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Published 6 May 2021
Covid-19 represents one of the biggest singular global ‘events’ of recent memory. The world has faced crises before, but this one is existential. Occasions of such scale prompt questions around the physical and mental health of the world’s citizens. No one country can say it is immune to the impact, and this has caused the media and the general population to seek comparisons. Here, Hamza Drabu explains why comparisons are not always helpful, analysing some of the key ways healthcare systems have improvised and adapted, and explaining why cross-border cooperation will help us to overcome Covid-19’s ongoing impact.
There are many psychological and sociological factors at play, which combine to form an innate desire to benchmark and to look over shoulders at the activity of others: ranking allows an assessment of winners and losers and the uncertainty of coronavirus means there is a strong desire to measure ‘how well we are doing’.
This measurement can reveal broad trends and best practice, and help with cause-and-effect mapping. As Ross Clark notes in The Telegraph, for instance, “Sweden has fulfilled the same role during the Covid-19 crisis as Argentina fulfils in every World Cup. It’s the team which everyone – apart from the natives themselves, naturally – wants to get beaten.”
This stems from the fact that Sweden represented an outlier, positioning itself firmly at one end of the spectrum of responses, with its “show must go on” approach, opting against lockdown and strict social distancing measures. Sweden gave its public health agency a large degree of autonomy and Anders Tegnell, state epidemiologist, made his position clear when he described lockdown tactics as “using a hammer to kill a fly”.
Tegnell cautioned against forcing comparisons, saying “it’s not a competition”. But despite this sentiment, many onlookers and commentators continue to be intrigued by the Scandinavian country’s approach .
In spite of the caveats outlined above, it is crucial that useful discussion of different approaches must be centred on the principle that – as far as possible – apples must be compared with apples.
“All comparisons are difficult, but the main thing is to try and compare like-for-like,” says Jonathan Pearson-Stuttard, Vice Chair of the Royal Society for Public Health, Clinical Research Fellow at Imperial College. “Sweden – for example – should be compared with Nordic countries, for various reasons including the similar population demographics.”
This sentiment is echoed by Chris Thomas, Senior Research Fellow at the Institute for Public Policy research (IPPR), who says “you have to look at countries with the same contextual factors – advancement of economy, size and spread of population, national budget and so on.”
Even accounting for the nuanced factors that make each country’s approach unique, inherent difficulties remain. Take for example:
• Reporting mismatches: even aside from which statistics are used, where they originate and how they are validated, differences can arise from how and when things are measured, recorded and published
• Fluctuating numbers and tactics: in such a fast-moving environment, with inconsistent and changing approaches, metrics are not sophisticated enough to provide accurate comparative data in real time
• Identifying cause of death (and lag time between positive test and death): uncertainty and inconsistency exists between what is classified as a ‘Covid-related’ death. Does the data reflect, for instance, someone who tests positive and is then killed in an unrelated road traffic accident, as a Covid-related death?
Of course, the picture is even more nuanced than this. Within ‘fluctuating tactics’ for instance, the speed of national response is another factor, as is the quality and authority of leadership communications. In Germany, Angela Merkel’s science background elevated her status as both a tactician and as a reassuring and reliable source of information. This was surely helpful for raising public trust in, and compliance with, her government’s Covid guidance.
“Having a scientist as Chancellor, explaining what the R rate means, and openly discussing its shortcomings in a knowledgeable but accessible way, helped with the credibility of message,” says Connor Rochford, Chief-of-Staff to Dame Sally Davies at Trinity College Cambridge.
Different responses and tactics must be considered not only in terms of the policy response itself, but also in light of what the country looked like when the pandemic hit, from a people and systems perspective. Pearson-Stuttard uses a ‘people’ example.
“The UK has a higher obesity rate than most of Europe and we know obesity is a risk factor for poor Covid outcomes,” he says. “But New Zealand has worse obesity than the UK and did ‘well’, so in that instance you look at other factors – the policy response.”
On the policy front, Pearson-Stuttard – who was part of a team at Imperial that researched excess death comparisons across 17 countries for the first phase of Covid-19 up to June – identifies the two main areas that national responses have been ‘judged on’.
“The areas we’ve seen that tended to be bigger determinants of whether a country did ‘well’ or ‘badly’ in handling the pandemic were lockdown – and the timing and completeness of that – and the capacity and infrastructure of contact tracing. South Korea, for example, has very good infrastructure, so it didn’t need to lock down as stringently.”
The influencing factors are manifold – China, South Korea and Taiwan were among those adapted their approach to healthcare by setting up parallel health systems, for example, with fever clinics and community screening on top of contact tracing.
Not all options are on the table everywhere, of course. In nations where there is less access to water and soap for handwashing, or no access to PPE, tactics must adapt. When you consider UNICEF data that shows 40% of the world’s population lack handwashing facilities with water and soap at home, the scale of the challenge becomes clearer.
Harnessing the expertise of different segments of society has worked well in various countries and we have seen how crucial collaboration has been at every stage of tackling the pandemic.
“Germany quickly involved the private sector in everything from oxygen to provision of ventilators,” says Rochford, who praises the sophisticated use of data that some jurisdictions have benefited from. Mobility data to test peoples’ response to contact tracing is a prime example.
“Mobile telecom companies have the best data there, so surely it makes sense that they would be involved in the contact tracing effort?”
He points to Spain, where the Instituto Nacional de Estadistica, has pulled together and made available upwards of 80% of mobile telecom data for analysis. Companies from non-healthcare sectors have realised they have a role to play in helping healthcare systems and practices adapt.
“The data is aggregated and privacy-preserving,” says Rochford. “It’s a similar story in South Africa, France and the Netherlands, where telecoms companies and the banking sector have been called upon. Those insights can then influence decisions from policymakers.”
As healthcare systems the world over have adapted, much work has gone into ensuring appropriate legal and regulatory standards are in place. Data protection is – rightly – a perennial concern. But in the UK, Palantir and NHSX have worked together on a privacy-preserving data store, to enable the NHS and government to look at trends to monitor the spread of the virus and implement appropriate measures to ensure services and support is available to patients.
Data aside, the Merkel example shows the impact of leadership, while the social and cultural makeup of a population is also relevant. A Cambridge University study published in the journal American Psychologist and based on a survey of over 101,000 people in 55 countries shows that personality impacts the likelihood of compliance with Covid guidance and social restrictions. Research suggests that tailoring messaging is a key to influencing behaviour.
Rob Walsh, Chief Executive of North East Lincolnshire Council and CCG, supports the localisation of communications and messaging as a means of delivering maximum community impact.
“National messaging is important,” says Walsh. “But the sooner you can get into local communications, targeted at the different segments of society, the more impactful the message will be.”
This has the dual benefit of people hearing from figures they know, trust and have greater access to, as well as allowing for greater tailoring of messaging to a local situation. It also taps into the tribe mentality of local populations, harnessing the psychology that people often come together where they see a tangible benefit for their ‘nearest and dearest’.
As a number of vaccines are developed, approved and rolled out, alongside new COVID variants emerging, the most efficient road to ‘recovery’ must be paved with continued collaboration in the scientific and healthcare communities, as well as co-operation across national borders.
The economic fallout of the pandemic extends beyond direct trade, support schemes and tax policy. But while personal isolation has been a security measure from a health perspective, political isolation goes against recent collaborative strides made. “Unfortunately, even champions of global trade like Germany do not seem to be immune to the globally spreading virus of protectionism,” says Oliver Kairies, partner at German law firm, Luther. “In the long term, foreclosure from foreign investment will be poison to the export-oriented German economy and the order of the day should be global cooperation, not isolation.”
In early October, the UK Government announced it would be joining Access Consortium, a scheme involving Australia, Canada, Singapore and Switzerland; and Project Orbis, coordinated by the US Food and Drug Administration and involving those same countries, plus Brazil. The two initiatives bring together some of the world’s leading regulators to allow pharmaceutical companies to submit medicines to be reviewed by several countries simultaneously. The initiatives aim to speed up approvals for innovative treatments, including for cancer, as well as pooling resources.
Covax, overseen by vaccines alliance Gavi, is another initiative. It is pooling international funding to help lower income countries address the vaccination question. Almost $2 billion has so far been raised through development pledges from richer countries, but given estimates of $35 billion being needed to vaccinate the global population, much work remains.
Meanwhile, Dame Sally Davies, Master of Trinity College, Cambridge and former UK Chief Medical Officer, has launched Trinity Challenge, bringing together leading business, academic and philanthropic institutions to harness data and analytics to better protect the world against health emergencies – a project that DAC Beachcroft LLP is delighted to support:
“We need to come together to make sure this never happens again,” she said upon launching the initiative. “We need new ways of working, new partnerships, new ideas, and believe that together this strong and growing coalition can and will generate acts that protect and improve lives and livelihoods everywhere.”
Successful international collaboration – whether between corporates, research institutions, governments or other authorities – is, of course, made tougher during a time of lockdown and travel restrictions.
“The challenge is that collaborating at a distance is difficult,” says Samuel Cronin, Healthcare Innovation Manager at the UK-Israel Tech Hub. “Communication can suffer from distance and lack of physical, in-person interaction, while the trust-building that often leads to collaborative breakthrough moments can also be stymied. In many ways it is tricky because we are only looking at half the challenge and it is not unlike calling the mechanic without them being able to see the engine. Remote diagnostics, and having the necessary tools in place, is essential for telemedicine to be effective.”
Of course, exploration of national approaches goes far beyond healthcare. Politics, psychology, communications, geography, demography, cultural difference and nuance all come into play, while the pandemic hit different countries at different times and to different degrees.
In spite of this, one clear and consistent conclusion has emerged. The ultimate realisation is that sharing and collaboration is the best way for the international healthcare community to rally together against a virus that has already had a devastating impact around the world.
We have produced some companion podcasts for this Health Adviser article, in which Hamza Drabu talks to Sam Cronin, Healthcare Innovation Manager at the UK Israel Tech Hub, to compare the UK and Israel approaches to managing COVID-19. In the second podcast Hamza speaks to Chase Spurlock, CEO and Founder of Decode Health, about the differences between the US and UK approaches.
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Anne Crofts, Alistair Robertson