Who has done a good job on Covid-19?

There has been a rush to judge which government’s have performed ‘best’ in response to the Covid-19.  Dr Antonis A. Kousoulis FRSA argues that this is both too simplistic and too soon and that assessment must take into account governments’ responses to the ‘epidemic cascade’ of wider impacts such as mental health.

Since as early as March 2020, and more actively recently, media around the world have started publishing analyses evaluating national responses, and politicians have started making claims to having led the best government responses to Covid-19. However, the arguments used to support these claims have been fairly crude, the analyses have largely been failing to take into account complex and long-term health outcomes, and the discussions have been undermined by polarisation.

Whilst there are some useful indications on the basis of which evaluations can be done, the accuracy of morbidity rates and case reporting has been highly questioned in the Covid-19 pandemic. This has led to most of the analyses so far having been based on a single outcome: the number of deaths as recorded by the systems of each country. Mortality is of course a valuable outcome, but it fails to take into account a number of critical factors.

First, despite sounding straightforward, the recording of deaths and estimation of mortality rates themselves has been inaccurate in many nations. For many, it has been difficult to differentiate between deaths with SARS-CoV-2 infection and deaths caused by SARS-CoV-2 infection, simply because the vast majority of patients who have died had one or more other major comorbidities that contributed to their death. Seasonal baseline mortality due to other causes has also not been taken into account in many cases, whilst deaths in care homes and outside of hospital (which might possibly account for the majority of deaths due to Covid-19) were initially not counted in several countries. This narrow definition of mortality has also left out the counting of deaths that have been caused due to running healthcare systems almost exclusively focused on treating Covid-19 patients.

Second, even if mortality rates were accurate, using a single metric in public health is old-fashioned and unhelpful as health is multi-faceted, shaped by the interactions of environmental, social, economic and community factors. Composite measures and indicators like these have been developed to evaluate trends and impact both in the Global Burden of Disease studies, and in diverse policy areas like patient experience, healthy ageing or social mobility. Despite limitations in our early understanding of Covid-19, where routinely collected datasets exist this should be no different in a pandemic context as it happens, in fact, in other areas of public policy.

Third, with lockdown and quarantine measures currently being revised in several countries, many politicians have been hastily reflecting on the success of such measures. But this short-term and limited assessment based on mortality is somewhat narrow-minded when considering the substantial role that other factors will have played in the spread of the pandemic in each nation, including global travelling networks and patterns, crowding indices, and the local context in each country and region. In addition, and perhaps more crucially, early ‘celebrations’ ignored the subsequent waves of the pandemic. Epidemic waves occur after a peak and a trough in cases over time, caused either by biological, environmental or demographic factors (as was the case in some of the previous flu pandemics) or by intervention (as in the current pandemic).

Lastly, all national evaluations of responses to Covid-19 should not ignore the role of the pandemic as a long-term force for change. A simplistic assessment of the spread and impact of the virus so far would be failing to grasp the complex and longer-term place-and-time-specific variables that shape the impact of public health crises. The pandemic – through both its spread to the most vulnerable and the universal lockdown measures – is one that is exposing and exacerbating social and health inequalities.

Several governments (including many of those that celebrated their successful response to the pandemic) have been following a damaging populist approach by taking advantage of the pandemic messaging to prioritise personal responsibility over structural interventions, and this is going to impact on public health measures and outcomes longer-term. The trend we have been witnessing in several democracies around the world is one heading towards a future that is less free. The experience from countries like Hungary, Poland, Turkey, and India – to name just a few – is one of erosion of checks and balances with laws passed to expand government powers in ways that are not serving their citizens. And as it often happens, it can be expected that communities that are already experiencing the most disadvantage and discrimination (e.g. ethnic minorities, those in unemployment or precarious employment, socially isolated young people due to sexuality or family problems), are the ones that will face the greater negative social and health impacts.

We already know that injustice and avoidable health inequalities are claiming more lives than short-term disasters. This includes the long-term mental health impact of the pandemic, which is likely to last longer and have a larger and more enduring health footprint than the infection, and is heavily influenced by the social and economic measures taken in each country. This growing mental health impact has been called a ‘fifth wave’ of the pandemic. Unless action is taken across a wide range of determinants, this will continue rising for the next several years and will directly and indirectly also influence the peak of the other curves (acute and iterative infections, delays in urgent care, neglected chronic conditions).

With promising vaccines on the horizon and the conversation shifting to recovery following this winter, the public, media and politicians alike should resist simplistic evaluations and celebrations. Assessment of national responses to the Covid-19 pandemic should go well beyond mortality rates and include policy action taken across multiple components including fiscal, monetary and macro-financial, exchange rates, balance of payments, and social assistance. The public health objective should be to address the “epidemic cascade”, which directly and indirectly drives devastating and lasting healthcare, social, economic and business impacts. Each government’s longer-term influence on the political, social, economic and commercial determinants of population health will be a much better indicator to judge who did a good job.

Dr Antonis A. Kousoulis is Director at Mental Health Foundation, London, UK

akousoulis@mentalhealth.org.uk