Lessons for the future: Covid-19, Preparedness & Research

BIC, May 2023

Covid-19 is no longer a public health emergency of international concern. This announcement by the WHO has received little attention. But, this is how the Covid-19 saga ends officially.

This week at the BIC a panel of public health professionals and clinicians reflected on lessons from COVID-19 pandemic. It had two clinicians – each from urban and rural contexts, an administrator who led pandemic response at BBMP and a former chief scientist from WHO who was in office during the early years of the pandemic. I have admired this city for its civil society that engages with issues that matter, irrespective of their popularity in public perception.

During the days that I wrote lockdown diary, I speculated on how will the pandemic’s end come about. Will there be a conclusive end to infections and daily deaths? Or, will the virus be rendered ineffective and human immunity will make the highly infectious versions of SARS CoV irrelevant to human bodies? I wrote the last entry of lockdown diary a year ago. Covid deaths have continued. The SARS CoV virus continues to evolve with downstream evolution being hard to determine.

Pandemic response across the world has been a heady mix of politics, public health crisis, economics and above all life sciences research. The discussion last evening reflected this in Bengaluru too. The administrators’ view was at odds with the clinicians’. The administrator from the health department reflected that it will be necessary for him to have guidance on what should his department’s response be over various time periods. The virus continued to evolve. The alpha, delta and omicron waves struck public health concerns in the same magnitude even though the public health department had the experience of preceding waves.

It would have been useful to see an acknowledgement from public health department that they had failed to learn from previous threats and limited spread of SARS and MERS viruses. It was easier to frame it as lack of guidance from medical and research fraternity.

The former chief scientist from WHO emphasised that the entire group of respiratory viruses must be seen as of concern. Routine tracking and investigation of evolving versions will be necessary for pandemic preparedness. However, there was little reflection on the failure of the entire WHO system and its bureaucracy in being of any help either with disease surveillance or contributing to management and cure.

A city-based pulmonologist shared insights from a hospital. The hospital continues to receive patients with covid-like symptoms. At the same time, number of hospitals in the city accepting covid patients has gone down. Prevention plan for respiratory infections can be as simple as not going to work or step outside if a person is sick.

The larger questions however were raised by a doctor who practices community medicine in a remote tribal community in B R Hills, about 200 KM from Bengaluru. How do we build caring and trustful health systems? How do we build health systems that are capable of responding to public health care crisis like covid. From a rural perspective he could see trust and equity playing out in significant ways as the pandemic progressed.

That the research community began figuring out the virus, its characteristics, pathogenicity, management and cure as the virus tore through populations seems unprecedented. If we can, this must not be repeated. Several molecular biologists and virologists were sure that the cure is theoretically clear and possible. Vaccine and drug, both, can be developed. The problem was that it wasn’t already done despite knowing that this group of viruses can emerge as a threat. Looking back, I think, this is what we missed out on. Fate of drug research and vaccine research for respiratory viruses has been the same as orphan diseases. Big pharma can’t earn from it. University labs won’t pursue it. There’s little funding for it.

In the three years since the declaring Covid-19 as public health emergency, this is how far research has come. The knowledge gaps that continue to exist seem staggering considering the state of technology and tools available for investigation. The prognosis may not read any different for some types of cancer.

The prognosis of COVID-19 is largely dependent on various factors that include the patient’s age, the severity of illness at presentation, pre-existing conditions, how quickly treatment can be implemented, and response to treatment. As previously described, the WHO’s current estimate of the global case fatality rate for COVID-19 is 2.2%. However, the case fatality rate is affected by factors such as age, underlying pre-existing conditions, and severity of illness. Results from a European multicenter prospective cohort study that included 4000 critically ill patients with COVID-19 reported a 90-day mortality of 31%, with higher mortality noted in elderly, diabetic, obese, and severe ARDS patients.

Cascella et al. 2023 https://www.ncbi.nlm.nih.gov/books/NBK554776/#article-52171.s15

In packaging away my exploration of what came off (in terms of research) from Covid-19 experience, I can only think of Lewis Thomas’ writing in an essay titled Making Science Work:

Biological science, with medicine bobbing some where in its wake, is under way, but only just under way. What lies ahead, or what can lie ahead if the efforts in basic research are continued, is much more than the conquest of human disease or the amplification of agricultural technology or the cultivation of nutrients in the sea. As we learn more about the fundamental processes of living things in general we will learn more about ourselves, including perhaps the ways in which our brains, unmatched by any other neural structures on the planet, achieve the earth’s awareness of itself. It may be too much to say that we will become wise through such endeavors, but we can at least come into possession of a level of information upon which a new kind of wisdom might be based. At the moment we are an ignorant species, flummoxed by the puzzles of who we are, where we came from and what we are for. It is a gamble to bet on science for moving ahead, but it is, in my view, the only game in town.

Lewis Thomas in Making Science Work. Book: Late Night Thoughts on Listening to Mahler’s Ninth Symphony