Learning From COVID-19: Prevention Is a Strategic Principle, Not an Option

Eight months into the coronavirus disease 2019 (COVID-19) pandemic, its day-by-day changing evolution makes hazardous all forecasts beyond short space and time scales. In addition, any assessment of the epidemic development and key factors at play, still in full swing, is necessarily selective and subjective; thus, this editorial is based on my personal point of observation (I live between France and Italy).

TWO LESSONS FROM THE FIRST WAVE

The first international warning by the World Health Organization (WHO) of an outbreak of “atypical pneumonia of unknown origin” in Wuhan, China, was formally issued on January 5, 2020.¹ During January while cases were accruing, researchers had identified the etiological agent and sequenced the RNA virus genome so that polymerase chain reaction (PCR) diagnostic tests became feasible. On January 30, 2020, WHO declared the coronavirus respiratory disease as a Public Health Emergency of International Concern. At the time, 7736 cases with 170 deaths were on record in China, 82 cases in 12 other countries were reported (with no deaths), and evidence of human-to-human transmission was found both in China and in four other countries.

Public Health Emergency of International Concern is the highest level of alarm in the International Health Regulations, one of only three WHO regulatory texts legally binding for Member States. It should trigger fast and forceful actions to counter the virus spread, yet in most European countries, actions were delayed for several weeks such that on March 11, 2020, WHO expressed deep concern because of “alarming levels of inaction.” There was, in fact, much action but little or no effect on the expanding epidemic, and two lessons to be retained emerged from the February to mid-March experience.

1. In most countries, plans, more or less updated, for tackling epidemic emergencies existed as legal and normative frameworks as well as technical directives but seldom as operational action plans specifying at different areal levels the needed and the available resources in materials and personnel and all the detailed steps to be taken within a rigorous time schedule. First major lesson: without preventive, concrete operational plans, a fast-emerging epidemic cannot be blocked or successfully controlled.

2. Impending or actual saturation and collapsing capacity of critical care units was in many countries—notably, Italy and France—the decisive factor driving government authorities to adopt adequate strong interventions (lockdowns of various degrees) that were socially and economically costly. As a result, health costs (morbidity and mortality) have been compounded with large social and economic costs. Second major lesson: adequate interventions, even if socially and economically costly, should be introduced when they can offset or reduce the health costs (i.e., at the early stage of disease incidence prevention, not at the late stage of critical care unit saturation). Public health officials and all health professionals bear key responsibility to prompt without delay governments to this difficult decision.

POLICY INCONSISTENCIES AND DELAYS

All European lockdowns were gradually relaxed starting in mid-May, with daily incidence of new cases drastically abated to only a few hundred in large countries such as France, Germany, Italy, Spain, and the United Kingdom.² Epidemic control currently relies on individual and collective barrier measures and, in parallel, on case and contact tracing, testing, and isolation. Scattered, well-controllable foci of contagion appeared as expected in May, June, and July (more). However, by late August, an epidemic resurgence was clear in many European countries: new daily cases in Spain and France rapidly increased to more than 6000 and almost 5000, respectively. Two features stand out behind this surge: policy inconsistencies and, once more, delays.

Policy inconsistencies are widespread, trying to balance a large spectrum of economic and social interests with health protection. Barrier measures must adapt to specific and local contexts, workplaces, schools, and means of transportation, but adaptive flexibility may result in inconsistent provisions. French railways require masks on board high-speed trains but allow all seats to be occupied during holidays,³ whereas Italian railways permit only alternate seats for physical distancing but allow regional occupancy regulations for other shorter-distance trains.⁴ In Berlin, Germany, brothels have reopened for massages but no sexual intercourse until September 1.⁵ In large towns, puzzled citizens wonder why masks are compulsory on one street but not on the next similar street. Examples fill a large kaleidoscope of requirements that vary and are often inconsistent not only between but also within European countries, hampering the population comprehension and compliance with recommendations and regulations.

Delays that plagued the epidemic’s beginning reappear in different but important forms. The most obvious affect the key process of case and contact tracing, testing, and isolation, popularly synthesized in the triad “three T: trace-test-treat.” Unfortunately, both process practices and the triad itself are defective because of a missing fourth “T,” “timely,” without which the other three become useless for controlling the virus spread. Time of process completion may vary substantially even within countries, but recent national one-week figures from France highlight a serious problem, potentially widespread.⁶ Only 25% of symptomatic new cases had the specimen for the reverse transcription–PCR test taken the same day or the day after symptom onset; for 54%, the delay was between two and four days and for 20% was between five and seven days. Adding to these initial delays the necessary time for the other phases of the process (reverse transcription–PCR analysis, testing contacts, isolation), the clear conclusion is that the machinery is much too slow to effectively counter the spread of a virus transmitted on average from one person to, at the very least, one to two others within a week (tests remain useful as diagnostic tools for individuals). An epidemiologically viable “four T” (timely tracing, testing, treating) process should not last more than two to three days.

PREVENTION IS A STRATEGIC PRINCIPLE

The lessons from the epidemic’s first phase and policy inconsistencies and delays at the time of writing (August 22, 2020) point to a common root: several advanced European health systems, often praised as the top of the world league, are so geared to disease diagnosis and treatment that it proves difficult and slow to switch them into prevention operating modes. Concurrently, all-pervasive managerial approaches of “just-in-time” work and “Taylorized”⁷ medicine act against a long-term vision and the strategic principle of “prevention first” for establishing priorities and allocating resources for health. Prevention is adopted essentially as a possible option, especially fitting in the form of screening programs or of administration of drugs and, most important for public health, vaccines: revealingly, all interventions involving social, behavioral, and environmental factors, key disease determinants, are defined via a negative as “nonpharmaceutical interventions.” Within this framework, it is an uphill task to devote time and resources to preventive preparedness (of materials, personnel, and detailed and tested methods of actions) for health emergencies that occur unpredictably. Yet these emerging hazards are unavoidable “new” priorities for health systems to confront: new species of potentially pathogenic viruses continuously accruing and—of overarching relevance—direct and indirect health effects of climatic change, most of which cannot be modified by vaccines.

With the COVID-19 scourge, nature provides a powerful warning and a unique occasion for analyzing and rethinking the structure and functions of an advanced health system in society, repositioning at the core of it prevention in its three dimensions: health promotion, preparedness to confront novel health problems as soon as they emerge, and actual application of specific preventive measures.