By Julio Frenk
President, University of Miami
and former Minister of Health, Mexico
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Over the past 18 months, for millions of individuals and families around the world, health care decisions have been complicated by a confluence of crises the enormity of which we had not previously experienced in our lifetimes. In Latin America, which is home to 8 percent of the world’s population, but has witnessed nearly a third of deaths due to COVID, the grief and loss is palpable.
This is the sixth pandemic or public health emergency of international concern in which I have played some decision-making role. But this one is unlike any other. Bill Gates has called it a “once in a century pandemic.” Its magnitude, its economic consequences, and the social unrest fueled by the disparities it has laid bare are unparalleled and have generated never-before-seen attention to our common frailty stemming from health risks.
While the current emergency is not yet over, we are all starting to imagine what a post-pandemic world could look like. In fact, there is much talk about a new normal. I would argue, however, that we have a once-in-a-generation opportunity to build a better normal. We owe it to all those who have suffered to apply the lessons we have learned thus far.
Understanding the Impact
As we do, there are two important facts we must keep in mind—here in the Americas and around the world. First, the impact of COVID-19 is far greater than imagined because it includes not only the direct death and disability toll caused by the pandemic, but also the indirect deaths and disability produced by delayed diagnosis and treatment of various diseases. Second, COVID-19 has not been so much a change agent as it has been a change accelerator, speeding up processes that were already under way. There are both luminous and gloomy facets of these shifts.
The right way to measure the full death-related impact of the pandemic is through what epidemiologists call ‘excess mortality,’ which is defined as “the number of deaths from all causes during a crisis above and beyond what we could have expected to see under ‘normal’ conditions.” Because the number of deaths tends to be relatively stable from one year to another, any significant sudden increase can be attributed to the direct and indirect consequences of the crisis.
In the case of the ongoing pandemic, we can compare the number of deaths in a specific country during 2020 with the average number of deaths in the previous five years. The difference between these two figures is the excess mortality. Excess mortality gives a better idea of the real impact of the pandemic because it includes not only confirmed COVID-19 deaths but also the COVID-19 deaths that were incorrectly diagnosed and reported, as well as deaths from other causes that can be attributed to the overall crisis.
Several studies have measured excess mortality in 2020 in various countries. One of those studies shows that excess mortality in Mexico in 2020 reached 45 percent, one of the highest in the world. As more data become available, we may well see similarly high rates in other low- and middle-income countries across the region.
Social Inequality Exposed
Some of the trends accelerated by COVID-19 are especially troublesome. The first and most glaring is the persistence of social inequality — in this case, in the context of health and health care. In almost all countries, the COVID-19 pandemic has disproportionately affected low-income and marginalized groups. This is reflected both in infection and in mortality rates. Lack of access to health care, scarcity of critical resources, and subpar infrastructure limited the prevention and treatment efforts in communities the world over.
Alongside public policies to reduce disparities in access to high-quality health care services, this reality demands the design of specific interventions to deal with the social conditions that account for higher rates of COVID-19 infection and death among specific populations.
Efforts to respond to the pandemic have also exposed the structural weaknesses in health systems. Even in the wealthiest countries, such weaknesses include fragmented public health systems resulting in poor coordination among national, state, and local agencies, as well as insufficient investment in robust surveillance and preparedness programs.
These shortcomings at the national level were exacerbated by the weakness of global health security arrangements that left the world woefully unprepared. One of the distinctive elements of this pandemic is that the global alarm systems did not perform as expected, and there is consensus around the sources of this failure: prior to the pandemic, the calls by multilateral agencies, academic institutions, and philanthropic organizations to strengthen the global protection mechanisms against common threats simply were ignored. The irony is that a miniscule fraction of the costs to the global economy inflicted by COVID-19 could have financed a very robust alert and response system.
This cannot happen again. We should take advantage of the attention that public health is receiving to introduce not only marginal but structural adjustments in the global health system that can protect us all in an increasingly interdependent world.
Capturing What We Got Right
Gratefully, like any crisis, this pandemic has also revealed some bright spots, which we must seek to understand so they do not simply fade away after the acute phase of the emergency but rather become crucial components of the better normal that should follow.
The first sign of hope is the remarkable levels of scientific collaboration across sectors and countries, which led to the development of safe and efficacious vaccines in record time. That great victory shows the way forward as a model for addressing other global challenges.
Another bright facet of the pandemic is the way it has spurred innovation in health care delivery. Salient among such innovations is the dramatic expansion of telemedicine during the last year. In poor countries, and also in underserved communities of rich but unequal nations, telemedicine can allow leapfrogging current practices in a way that would vastly expand access to personalized treatments designed to improve outcomes while reducing costs.
The last and perhaps most encouraging sign of hope is the attention being paid to health risks and a new awareness of our interdependence and common frailty. Thanks to COVID-19, governments, businesses, communities, and individuals now know that no country is safe until every country is safe.
If we leverage these shifts in our understanding across the region, this pandemic can give way to the promise of a better future for aging populations and, as the impact resonates longer term, the generations to follow.
This column was adapted from a longer, more cancer-focused keynote address presented at the 2021 meeting of the American Society of Clinical Oncology.