Post–COVID-19 Reflections Around the World: A New AJPH Forum

“The history of epidemics is therefore the history of disturbances in human culture.”

—Rudolph Virchow, 1870

This new AJPH forum theme—post–COVID-19 reflections around the world—is an invitation to specialists and officials from all over the world to evaluate the world’s response to the pandemic, the adequacy (or inadequacy) of public health organizations and structures, and what has been (or is being) learned from the experience of facing this new challenge.

Although much has been published about COVID-19, we invite critical analyses on the aspects of the public health system and infrastructure that allowed the strategies employed to deal with this crisis to be implemented successfully or that contributed to their failure. We hope that through a broad international conversation on these important topics we can stimulate a debate on how to build a strong and resilient public health infrastructure that will ensure that future health challenges can be confronted successfully at the local, national, and international levels.

The responses to this new challenge have varied a lot, between and within countries, creating situations that have amounted to a sort of set of natural experiments on the different measures and approaches used to face the pandemic. This has become a stress test for public health systems, health care infrastructures, and social and political organizations and values. This test allows us to look at critical issues in the response to the pandemic, such as the hesitation in adopting stringent measures of containment, the strength of the public health infrastructure, and the level of coordination and communication among the different structures involved in the country or community response. Other important issues include the balance between the value of human life and the value of the economy; the level of coordination of communication with the public, the nature of social discourse, and the resulting social cohesion in responding to this unprecedented challenge; the public trust in institutions; and the balance between individual liberties and the public good.

Because we do not yet have the traditional biomedical resources to deal with COVID-19 (i.e., vaccines and medication), various attempts to create barriers to interpersonal transmission of the virus have been put in place. The necessary restrictions, which have included various forms of voluntary and forced confinement of individuals and communities, have had a devastating impact on economies, generating dissent and even open conflicts about the correct course of action.

Countries differed significantly in their initial approaches, for example, hesitating in Italy and the United Kingdom and using a deliberate strategy in Sweden. Some countries (e.g., the United States and Brazil) have had erratic responses, with wide regional variations in their approach because of ineffective communication or coordination among the various institutions, agencies, and offices charged to respond to the pandemic. High caseloads in these countries have shown the pitfalls of a weak policy approach to the pandemic.

Preparedness for this event was an important factor in determining a successful initial response to the pandemic. The fact that most Asian countries have been able to deal successfully with the pandemic is partly attributable to the knowledge acquired facing the devastating 2002 through 2004 SARS (severe acute respiratory syndrome) epidemics. Although it may be unfair to expect that all governments (especially in the West) should have been prepared for such a devastating event (despite the warning from many epidemiologists and microbiologists), it seems reasonable to expect that they were “prepared to get prepared,” that is, that adequate responses would have been put into place with the necessary speed and adequate resources.

Although the lockdown measures have been shown to be effective in reducing the spread of the disease, they have resulted in significant declines in the output of the economies of many countries,¹ calling into question the role of public health in informing the debate on these critical aspects of life and death.

Science has been rushed to generate eagerly sought-after responses; this urgency has created its own problems, with conflicting viewpoints from various “experts,” publication and wide distribution of data before peer review, and the retraction of multiple articles from multiple venues, including prestigious medical journals. Scientific and medical controversies have spilled over from their respective domains and reached the front page of the traditional press and news outlets: Should the public wear masks? Are certain drugs effective? How intensive should testing be? Who should be confined to their own living spaces, if anyone?

The dominant thinking in economics was also challenged. Variations of Keynesianism were dusted off and put into practice; previously generalized calls for more and more austerity have all but disappeared from the media.

At the same type, all sorts of misinformation has proliferated through both traditional and new media, leading the World Health Organization director-general, Tedros Adhanom Ghebreyesus, to declare, “We’re not just battling the virus; we’re also battling the trolls and conspiracy theorists that push misinformation and undermine the outbreak response.”² The misinformation and conspiracy theories have been fueled by politically motivated discord as well as differing viewpoints regarding the value of individual rights versus the rights of the community and the relative importance of saving the economy versus saving lives. They have generated uncertainty and skepticism regarding prevention strategies that have been proven to be effective in reducing the spread of COVID-19.

As the pandemic and the various responses to it continue to unfold, scientists, while feverishly working on developing vaccines and identifying effective treatments, are continuously trying to figure out many of the still obscure aspects of the disease. Politicians and public health officials are striving to adapt to the contradictory demands of the situation. Well-founded critical analyses of the various responses will hopefully provide a valuable resource for helping us face similar challenges in the future.

It is clear that the issues of this pandemic are complex and intertwined and cannot be addressed through a purely technological approach. As always, public health emergencies involve many aspects of our way of life: the different social, behavioral, and political priorities of different countries, communities, and individuals. Devastating experiences such as the COVID-19 pandemic bring into question the basic principles and values of our societies and our support infrastructures. Among the main factors in determining how well a country has fared in this devastating “stress test” are the strength, resilience, and robustness of the public health infrastructure and its ability to positively interact, coordinate, and relate with governmental agencies, the scientific community, and the public at large.

Preparedness has played a critical role in determining our success in dealing with the COVID-19 pandemic. We hope that in this new AJPH forum—through an exchange of experiences and ideas from a broad range of experts and practitioners—we can learn important lessons that will make us better prepared and help us design and implement a more robust and resilient public health infrastructure. And we hope that that this improved infrastructure, relying on the global experience, will be ready to quickly and decisively react to and successfully deal with the next potentially devastating challenges our communities will face.