The Lancet Commission on Lessons for the Future from the COVID-19 Pandemic: A Critical Review

Yves here. KLG argues that a careful reading of the Lancet Commission paper on the Covid-19 response and what lessons can be learned from it shows that neoliberalism played a major role in the poor results.

By KLG, who has held research and academic positions in three US medical schools since 1995 and is currently Professor of Biochemistry and Associate Dean. He has performed and directed research on protein structure, function, and evolution; cell adhesion and motility; the mechanism of viral fusion proteins; and assembly of the vertebrate heart. He has served on national review panels of both public and private funding agencies, and his research and that of his students has been funded by the American Heart Association, American Cancer Society, and National Institutes of Health

I did not expect to return to COVID-19 so soon after my previous post on the COVID-19 scientific literature, but sometimes an irresistible rabbit hole appears, especially if it leads in a direction one is primed to follow.  In my case, that would be the institutional and academic responses to the current pandemic and how they have been useful.  And how they have not.  The Lancet Commission on Lessons for the Future was published as an open-access article on 14 September 2022.  The pdf downloads as a 57-page scientific paper, and the content is supported by 499 references in the bibliography.  This fairly screams tl;dr.

But I did read it and a number of the references and it is very impressive.  Lessons for the Future is a very detailed explication of how the pandemic has affected all of us, all over the world, rich and poor alike.  While the Lancet Commission is not a scientific body, it does cover the pandemic well, and I recommend it highly as a starting place for understanding COVID-19 as a problem of public health, public policy, and political economy.  The report also directs the reader to much of  the relevant biomedical science.

I cannot, on the other hand, recommend Lessons for the Future as a serious attempt to map how we should respond to COVID-19 as it continues, contra President Biden, and to future pandemics that will undoubtedly accompany a warming planet and the forced human migrations to come; this classic is a good place to start on emerging infectious diseases.

Lessons for the Future comprises three main sections:

(1) Conceptual Framework for Understanding Pandemics (p. 4-8)

(2) A Review of Global, Regional, and National Responses to COVID-19 (p. 8-40)

 (3) Recommendations for Ending the Covid Pandemic, Preparing for the Next, and Long-term Sustainable Development (p. 40-45).

Section 1 begins with the conventional and correct wisdom that Five Pillars are essential for the successful fight against an emerging infectious disease:

(1) Prevention – to stop it before it starts by taking proactive measures to prevent the emergence of  novel, dangerous pathogens

(2) Containment – eliminate transmission of disease after it emerges

(3) Health services – save the lives of people with the disease and ensure the continuity of other health services

(4) Equity – ensure that  economic and social burdens are shared among the population and that the most vulnerable groups and individuals are protected, and

(5) Global innovation and diffusion – to develop, produce, and distribute new therapeutics and vaccines in an equitable and efficient manner.

Without going into all the details that are included in Lessons for the Future, notwithstanding pandemic triumphalism motivated by magical thinking (here and here and here), we have failed at the base of each of these pillars: 6.9 million reported deaths, and an estimate of 17.2 million deaths worldwide as of 31 May 2022.

The review of responses to the pandemic in Section 2 is remarkably extensive, beginning with the origin of SARS-CoV-2.  Where the virus came from may be considered an academic question at this point, but its origins are important for prevention of the next pandemic caused by a respiratory pathogen.  Beta-coronaviruses are endemic in bat populations, so SARS-CoV-2 could be the result of natural spillover from bats or a secondary animal reservoir followed by person-to-person transmission.  Palm civets or raccoon dogs were implicated in the original SARS outbreak in Guangdong in 2003 and dromedary camels during the subsequent MERS outbreak of 2012.

The other hypothesis for the origin of SARS-CoV-2 is that the virus could have escaped from a laboratory in Wuhan as the result of infection of lab personnel in the field, infection by a natural virus in the laboratory, or infection with a manipulated virus in the laboratory[1].  As noted, “the US National Institutes of Health (NIH) has resisted disclosing details of the research on SARS-CoV-2-related viruses that is had been supporting, providing extensively  redacted information only as required by Freedom of Information Act lawsuits.”  Who knows what to make of that, but it is not trust-inducing.

Following Origins, Lessons for the Future discusses the early responses to the pandemic in China and the rest of the world.  China announced a strict lockdown of Wuhan and several other provincial cities on 23 January 2020, while WHO followed a week later to declare a “Public Health Emergency of International Concern.”  WHO subsequently responded poorly to increasing tensions between the US and China, and during the initial period of uncertainty regarding COVID-19 “repeatedly erred on the side of reserve rather than boldness.”  This can be contrasted with the response to the H1N1 flu in 1976, which never happened, but the Swine Flu Vaccination Program, which I remember well, did cause a backlash.  The lax response to the 2009 H1N1 pandemic, when national authorities in the US deferred to local authorities, resulted in as many as 500,000 deaths worldwide.

Based on the Five Pillars, a mistaken “overreaction can be politically embarrassing, (but) the COVID-19 pandemic has shown that centralized underreaction can be devastating.”

The late recognition of airborne transmission of SARS-CoV-2 was crucial in the expansion of the pandemic, and this still seems to be an institutional blind spot.  As widely recognized, failures of international cooperation include slow notification of the initial outbreak, lack of coordination of responses to the pandemic, failure to ensure “adequate global supplies and distribution of critical commodities[2] such as “protective gear, diagnostics, medicines, medical devices, and vaccines.”  The “inability or unwillingness to combat systematic disinformation” is also listed.  To which I can only respond with this.  Crumbling pillars: 1-2-3-4-5.

Regional differences in responses to the pandemic led to different outcomes.  Suppression of COVID-19 in the Western Pacific and China in the early phases of the pandemic worked very well, while flatten-the-curve policies in the Americas worked markedly less well.  In the US, the initial test kits provided by CDC did not work and public health responses were inadequate after a generation of chronic underinvestment on public health.

The goal of flatten-the-curve soft lockdowns in the Americas was to slow transmission of the virus rather than to eliminate contagion by reducing the reproduction rate to below 1.0.  The consequences for communities of the most vulnerable populations were stark: the elderly in care homes; minority populations in medically underserved regions, which in the US includes most of the country; low-income essential employees required to work in enclosed spaces (e.g., meatpacking plants) and/or facing the public.  The premature lifting of public health and social measures around the world in spring  2022 – face masks, social distancing, indoor gatherings, decreased testing – probably contributed to the emergence of the omicron variant, which was much more transmissible that the delta variant.  Crumbling pillars: 2-3-4-5. 

The need for strong health systems comes next.  Well, yes: “An effective response to COVID-19 and any future pandemic requires not only a checklist of policy actions but also health systems that can deliver needed outcomes and can provide support to individuals to perform prosocial behaviors.”  And then, “a bright spot of the pandemic has been the rapid deployment of scientific knowledge and evidence, most importantly in the development and introduction of effective vaccines…(which was) an impressive example of private-public (usually “public-private” in which the public pays and the private profits) partnership and transnational scientific collaboration.”  One hardly knows how to respond to this statement.

But Lessons for the Future covers the ground, perhaps inadvertently.  As Sachs et al. note, the US Government has supported the research that led to mRNA vaccines, including the pandemic-inspired development and testing of the Moderna mRNA vaccine ($2.5B).  BioNTech received 100 million Euro from the European Investment Bank and a 375-million Euro grant from the German Government.

Despite the underwhelming effectiveness of the Moderna and Pfizer/BioNTech vaccines, which neither prevent transmission or disease but may lead to better outcomes for those infected[3], “the great success of vaccine development led to massive profits for the producers of mRNA vaccines, despite their support from public funds,” with the market capitalization of Moderna increasing from $8B in late 2019 to $65B two years later.  BioNTech capitalization increased from $7B to $35B over the same period.  The US government did not share in these gains and purchased mRNA vaccines at commercial rates, which included >$50B to Pfizer in 2021 and 2022.  This is a much broader subject for another time in that target-rich environment, but the people do rightly wonder about priorities.  Crumbling Pillars: 3-4-5.

The term “prosocial” appears early in Lessons for the Future and prosociality is presented as the solution to the pandemic.  Which brings us directly back to the Five Pillars of understanding pandemics: (1) Prevention, (2) Containment, (3) Health Services, (4) Equity, and (5) Global Innovation and Diffusion.  To accomplish these five pillars prosociality “requires an ethical framework of prosociality – the orientation of individuals and government regulations to the needs of society as a whole, rather than to narrow individual interests” (p. 4).

A short gloss on prosociality follows.  An early example derives from the origin of “quarantine,” which comes from the Italian quaranta giorni, or the forty days  Venice required ships to remain at anchor before landing in the 14^th century as Venetian authorities battled the plague with varying success.  A current example is the proper use of masks by individuals during COVID-19.  But who uses masks in September 2022?  And why should they, given that the pandemic is over?

Prosociality also enjoins governments to enforce workplace safety standards that prevent transmission of disease.  Yes, this happens in wealthy precincts, but in relatively few other places.  There is no good way to paraphrase the challenge of and to prosociality, so here goes, without violating fair use, I trust:

Challenges of prosociality arise especially in circumstances of strategic dilemmas, in which the pursuit of narrow self-interest by each member of the society ends up weakening the society as a whole.  By turning from the pursuit of narrow self-interest to the pursuit of shared interests, members of society can increase the wellbeing of all.  Prosociality generally requires some form of the Golden Rule (doing to others what you would have done to you) or the Kantian Imperative (acting according to maxims that can be universal laws).  Pandemics have many strategic dilemmas, and therefore require cooperative responses rather than selfish – and self-defeating – behaviors.

Prosociality was at a low ebb in many societies during the past 2 years.  In many countries, social trust in government and other authorities among citizens has declined markedly in the past two decades (and over the past four decades in the United States)—related, at least in part, to the persistent increase in socioeconomic inequalities. In places of low social trust, prosocial behaviors are rejected by many groups within society.  Additionally, at the national level, many governments showed themselves to be untrustworthy and ineffective.  At the global level, cooperation among governments was undermined by rancor among the major powers.  This hostility gravely weakened the capacity of international institutions such as WHO to conduct their assigned roles in the pandemic response.” (p. 4-5)

There is a lot to unpack here.  One is impressed by the inclusion of the Golden Rule and the Categorical Imperative, which nevertheless are honored mostly in the breach.

But to put it bluntly, while prosociality is an interesting and useful concept in evolutionary biology, it is not at all clear how it can apply in our current political economy of late capitalist non-democracy of the neoliberal variety, which precludes policies and behaviors that are other-directed, the other being any part of Creation.

Having said that, one definition of neoliberalism is not just as good as another, and my priors lie with Wendy Brown in Undoing the Demos:

The claim that neoliberalism is profoundly destructive of the fiber and future of democracy in any form is premised on an understanding of neoliberalism as something other than an set of economic policies, an ideology, or a resetting of the relation between state and economy.  Rather, as a normative order of reason developed…into a widely and deeply disseminated governing rationality, neoliberalism transmogrifies every human domain and endeavor, along with humans themselves, according to a specific image of the economic.  All conduct is economic conduct; all spheres of existence are framed and measured by economic terms and metrics, even when those spheres are not directly monetized…we are only and everywhere Homo oeconomicus[4]…which is an intensely constructed and governed bit of human capital tasked with improving and leveraging its competitive positioning and with enhancing its (monetary and nonmonetary) portfolio value across all of its endeavors and venues.  These are also the mandates of…neoliberalized states, large corporations, small businesses, nonprofits, schools, consultancies, museums, countries, scholars, performers, public agencies, students, websites, athletes, sports teams, graduate programs, health providers, banks, and global legal and financial institutions.” (p. 9-10)

States, large corporations, nonprofits, schools, countries, scholars, public agencies, health providers…the corporate institutions charged with responding to COVID-19 or any other emergency.  Anthropogenic climate change, for example.

So, yes indeed, “Prosociality was at a low ebb in many societies during the past 2 years.” And also going back to the final years of the Carter Administration in 1979-1980.  Which brings us to Section 3: Recommendation for Ending the COVID-19 Pandemic, Preparing for the Next, and Long-term Sustainable Development:

All ongoing risks highlight the continued urgency of global cooperation to end the COVID-19 pandemic and to prepare for future pandemics.  Although we have largely failed in terms of global cooperation during the first 2 years of this pandemic, putting such cooperation into place is still urgent.

And essential for this the implementation of a vaccination-plus control strategy, which is perhaps the strongest and most feasible recommendation in Lessons for the Future.  This would include mass immunization (that actually works, perhaps nasal vaccines or functional universal SARS-CoV-2 vaccines), universal testing, development of novel pharmaceutical treatments and the repurposing of existing drugs for new SARS-CoV-2 variants, rehabilitation for those afflicted with long-COVID, and complementary public health measures that include the widespread use of masks and the promotion of safe workplaces (improvements in ventilation, for example), and economic and social support for self-isolation when necessary.  An pressing question regarding the use of novel or repurposed drugs as pharmaceutical interventions in the treatment of COVID-19 is whether this will even be legal.  As California goes, often so goes the nation. (h/t to J-LS).

Some of these strategies have been tried during the initial phase of the pandemic, but the neoliberal consensus militates implacably against every one of the Five Pillars, and no amount of social policy or cultural psychology in isolation is likely to overcome these forces.

One particularly fascinating rabbit hole in Lessons for the Future (p. 25) covers how “behavioral science provides evidence about the effectiveness of interventions and policies across contexts and the processes required to bring about change; for example, evidence-based optimal behaviors for pandemic control include getting vaccinated and tested, isolating when infectious, wearing face masks, and physical distancing.”

For example, something called the COM-B model[5] is a “synthesis of frameworks of behavior change that has identified nine types of intervention strategy and seven policy options to underpin them…most effective when selected in combination according to a scientific understanding of behavior in the political and socioeconomic context.”  OK, then.

Or you can just tell the people the truth as you understand it.  For example, after the rollout of the Salk polio vaccine in 1955, problems with manufacture by one contractor led to several hundred cases of polio because a batch of killed virus was contaminated with live virus.  The response to that mostly localized catastrophe was rapid.  The production error was identified and corrected immediately and transparently.  Vaccinations were continued after a brief pause, and by 1957 cases of polio were down 90% from those reported in 1952.  By 1961 polio cases were down by 97%.

Prevention would require us to stop exploiting every ecosystem, geographical space, and geological resource on earth to keep capitalism expanding, as it must.[6]

Containment would entail strategies that have worked, such as contact tracing and mandatory treatment of tuberculosis, which is an ongoing scourge in parts of the world.  But where is the money in that?

Health Services must be provided as a human right, not as something to be sold and bought.  This does not mean healthcare should be free, but healthcare, not access to healthcare, should not require payment at the time of service.  Said payment should come out of taxes paid by all.  Period.  But this is not the world we live in, or even imagine.

Equity is not a thing under neoliberalism, either within a nation or among the community of nations.  In my view Rosa Luxemburg was right, as delightfully discussed recently in A Good and Dignified Life by Joke J. Hermsen.

Finally, Global Innovation and Diffusion travels only as far as transnational corporations can make money from the enterprise.

So, what is to be done, after

….the COVID-19 crisis has exposed major weaknesses in the UN-based multinational system, resulting from excessive nationalism, tensions among the major powers, chronic underfinancing of global public goods, including the UN system itself, lack of flexibility of intellectual property regimes to ensure that global public goods are available to all, lack of sustainable development financing…our most basic recommendation is the strengthening of multilateralism in all crucial dimensions: political, cultural, institutional, and financial.

All noble, all logical, all perfect Professional Managerial Class.  And good luck to all of us.

_________

[1] The full and free international cooperation necessary to determine the origin of SARS-CoV-2 is unlikely for obvious reasons.  Immediate responses regarding the origin of SARS-CoV-2 can be found among some of the usual suspects, here, here, and here.

[2] Commodification of healthcare, as well as agriculture, is a subject for another time but is typical of the blinders unknowingly(?) worn by conventional politicians, policy makers, scholars, and analysts.

[3] Moving clinical outcomes are common in Evidence-Based Medicine.  Despite well-known problems with lasting immunity to coronaviruses, the COVID-19 vaccines were “sold” as typical vaccines against a lethal pathogen, i.e., they will prevent transmission and infection.  When they did not prevent infection or transmission, the relevant clinical outcome became “the vaccinated tend to do better when they are infected.”  While this may be true, it is also true that the clinical management of COVID-19 improved as the first wave subsided.

[4] Usually written homo economicus, but the biologist in me simply must capitalize the genus and leave the species uncapitalized.

[5] “The behaviour change wheel: A new method for characterising and designing behaviour change modifications,” Susan Michie et al. 2011.

[6] The late Mark Fisher (following Frederic Jameson?): “It is easier to imagine the end of the world than the end of capitalism.”