COVID-19, global governance and the impact on children
A conversation with public health expert Devi Sridhar
Expert Q&A | 5 minute read
How well is global governance responding to COVID-19? And is the pandemic affecting children in ways we may be overlooking? Earlier this month, the Global Insight team invited Devi Sridhar, Professor and Chair of Global Public Health at the University of Edinburgh, to join us for a discussion on these and other issues related to the pandemic. In the Q&A below, our partnership lead Yoonie Choi followed up with Devi on some of the most interesting aspects of our discussion. The transcript has been edited for length and brevity.
Data tracing and surveillance have helped countries limit the impact of COVID-19, but they have raised concerns over loss of privacy. Are we giving enough thought to the rules and norms for health surveillance?
Devi Sridhar: I think the priority for the global community has been on how to collect the necessary data and respond effectively to the outbreak, and I haven’t seen as much discussion on the rules and norms for health surveillance. These norms may also shift as the epidemic progresses. For example, the lockdowns we now have in European countries would have been unthinkable a few weeks back, but compliance is reasonably high now.
There's also a difference between public health surveillance at a population level and concerns about privacy and protection at an individual level. Public health surveillance is usually just at the population level, with questions like “How many people have flu?” The data on these measures is anonymous. But because of the need to trace contacts and to know who has the virus in this pandemic, the data can no longer be anonymous because you have to identify individuals. And that's where you're seeing a tension between public health surveillance and the need to know where the virus is in the population. The anonymous level no longer works. It has to be at an individual level and a household level, and that's obviously where each country is having to find its own way through.
Do you think the global governance system is bearing up well?
DS: The World Health Organization has been playing a constructive role. Given rising geopolitical tensions, it has had to be diplomatically smart, technically strong, and to communicate clearly. The WHO has had to navigate these challenges, while also paying attention to low- and middle- income countries, which are usually left behind. In this context, I think the agency has done a good job in terms of mailing out test kits to low-income countries early on and putting out daily situation reports and accurate information.
I think the Health Emergencies programme is holding up as best as it can, and that it’s more responsive than in 2014 with the West Africa Ebola outbreak. It's quite stretched because it's a small team having to respond to a lot of countries. The real challenge is now going to come when the virus starts taking its toll in low- and middle-income countries, and we'll be looking at WHO, which is not a financing agency. For this reason, I think the World Bank will become important, so we'll see what the Bank is able to do rapidly to help countries.
Countries with recent experience of tackling epidemics like SARS and Ebola seem to be managing COVID-19 most effectively. In sub-Saharan Africa, for example, Senegal quickly set up a new task even before the virus arrived. But the Global Health Security Index ranks the U.S. first and Senegal 95th. Do we need to revise our assumptions about who's prepared to deal with public health risks?
DS: I think this points to the biases and assumptions put into the creation of these indices. Judgements and subjective decisions go into deciding what metrics are important for health security, so these are not objective measures of preparedness. COVID-19 has shown that this ranking is not in line with what we are seeing in terms of response.
I think a lot of it has to do with complacency about what infectious disease outbreaks could look like in a high-income setting. I mean, who would think New York City would look like it does now? These metrics are only as good as what you're measuring within them.
So, going forward, it will be interesting to look at these indexes and actually see if we need to change the way we build them. I can't really say exactly what could be shifted within the Global Health Security Index, but I think that will be a project that people will do after this.
Models have led to dramatic changes in public policy. For instance, Imperial College’s modelling led the United Kingdom to radically alter its approach. But with a virus that’s not yet fully understood, how much should we rely on models?
DS: I do find models useful [...] because they’re a scaffolding on what things could look like in the future. But they have to be cross-checked with other sources of data such as policy documents, actual talking to front-line staff, analysis of other countries’ policies and consideration of data even if it is preliminary and only descriptive.
For example, in this outbreak, it might be more useful to look at a country's past history of dealing with an outbreak and thinking through the policy response rather than just going on broad sweeps of big policy instruments. It’s also always useful just talking to people in the field, who understand the countries, such as social scientists. We learned this from the West Africa Ebola outbreak. During the crisis, anthropologists were useful because they understood burial practices. They also were helpful in understanding that perhaps you can't just roll in with a military response and start vaccinating people. You have to build trust within populations, understand and think about questions like how you actually implement interventions based on people's social context. It's always very useful not to think of people just as kind of biological beings, but actually as part of a culture, a part of the society, and how and what your interventions might look like in that context and how they could be more effective.
So, I think you just have to have different data sources and work across them. And it's not going to be perfect, because this is all forward looking. And a lot of what we're trying to build off is uncertain data sources, but it's the best we can do.
What are your biggest concerns about the impacts of the pandemic on children?
DS: I worry about increased child abuse and children losing access to supportive environments outside the household, such as schools and recreational programmes; more kids falling into poverty and going hungry; the loss of education and teacher interaction, especially for kids who need this support; limited social interaction with other kids and play, which is important for social development and physical activity; the loss of loved ones and caregivers – will we see COVID-19 orphans?; and, finally, delayed paediatric care for non-COVID conditions because of overwhelmed health systems.
I think one of the most concerning is delayed pediatric care. It’s very important to remember all the kids who are going to lose access to routine vaccinations and also all the children who need care for things like diarrhea, who may not get help. So basically, if you have your whole health sector focused on one disease and nothing else, what does it mean? And, beyond children, for example, what does it mean for women giving birth?
Again, the main narrative I hear is that children will be fine. But children will also be impacted in different ways, and we need to be attentive to these so we can respond with interventions. I'm starting to build a research project and [during the 2nd week of April] we just finished doing some scoping. We started digging out some of the early data from Italy about what is happening with pediatric care. If there's anyone from UNICEF who'd like to be looped into that project, I can show you some of the early work our team here has done.
Devi Sridhar is a Professor at the University of Edinburgh where she holds a Personal Chair in Global Public Health. She is Founding Director of the Global Health Governance Programme and holds a Wellcome Trust Investigator Award. @devisridhar
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