Is it even possible to prepare for a pandemic?

20th July, 2023

Be prepared! It’s the scout’s motto. But prepared for what? In The Lion King, the song “Be Prepared” is a rousing celebration of fratricide, while Tom Lehrer’s song of the same title advised boy scouts: “Don’t solicit for your sister, that’s not nice / unless you get a good percentage of her price.”

Clearly, preparation is not enough; one must prepare to do the right thing. The UK’s Covid-19 inquiry recently began hearings into the country’s “resilience and preparedness”. It’s about time. In an ill-prepared world, the UK is often thought to have been more ill-prepared than most, perhaps because of the strains caused by austerity and the distractions of the Brexit process.

“It is apparent that we might not have been very well prepared at all,” remarked Hugo Keith, the inquiry’s chief counsel, on the first day of proceedings, while the counsel for a group representing bereaved families declared: “Proper planning, adequate resourcing and swift action saves lives. From the families’ perspectives, the UK had none of those three things.”

I’m sympathetic to these views, but here’s a question: who was well prepared, not with hindsight but before the pandemic? In 2019, the well-respected Johns Hopkins Centre for Health Security assembled an international team of experts to compile a “Global Health Security Index” (GHS). The GHS Index relies on more than 100 measures, ranging from “Does the country have a national emergency response plan for a pandemic?” and “Can the country’s lab system conduct five or more WHO core tests?” to “Does the country have an adequate road network?”.

According to the GHS Index, the best-­prepared country in the world was the US, while the worst-prepared country was Equatorial Guinea. But the death rate from Covid in the US was vastly higher than that in Equatorial Guinea. So what benefit did the US gain from being prepared? Admittedly, that sole comparison might be misleading. Elderly people were hugely more at risk of death from Covid, and there are more of them in the US. Many Covid-related deaths in Equatorial Guinea may have gone unrecognised or untallied.

Yet, in an unsettling study published late last year, the economists Robert Tucker Omberg and Alex Tabarrok took a more sophisticated look at this question and found that “almost no form of pandemic preparedness helped to ameliorate or shorten the pandemic”. This was true whether one looked at indicators of medical preparedness, or softer cultural factors such as levels of individualism or trust. Some countries responded much more effectively than others, of course — but there was no foretelling which ones would rise to the challenge by looking at indicators published in 2019.

One response to this counter-intuitive finding is that the GHS Index doesn’t do a good job of measuring preparedness. Yet it seemed plausible at the time and it still looks reasonable now.

Another response is that pandemic preparation might have worked very well against a different pathogen. The Sars-Cov-2 virus spread widely even from people without symptoms, and was deadly enough to kill millions while being mild enough, often enough, that people kept wandering around unwittingly infecting others. Next time it may be, say, bird flu, and a well-prepared public health system may be more decisive.

But perhaps we need to take the Omberg/Tabarrok study seriously: maybe conventional preparations really won’t help much. What follows?

One conclusion is that we should prepare, but in a different way. There are things that are obvious now which were not obvious in 2019, even to many experts. For example, Joshua Gans, economist and author of The Pandemic Information Solution, argues that we’ve learnt that pandemics can be thought of as information and incentive problems. If you can muster enough reasonably accurate tests, provide incentives to people to take those tests and act appropriately on their results, you can isolate many cases and prevent the disease spreading without locking down everything. Preparing a nimble system of testing and of compensating self-isolating people would not have figured in many 2019 pandemic plans. It will now.

Another form of preparation which might yet pay off is sewage monitoring, which can cost-effectively spot the resurgence of old pathogens and the appearance of new ones, and may give enough warning to stop some future pandemics before they start.

And, says Tabarrok, “Vaccines, vaccines, vaccines”. The faster our systems for making, testing and producing vaccines, the better our chances; all these things can be prepared.

But we also need to be able to step back and look at the big picture. There is one indicator of preparedness that was correlated with a lower death toll, and it’s the broadest of all — “state capacity”, or the ability of a state to get things done. The political scientists Jonathan K Hanson and Rachel Sigman have measured state capacity by combining indicators such as the ability to raise complex taxes and the availability of good statistics. (Predictably, Denmark is top of the list, Somalia is at the bottom, and the UK and US perform less well than Germany and South Korea but better than France and Italy.)

It verges on a tautology that states should aim to improve their own capacity, but even tautologies can be worth remembering. The inquiry is doing an essential task in evaluating the UK’s preparedness for the last pandemic but the next one may be quite different, and the next crisis will probably not be a pandemic at all. From this perspective, “Be prepared” simply means “Get your shit together”. It’s not exactly one for the scouts, but it’s not a bad mission statement for the British state.

Written for and first published in the Financial Times on 23 June 2023.

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