Podcast: Future pandemic preparedness

Published March 8, 2023

The global pandemic: Three years later

Three years after we first began forecasting the trajectory of the COVID pandemic, we bring together IHME experts to discuss the ongoing effects of COVID and where we go from here. 

“To really understand how we can do better in the next pandemic, we need to interrogate what made a difference in this one.” - Dr. Thomas Bollyky

In todays episode, we hear from Dr. Bollyky and Dr. Joe Dieleman about the factors that led some countries to have lower death tolls during the COVID pandemic, and how we can harness those measures to prepare for the next one.

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Key takeaways:

  • The measure that had the greatest impact on a country’s outcomes during the pandemic was the level of trust that people had in their government and in one another.
    • Higher trust led to greater likelihood to wear masks, get vaccinated, and engage in other protective measures.
  • How do we sustain trust in a society in crisis? What are concrete steps governments can take to prepare for a future pandemic?
    • Invest in communication and strategies that benefit all parts of the population. Appropriate messaging alongside interventions is key.
    • For a global crisis, there needs to be a global response. Allocate resources appropriately based on the unique characteristics of each country or region and their individual needs.
    • Work at a local level to instill trust in public health systems.
    • Establish vaccine manufacturing centers more equitably around the world so all countries aren’t relying on just a few centers.

Read the research

The transcript has been lightly edited for clarity

Pauline Chiou: Welcome to our Global Health Insights podcast. I’m Pauline Chiou in media relations at the Institute for Health Metrics and Evaluation. As we navigate into year four of the COVID-19 pandemic, how prepared are we for the next pandemic? That's a big question. So we have Joe Dieleman, an Associate Professor in global health at IHME with us, as well as Tom Bollyky, Director of the Global Health Program at the Council on Foreign Relations and also founder of Think Global Health, an online health platform that’s an initiative between the CFR and IHME.

So thank you both for being with us today.

Tom Bollyky: Thanks so much for having us.

Pauline Chiou: Joe, let me start with you. We’ve lived through three years already of COVID. How prepared are we for the next pandemic?

Joe Dieleman: Yeah, thanks Pauline. That’s a really great question. I think probably the most important question as we look forward is to take a second to just look back. Tom and I worked together on a paper with a large group of co-authors for IHME and CFR that was published in The Lancet last February (2022) that looked at the variation that we saw across countries.

If you look across the world, there’s really amazing variation in both infection rates as well as infection-fatality rates. So, of the people that got COVID, how many of them passed away? And so that analysis really was sparked from this idea that there’s a lot of variation and there tend to be metrics that have existed for quite some time about how prepared a country is in some ways, you know, almost a grading system across countries that identified who’s most prepared. 

And Tom and I started looking at this really quite early in the pandemic, and realized that in very simple associations and scatterplots, you didn’t see much of a relationship. And so that really led to this paper, again, that was published in The Lancet about a year ago, where we continued to really rigorously try to investigate what explains why some countries were doing better than other countries.

And one important lesson from that was that there are some very clear things that make it harder for a country to be prepared for a pandemic. In some ways things like population density, general wealth of the country, the age of the population, and presence of co-morbidities, these sort of things that make the population more frail, more susceptible to passing away from COVID.

But then we went on and started to look at all these other characteristics about health care spending, number of beds per capita, measures of pandemic preparedness that I mentioned are kind of the global yardstick, and continued to show that there really was no relationship. And that was really important for us to kind of pose the question, So what was important? And I think that’s where in some ways the paper started to leave off and really start to think about what our next steps are going forward with the few things that we did find, and maybe I’ll pass it to Tom, who I think knows many of those things quite well.

Pauline Chiou: Yes. Tom, what were some of the things on that yardstick that came out as very important in this research?

Tom Bollyky: Great. Thanks so much for having me. So the question was to really understand how we can do better in the next pandemic, we need to interrogate what made a difference in this one. So that is really the question of what were the factors that explain the mysteriously large differences in outcomes we see at the country level in this pandemic, where you have neighboring countries sometimes with a twofold difference in deaths from one another.

And to look at that, we looked at a lot of the pet theories that you might have heard in this pandemic. So whether it’s democracy that makes a difference, or income inequality on the economic side, or health care capacity in measures like the number of doctors you have or hospital beds, or social measures like populism or the level of trust you have in your government.

And what the paper made clear is that it really wasn’t most of these pet theories that people have in this pandemic, wasn’t the level of capacity you had. It wasn’t the form of government. It was really the ability of the government to convince its people to take the measures that can protect themselves in that way.

The most effective thing the government can do in a health crisis like this with a contagious, deadly virus is to convince people to wear masks or get vaccinated or engage in the strategies that can protect themselves. And what we found there is it really is the trust that people have in their government and the trust they have in one another.

That is the resource that governments pull from to mobilize that trust and that collective action of people protecting themselves in the pandemic. And the question is now a year later, or three years into this pandemic, whether we are any closer to governments being able to build that solidarity, that level of trust in their people to respond differently and better next time.

Pauline Chiou: So that’s a very difficult question to answer when you’re looking country by country, isn’t it? Because you look at sort of divisive conversations in the US and then you might look at another country where there is a higher level of trust in the government. And, you know, as you were answering that question, Tom, I was thinking about Japan.

You know, in the beginning of the pandemic. And would you say, for example, Japan, there was a higher level of trust in the government and more of a uniformity in following the mandates there, compared to other countries?

Tom Bollyky: Yeah. So I will say a few things: there are some big differences in trust in government and social trust. The trust that people have in one another internationally, historically, you see pretty high levels of trust in government in a lot of East Asian nations, including Japan, whereas you see higher trust in one another, often in, let’s say, Scandinavian or Northern European nations, so a lot of inconsistencies there.

But those are kind of the trends that you see, and that definitely has been apparent in the pandemic, where some of the countries that report higher levels of trust, both trust in government and social trust, have been able to respond better in the pandemic. But one important thing to recognize, the question about whether this has changed over the course of the pandemic is the pandemic tends to erode its solution.

Trust is declining, even in countries that have done well in the pandemic. It is a lot to demand on this society to take these extraordinary measures to limit the transmission of a deadly virus or to protect themselves and their neighbors. So this, looking forward, really sets an agenda about first, how do we sustain trust in a society in a crisis?

How do we reduce the speed with which it erodes over the course of the crisis? And last and I think somewhat most importantly, what do we do in low-trust societies to try to be able to inspire cooperation? Because the reality is that there are many low-trust societies and low-trust communities within societies, and we need to look at strategies of how we can mobilize cooperation and get people to protect themselves in environments like that as well.

Pauline Chiou: And Joe, based on the research that both you and Tom have done, and looking ahead, how would you answer some of those questions? How do you build trust in some of those low-trust countries? How do you make sure that people continue to build this trust when life has gotten back to normal? But you’re still looking ahead to what you can do to prepare for the next pandemic?

Joe Dieleman: Yeah, thanks. You know, so one thing about trust that I’ve learned in researching for this paper and this research that we did is that it’s not immutable. It changes over time. Like Tom said, through the course of this pandemic in many countries, trust in the government and indeed our personal trusts have gone down. But there are also strategic ways to increase trust over time.

So I think investing in governments and investing in not only leading, are acquiring more trust for themselves and really investing in that thinking specifically about the public health system and the public health system needing to do that same thing to really acquire trust over time, to invest in communication and strategies to all parts of the population.

The other thing that I think is as valuable is that in a global crisis, there needs to be a global response in some ways. And so the countries that do have low trust can be benefitted from the international community. And so thinking about how do major development agencies work in low-trust environments, what are the things that a country with low levels of trust needs that are different than maybe what a country that has high levels of trust needs?

And so really thinking from a development agency perspective, thinking about where resources are being allocated, what types of resources are being allocated based on the unique characteristics of a country and what they really need, and in particular in regard to trust, is really important.

Pauline Chiou: And when you’re talking about resources, Joe, you know, we all remember at the beginning of the pandemic, there was there was a mad scramble for PPE, a mad scramble for ICU beds. Staffing was an issue. Ventilators, the competition for ventilators. Is that what you’re talking about when you’re talking about resources and planning ahead?

Joe Dieleman: Yeah, to some degree it is what I’m talking about. I think having infrastructure in place where health systems have the resources they need, like PPE and eventually have access to vaccines. Those things are critically important. What I was really thinking about, though, is acknowledging that that might not be enough in some places and that helping with messaging, with response, is also essential.

One thing that we investigated was the costs of delivering vaccines. So the global community put effort into, I shouldn’t say did a really good job, but put effort into getting vaccines spread across the globe, but of course, getting them into arms is a different matter. And so, asking the question, what does a country need to actually get the preventive measures or the treatment where it needs to go?

And again, I think that, in many ways, is to some degree a country-by-country conversation. The other thing is I do think there’s space for planning, and I think development agencies in particular in environments with a lot of trust can think about what can they do, as a catalyst for planning for the future, essentially developing a response within a country and helping countries develop those plans is really important.

I think development agencies can do that.

Pauline Chiou: And Tom, what are some of your thoughts about concrete plans in terms of planning ahead? We saw that the vaccine was created quite quickly from a scientific point of view, but that it was the logistics of getting the refrigeration and the supply chain and the vaccines into arms of people in other countries. What do you see as the solution to streamlining that?

Tom Bollyky: Great. So two things. One, I want to put stamp or build on a couple of points Joe made on trust because they are so important. We spend a lot of time talking about the trust conversation. How can we make people trust the public health response? But that’s really looking at it the wrong way. It really is a question of what can we do to make that public health response, to make governments trustworthy, to encourage that response.

It’s important that that’s done at the local level. There actually tend to be often bigger differences between the level of trust within a country than there are internationally between countries, and low-trust societies have very particular needs. They tend to respond less well to mandates. That’s not true for high-trust communities where mandates often inspired people to go along in the sense that they become confident that everyone else will.

It has the opposite effect in a low-trust community. Look at things that can mobilize. That cooperation is really important. So I just wanted to emphasize those points that Joe made on the issue of vaccination. On the positive side, to circle back to your initial question, the one area where I do think we are better prepared than we were three years ago is in terms of vaccine manufacturing and distribution globally.

It is frankly remarkable that we went from identification of a virus to a candidate in clinical trials in 67 days and we had a vaccine authorized for expanded public use in just over 10 months. That's quite remarkable. The amount of doses administered globally exceeds anything the world has ever produced before. That said, it was obviously not enough in this pandemic, and it was not fairly enough distributed, and it’s certainly not going to be enough in a pandemic of a more easily transmissible virus than even the one we’ve had here.

So, for instance, in a flu pandemic, we will have to do much, much, much better. So it is going to be important there to see a more equitable distribution of manufacturing globally so that we aren’t just reliant on a few centers. It will be important to ensure that doses and the underlying inputs and supplies can move across borders, so you don’t have the phenomenon of governments hoarding because they believe other governments are hoarding as well.

They need to have the confidence that those supplies will move. And it does require, as Joe suggested, this investment in localized distribution and ministry action. And that is a challenge in the global health context, where historically we invested very heavily in childhood immunization but not in immunization of adults.

And we had that struggle and this pandemic. So that’s going to be important. All that is going to be important moving forward. But again, if you’re looking for a silver lining in this pandemic, where I think a lot of us are dissatisfied with the global and domestic response, the silver lining really is around vaccine R&D and production. The question is, can we build on that to make us even safer in the future?

Pauline Chiou: There’s so much to digest with all the points that both of you are bringing up. And as we wrap up the podcast, I’d love to give both of you just some final thoughts. Joe, do you have any final thoughts to what Tom just said or anything that we haven’t discussed yet?

Joe Dieleman: Yeah, to build off of one thing that Tom said. You know, he was identifying a silver lining, and a silver lining that I would identify that's a little bit different was the international response regarding development assistance. And so development assistance scaled up between 2019 and 2020 by 44%, an increase that has just never been seen before. And so the ability for the development agencies, many of whom had never worked in pandemics or communicable diseases to pivot and provide resources to low-income countries in need was really remarkable.

And the ability to essentially generate new resources from traditional sources of development assistance was really remarkable. You know, 44% increase is just unprecedented and was sustained. It went up between 2020 and 2021. So really remarkable growth, and I think it shows what the development community is capable of. There is also a history of kind of panic and neglect that’s associated with development assistance that we’ve seen in a few cases: where there is an epidemic of global interest, development assistance to that region increases for a short amount of time and then a few years after the crisis, there is far less interest in investing in preparedness.

And I think the challenge going forward is not only to identify what it means to be prepared for the next pandemic, but also to finance it globally, and that requires sustained interest in funding for pandemic preparedness. It doesn’t mean we do the exact same thing we did in the past, but it does mean there needs to be resources that are distributed equitably across all of them.

Pauline Chiou: And Joe, I know you research that in depth every year with the financing of global health, and the report that comes out of IHME. Tom, do you have any final thoughts?

Tom Bollyky: Great. So I think moving forward on this third anniversary, I think it’s going to be really important to be responsive to the lived experience of this pandemic. What went wrong? There’s a lot of support in future pandemic preparedness and response to invest in surveillance, for instance, and rebuild health systems. Both are very important. But I think what really this pandemic has shown is it’s been the sluggishness of governments to respond to reports of the virus and the struggles they’ve had in mobilizing the cooperation and buy-in of their publics.

That ultimately has to determine how nations have performed in this pandemic and that there are areas we are still slow to invest in with regard to future pandemic preparedness and response. So that’s an area that Joe and I and others have kept working on in terms of formulating what that looks like, the concrete investments one can make in that space.

But I think it’s going to be important not just that we don’t have a repeat of a pandemic like this one, but also that we can mobilize the support of governments that can have confidence that the things we are doing now to respond to pandemics in the future would have made a difference in this crisis. And that’s where we’re hoping to make progress.

And I’m looking forward to reporting more success in that regard, ideally next year when we have this anniversary.

Pauline Chiou: Well, thank you so much for illuminating all of us on what you are seeing, looking forward and all of your insight on your research. Tom Bollyky, Joe Dieleman, thank you very much.

Joe Dieleman: Thanks so much.

Tom Bollyky: Thanks a lot.



Scientific Publication

Pandemic preparedness and COVID-19: an exploratory analysis of infection and fatality rates, and contextual factors associated with preparedness in 177 countries, from Jan 1, 2020, to Sept 30, 2021


Financing Global Health 2021: Global Health Priorities in a Time of Change