich and poor countries alike could easily soon see the emergence of illicit markets for counterfeit vaccination credentials.
The best way to deal with all these problems is to isolate and correct the root cause: Namely, the fragmented and outdated approaches many countries have to collecting, securing, aggregating and analysing health data.
For countries that have yet to commence large-scale vaccination programmes, it is not too late to get the right data infrastructure in place. For those that already have large-scale vaccination programmes underway, it may not be viable to pause and reset immediately – but the work to prepare a more sustainable long-term solution should start without delay.
Achieving the necessary step-change in data and situational awareness will require:
Cloud-based data storage and software, enabling health-care workers and medical devices to record data quickly and accurately.
Real-time data reporting, analysis and insights to inform decision-making, from early warning of pressure points to algorithmic optimisation of vaccine rollouts.
Best-in-class security, access controls and audit, encrypting all data as standard and ensuring personally identifiable data is never exposed without permission.
A unique and persistent identifier for each citizen, enabling them to access their health data and prove their status to others, while at all times protecting their privacy.
Better tools to pool data to expedite safety and efficacy trials, including for securing regulatory approval and large-scale post-treatment and post-vaccination surveys.
Better tools to manage the logistics for mass testing and mass vaccinations, including allocating and distributing supplies and certifying that they are authentic.
Internationally agreed data standards and definitions, so that countries are aligned on how to identify and respond to new threats in a timely and targeted manner.
The building blocks for this can be assembled by repurposing and extending existing technologies – indeed, a system much like the one outlined above is already being used to manage large-scale testing, therapeutic and vaccination programmes in the United States (and is also being opened up to meet the needs of a number of other countries in Africa and elsewhere). The White House has signalled a gear change on Covid-19 under the new administration, and having robust digital infrastructure at its disposal will be critical to achieving its ambitious goals.
Critical to all of this, however, is policy leadership and public trust.
Every country has a different public-health setup, different institutions with different interests and mandates, different quantities of technical debt accumulated over the years and different capacities for innovation. And in the face of a global pandemic that soaks up every ounce of energy that people throw at it, the default state of most bureaucracies is to ‘make do and mend’ rather than attempt radical reform.
But the extreme pressure of a global health emergency, and the mounting cost of failing to contain it, is precisely why radical reform of global health data infrastructure is now more urgent than ever before.
In the 1940s, the Manhattan Project was instrumental in ending the Second World War. In the 1960s, the Apollo space programme set the stage for America to outlast the USSR. Both were pursued with unprecedented urgency, both required the old ways of doing things to be set aside, and both changed the course of history.
In the 2020s, Covid-19 is ravaging the world. Concerted global action to acquire the data, knowledge and understanding to overcome Covid-19 and prevent future pandemics must be our legacy to future generations.