"Never will so many ask so much of so few."
In his choice of language on St Patrick's Day to pay tribute to healthcare workers, Taoiseach Leo Varadkar's echo of Winston Churchill’s wartime words added him to a growing number of national leaders using bellicose speech when talking about Covid-19.
The UN Secretary General Antonio Guterres, UK Prime Minister Boris Johnson and French President Emmanuel Macron all compared the struggle against Covid-19 to war.
Churchill’s famed speeches provide a wealth of morale boosting material for a crisis, but his pre-WWII utterances are relevant too: In the 1930s, he, and others, foretold the great threat the Nazis would present.
They were largely ignored and Europe, when war came, was woefully under-prepared.
Similarly, vital time was lost in reacting to the current pandemic in Europe and elsewhere, despite multiple warnings that the world needed to be ready for just such an outbreak.
In September 2019, the report 'A World at Risk’ was released by the Global Preparedness Monitoring Board (GPMB).
The board is a joint initiative of the World Bank and World Health Organization. Its report laid out the actions needed to prepare for a health emergency.
The case for preparing was laid out in stark and detailed terms: "There is a very real threat of a rapidly moving, highly lethal pandemic of a respiratory pathogen killing 50 to 80 million people and wiping out nearly 5% of the world’s economy.
"A global pandemic on that scale would be catastrophic, creating widespread havoc, instability and insecurity. The world is not prepared."
The GPMB was convened in reaction to the outbreaks of Ebola in 2014-16 and the 2009 H1N1 flu pandemic.
Its 48-page report is full of policy prescriptions and targets to be achieved by September 2020 in order to ramp up global preparedness.
Arguably, the 2019 GPMB report is too recent to have been acted on and its deadlines for action too late for this pandemic.
However, there have been other, earlier reports warning against complacency and inaction.
'From Panic and Neglect to Investing in Health Security’ was prepared by the International Working Group on Financing Preparedness (IWGFP).
Drawn from the World Bank, the IMF, a number of universities, governments, UN bodies, businesses and foundations, the IWGFP prepared its report during 2017, nearly two years before the GPMB’s efforts.
It called for investment in capacity building in health and financial services, as well national and international emergency simulation exercises. The opening paragraph of the report, which is worth quoting in full, warns that a fatal global pandemic was not a matter of ‘if’ but ‘when’.
"Multiple pandemics, numerous outbreaks, thousands of lives lost and billions of dollars of national income wiped out — all since the turn of this century, in barely 17 years — and yet the world’s investments in pandemic preparedness and response remain woefully inadequate.
"We know by now that the world will see another pandemic in the not-too-distant future; that random mutations occur often enough in microbes that help them survive and adapt; that new pathogens will inevitably find a way to break through our defences; and that there is the increased potential for intentional or accidental release of a synthesized agent.
"Every expert commentary and every analysis in recent years tells us that the costs of inaction are immense. And yet, as the havoc caused by the last outbreak turns into a fading memory, we become complacent and relegate the case for investing in preparedness on a back burner, only to bring it to the forefront when the next outbreak occurs. The result is that the world remains scarily vulnerable."
"Multiple pandemics, numerous outbreaks, thousands of lives lost and billions of dollars of national income wiped out—all since the turn of this century, in barely 17 years—and yet the world's investments in pandemic preparedness and response remain woefully inadequate" - 'A World At Risk', Global Preparedness Monitoring Board report, 2019
Incidentally, some of Winston Churchill’s words feature as a prologue in the IWGFP report’s opening pages in the form of ‘The Influenza’, a poem he composed in 1890, prompted by an earlier epidemic.
Oh how shall I its deeds recount,
Or measure the untold amount
Of ills that it has done?
From China’s bright celestial land
E’en to Arabia’s thirsty sand
It journeyed with the sun.
The IWGFP in turn recommends the urgent implementation of the WHO’s 2005 International Health Regulations (IHRs).
The IHRs were updated in 2005 as a direct result of the SARS outbreak two years earlier and recognised the risk posed by a respiratory epidemic in an increasingly globalised world.
Preventing the spread of diseases through timely and detailed information-sharing is the main aim of the IHR, as well as asking countries to "develop certain minimum core public health capacities".
As part of the effort to implement the IHR’s, from 2016 the WHO began working with countries to develop a National Action Plan for Health Security (NAPHS).
"Preparedness for health emergencies was identified as one of the three strategic aims" for the period 2019-23, the WHO said.
A detailed template for emergency plans from inception to implementation was provided in a short 2018 document, described as ‘A Step Strategic Framework for NAPHs’.
Ireland’s own national risk assessment - ‘National Risk Assessment 2019 Overview of Strategic Risks’ - notes that, "Pandemic influenza was determined as the reasonable worst-case scenario in the Irish context... Historical evidence shows that such pandemics have the potential to cause death and illness on a significant scale and to disrupt normal social and economic activity".
The risk review also describes the inevitability of a health emergency: "When the next pandemic occurs, it will require a whole-of-government response to ensure that threat to public health and disruption of services and society are minimised."
In a self-assessment submitted to the WHO by Ireland, a high level of preparation -100% in fact - was recorded in a number of areas, such as access to health services and management of emergency response operation.
However, it awarded itself a bare pass, 40% under the heading 'Case management capacity for IHR relevant hazards', which includes pandemics.
Ireland gave itself 20% - a fail mark - in the area of "Financing mechanism and funds for the timely response to public health emergencies".
A 0% score was awarded for "Effective public health response at points of entry [i.e. screening at ports and airports]".
'Human resources to Implement IHR Capacities' were also a point of concern with a mark of 60%. The assessment is nearly a decade old, with 2012 being the most recent date given for any of the marks.
Maybe the various reports' emphasis on the effects of pandemics on the most vulnerable allowed for complacency to creep into richer, developed states.
The GPMB report clearly identifies that "Outbreaks hit lower-resourced communities much harder given their lack of access to basic health services, clean water and sanitation; this will aggravate the spread of any infectious pathogen".
But if a sense of relative security was felt in more developed countries, the report went on to point out that this was not justified, resorting to bold print, in case any policy-maker missed the urgency of the language: For its first report, the GPMB found that "Many of the recommendations reviewed were poorly implemented, or not implemented at all, and serious gaps persist.
"For too long, we have allowed a cycle of panic and neglect when it comes to pandemics: we ramp up efforts when there is a serious threat, then quickly forget about them when the threat subsides. It is well past time to act".
The IWGFP notes that some Asian countries had preparations in place for an influenza-type pandemic, but they learned their lessons about planning the hard way.
South Korea saw 38 people die out of 186 cases in the MERS outbreak in 2015. A further 16,000 were quarantined and the tourism and entertainment industries – which make up 14% of the economy - were temporarily shut down. A $9bn supplementary budget was put together to mitigate the impact.
By contrast, nearby Thailand saw only three cases after mounting an intensive early surveillance effort.
Speaking to the report’s authors, a South Korean spokesperson said: "We cannot afford not to [prepare], as this is a tangible threat to the health of our citizens, people in the region and the economy of our nation."
The dividends of South Korea’s crisis planning were seen in its response to Covid-19. Its ability to conduct rapid and widespread testing has been held up as a life-saving model of best practice.
Elsewhere, the absence of lived experience of a health emergency like SARS or MERS, makes prioritising pandemic preparedness a tough ask.
Planning and capacity-building costs money and politics is often about prioritising spending according to the most pressing immediate need.
Much of the world concentrated on the fallout of the economic crisis for most of the decade from 2008. Brexit has taken up recent political bandwidth in Europe as a major risk.
"Elsewhere, the absence of lived experience of a health emergency like SARS or MERS, makes prioritising pandemic preparedness a tough ask. Planning and capacity-building costs money and politics is often about prioritising spending according to the most pressing immediate need."
The IWGFP acknowledges that pandemic preparation is in danger of consistently falling to the bottom of the agenda.
To remedy this, it advises that a country’s state of readiness should have hard cash implications, in order to ensure planning is taken seriously: "If a country’s economic vulnerability to infectious disease outbreaks was incorporated in mainstream macroeconomic analyses, bond ratings and investment criteria, investment in pandemic preparedness would no longer be solely the concern of the Health Minister".
Only last month, the WHO Director General, Dr Tedros Adhanom Ghebreyesus, addressed the Munich Security Conference, where senior figures from the worlds of defence, security and politics assembled.
He could not have been more clear or specific, summarising the numerous reports.
He told the audience: "For too long, the world has operated on a cycle of panic and neglect. We throw money at an outbreak, and when it’s over, we forget about it and do nothing to prevent the next one.
"The world spends billions of dollars preparing for a terrorist attack, but relatively little preparing for the attack of a virus, which could be far more deadly and far more damaging economically, politically and socially. This is frankly difficult to understand, and dangerously short-sighted."
To paraphrase Churchill, one might reasonably ask why so many listened so seldom to those who warned so often.