In May 2018, U.S. leaders met at a Washington hotel to discuss their response to a crisis: a malign actor had released a newly engineered virus—a bioterror agent known as “Clade X” that killed 150 million people in less than two years. The United States faced its first global pandemic in a century, and political leaders had to make tough calls while awaiting the development of a vaccine.
The exercise was just a simulation among high-level government leaders, but it yielded a clear message: the world was not prepared for a pandemic. Tragically, a comparable scenario played out in real life with COVID-19, and the world failed that test, too.
The novel coronavirus can’t be said to have caught world leaders completely off guard. A similar pathogen, SARS-CoV-1 (the virus that causes SARS), struck parts of Asia in 2003, after which the World Health Organization (WHO) revised its International Health Regulations with the goal of helping countries become better prepared to address infectious disease outbreaks. In 2014–15, Ebola ravaged parts of West Africa, leading many countries to improve their state of preparedness to face a major biological threat. Nigeria established a new and highly effective Centre for Disease Control (NCDC), and the African Union set up a regional CDC that has played an important role in strengthening Africa’s response to COVID-19.
Even more significant, following the Ebola epidemic, more than 100 countries have availed themselves of an international tool for evaluating and shoring up readiness to meet pandemic threats. The WHO, along with a coalition of international partners including Finland, South Korea, the United States, and others, devised the Joint External Evaluation in 2016 as a voluntary, transparent, and objective assessment of each country’s level of preparedness to meet its obligations under the International Health Regulations. The JEE examines a country’s capacity in 19 technical areas and identifies those that need improvement if diseases are not to spread uncontrolled. Many countries—including the United States—have responded to their JEEs by working to strengthen their ability to prevent, find, and stop outbreaks.
The current pandemic has led some to conclude that the JEE failed. The United States, after all, scored high on this assessment, as did the United Kingdom on a precursor to the JEE. Neither of these countries can be said to have set a particularly high standard in responding to COVID-19—both have had much higher COVID fatality rates per population than many other high-income countries. Therefore, critics conclude, the JEE misapprehended readiness to confront a pandemic and should be abandoned or radically altered.
Why wasn’t preparedness, as measured by the JEE, fully indicative of success in managing COVID-19? The answer is not that the JEE is flawed but that it evaluates the fortitude of only one of the pillars on which effective pandemic response rests. The JEE examines a country’s public health capacities: the robustness of its laboratory systems, for example, and the presence of a trained workforce. But political indicators also matter. Evaluating how prepared countries are for the next pandemic will mean looking to the JEE, as before, but also supplementing that process to provide visibility into governance.
Governance Mattered
Good public health capacity can be undermined by bad political leadership. We recently completed an analysis showing, starkly, that countries failed the COVID-19 test if either their health systems lacked capacity or their leaders failed to use evidence to drive effective responses. Preparedness as measured by the JEE turned out not to be sufficient by itself to mitigate the impact of COVID-19: the United States scored 87 out of 100 on the JEE yet has one of the highest cumulative death rates from COVID-19 of any country. Such underperformance was far from unique to the United States, but the spectacular failure of U.S. leadership to develop a plan, a nationally organized response, science-based policies, or effective and accurate communication epitomizes the problem.
Many countries with high JEE scores performed well in the pandemic—some, by our analysis, better than commonly presumed, if one accounts for the higher rate of COVID-19 testing that identified more infections in these countries than in others. Countries that had experienced outbreaks of SARS and MERS, primarily in Asia, implemented strong, science-based policies early in the COVID-19 pandemic. These prior outbreaks had made governments and civil society familiar with simple measures, such as masking, to prevent disease spread. The WHO Western Pacific Region has the highest proportion of countries with JEE scores greater than 80 out of 100, and many countries in the region did well in their COVID response: Australia, Japan, Malaysia, New Zealand, Singapore, and South Korea.
The U.S. story, by contrast, highlights the critical importance of good governance. Evidence-based policies, responsible political leadership, and clear communication to counter misinformation are all components of an effective government response. The United States and other countries that performed poorly were missing these components, regardless of their preparedness scores. Bad politics trumped good public health.
Good public health capacity can be undermined by bad political leadership.
We were able to examine the relationship between governance and public health preparedness by analyzing JEE findings together with those that Foreign Policy magazine compiled in an index of government responses to the pandemic. Foreign Policy scored countries based on policy actions that seek to contain the virus, such as mask mandates and business closures; those that provide financial support to people and businesses affected by the pandemic; and those that seek to disseminate fact-based information to the public.
We found that higher JEE preparedness scores were significantly associated with lower COVID-19 caseloads and deaths when we adjusted for testing rates. A handful of capacities that the JEE measures showed a particularly robust relationship in this regard. Countries did well when they had strong national legislation, financing, and policy for health emergencies; when they possessed strong surveillance systems to detect and report new diseases; and when their communication programs could both ensure timely public access to reliable information and swiftly identify and combat misinformation.
But good governance, too, strongly correlated with an effective pandemic response. High scores on the Foreign Policy index were independently associated with fewer COVID-19 cases and deaths. When we put the two measures—for preparedness and governance—into the same model, we found that they were statistically independent: even countries with strong public health systems could have their responses undermined by weak governance, and countries with strong governance, even with relatively weak public health systems, could mount effective responses.
Find the Gaps
To say that better governance, in this case measured by effective pandemic responses, would result in better COVID-19 outcomes may seem a tautology. And perhaps in hindsight, it is obvious that measures such as universal masking, physical distancing, and economic support for affected populations would curb COVID-19 transmission and save lives. But many countries, including those with high JEE preparedness scores, did not adopt such measures quickly or extensively enough. Governments guided more by politics or ideology than by science failed to do what now seems obvious, resulting in the avoidable spread of disease and consequent deaths.
Many African countries adopted measures that forestalled waves of transmission that some wealthier countries suffered. Ghana, for instance, had a relatively low JEE score for preparedness but among the highest scores on the Foreign Policy metric for political response. With total case and death rates among the lowest in the world, Ghana benefited from strong governance capabilities that overcame the country’s low level of preparedness. Early in the pandemic, Ghanaian President Nana Akufo-Addo memorably stated, “We know how to bring the economy back to life. What we do not know is how to bring people back to life.” Liberia, which was devastated by the 2014–15 Ebola epidemic, leveraged a World Bank program during the COVID-19 pandemic to strengthen its surveillance and response capacities. By early March 2021, the country had recorded just 85 deaths from COVID-19.
The JEE identifies critical gaps in preparedness and helps direct countries toward the measures needed to close those gaps. The process includes follow-up assessments to determine whether countries have addressed the shortcomings identified. The JEE is not perfect—we have recommended reforms, particularly to better capture prevention and control of the spread of infections in health-care facilities—but its process needs to be strengthened, not jettisoned or radically altered.
Filling the gaps identified during the JEE process will make the world safer, but it will require sustained investment. Low- and middle-income countries will need funding on the order of $5 billion to $10 billion per year for a decade to fill the most important gaps identified by their JEEs. The cost of inaction, however, is much greater: the International Monetary Fund estimated in October 2020 that COVID-19 has already cost the world some $20 trillion. Together with funds, many countries will need technical assistance and help strengthening public health institutions and governance.
COVID-19 has posed the ultimate test—not just of health systems but of governance.
Governance is a blind spot for the JEE, not least because its efficacy is difficult to measure. But some degree of assessment is possible. Governments should routinely evaluate and report how quickly they detect, notify, and respond to serious public health threats. We propose as a starting point for discussion a target of 7-1-7: every country should be able to identify a new suspected outbreak within seven days of emergence, start to investigate and report it within one day, and mount an effective response (what this would entail could be defined clearly for each dangerous pathogen) within seven days.
A government’s capabilities change when new people and parties come to power. New governments should conduct pandemic simulations in order to test both their countries’ public health systems and their leaders’ ability to work together in a health crisis. The “Clade X” simulation uncovered blind spots that required government action outside the hotel ballroom. Among the recommendations that emerged from the exercise were that the United States develop the capability to produce new vaccines and drugs for novel pathogens within months (not years); that it increase its national and global commitments to rapidly detect and respond to outbreaks before they become pandemics; and that it improve coordination among various levels of government to better manage the complexities of a pandemic response, including quarantine policies.
Governments don’t have to wait for a rare and devastating pandemic to assess the effectiveness of their likely responses. From cholera to Legionella to food-borne illness to measles and more, the microbial world, unfortunately, provides ample opportunity to assess how well health and political systems respond. Consistent, complete, and public reporting on the 7-1-7 metrics for these everyday outbreaks can help policymakers understand and address weaknesses in their public health and political systems and make them better prepared for the inevitable emergencies.
COVID-19 has posed the ultimate test—not just of health systems but of governance. Never before has the scientific community been so unified to address a single issue. But the science hasn’t been the world’s Achilles’ heel. The last year’s deadly and expensive test revealed that governments that work well with limited tools do better than those that work poorly with the best tools. Will the world do what is needed to strengthen both public health and governance?
