Interview on COVID-19 with Professor Elias Mossialos, Brian Abel-Smith Professor of Health Policy, Head of the Department of Health Policy at the London School of Economics and Political Science (LSE) and Director of LSE Health, UK, and Chief Adviser to the Greek Government on the COVID-19 pandemic.
How was Greece’s successful COVID-19 response organised?
Greece’s handling of the crisis, and its low number of COVID-19 deaths and hospital admissions relative to other parts of Western Europe thus far, is largely due to the early introduction of physical distancing measures. These were accompanied by transparent and clear messaging. Partly as a result of this, but also to their enormous credit, most Greek residents respected government guidelines on social distancing.
By mid-February, international concern about the virus had become more prominent, and the Greek Prime Minister held a special pandemic response cabinet meeting to which I was invited. Even though COVID-19 transmission in Greece was still low, the meeting resulted in the introduction of pre-emptive social distancing measures, eventually followed by a full lockdown. By acting early and decisively, and applying principles of precaution, we were able to avoid overwhelming the health system. Thus we minimised transmission, which has ultimately allowed us to begin transitioning out of lockdown sooner than many other countries.
As Chief Adviser to the Greek Government’s response to COVID-19, in your opinion, what is the importance of science advice to policy-makers and how could it generally be improved?
Transparency is vital to the management of responses to health crises. This includes transparency of the scientific evidence received for the decision-making process, and how that scientific evidence is taken on board and appraised by decision-makers to formulate policy responses.
Many governments claim that they are being guided by scientific advice in making their COVID-19 policy decisions, but the scientific evidence they are receiving and the scientists they are receiving it from, has in some instances, been opaque. Black-box policy-making can lead to negative consequences. Not only is the public less likely to adhere to guidelines which are not backed by publicly provided scientific evidence, but this sort of policy-making also puts scientists at risk of being made scapegoats for policy mistakes.
I believe that questioning and critiquing evidence is necessary to ensure that it is of the highest quality possible, however, criticising and blaming scientists for policies is misguided. Indeed, it is the job of the policy-maker, and not the scientist, to combine scientific evidence with political, economic and social considerations. Additionally, it must be made clear where the scientific advice is coming from to provide assurance to the public and to other experts that sufficient diverse perspectives have been gathered, and that all eventualities have been planned for. Doing so will maximise the range of meaningful options that policy-makers have available, increase trust in policy, and subsequently improve the chances that people will adhere to it.
Greece has started gradually easing its lockdown measures. What are the most important actions during this next phase? What exit strategies should be taken?
As countries consider ways to ease lockdown measures and reopen economies, they must consider the epidemiological evidence and also take account of broader health, economic and policy implications. Lockdown measures should not be lifted all at once, and instead should be taken in a stepwise approach, which is constantly reviewed and evaluated, so the necessary adjustments can be made in a timely way. There is no ‘one-size-fits-all’ strategy to end lockdowns, nor can the course of events be reliably predicted. Responsiveness is vital.
Most exit strategies will rely largely upon the implementation of testing and contact tracing so that new outbreaks of the illness can be isolated and quickly contained. A sustainable exit strategy must be based on the virus’s epidemiology, but must also go beyond it. It has been politically challenging to implement social distancing measures, but it is — or ought to be — technically straightforward. In contrast, because of limited evidence, easing social distancing measures will be technically more challenging. In reality, this will be a process of trial and error. We will have to learn from each other and bear in mind that there will be challenges in translating the emerging evidence across different national contexts. We must not forget that a decade of austerity has left healthcare systems under-resourced and exposed. Future planning must include sustainable funding and building resilience to prepare for any potential major future health threats.
Do you think we will see a second wave of infections?
Viruses are unpredictable, we aren’t out of the woods yet. WHO has warned that the coronavirus “may never go away”. A second wave of the coronavirus may be inevitable but we don’t know what’s going to happen next and there is no proof that there will be rebounds or a second wave. Immunity to COVID-19 is still poorly understood, in terms of how individuals’ immune systems respond, how long immunity may last, and whether immunity against one strain confers protection against others. However, we cannot wait for proof, and attention should be focused on the best ways to avoid second or even third waves of COVID-19 infections. Research into the virus and our immune responses to it is of vital importance, and must accompany efforts to develop effective treatments and vaccines.
What can the European Union do to help the pandemic crisis?
Every country in the world is making efforts to tackle COVID-19 in their own geopolitical territories. However, these efforts are often disparate, and in some instances, they even undermine global solidarity. The recent announcement of the new €9.4 billion programme called EU4Health should certainly be commended, but there is still further work to do and changes to be made.
It is evident that there are several obstacles limiting European institutional and governance capacity which have in turn hindered the response to COVID-19 and its economic and social consequences. Many European countries were late in their recognition of and response to the disease outbreak, and going forward, several changes will need to be made to improve the regional situation.
Additionally, although the ECDC cooperates with WHO and neighbouring countries, its formal remit ends at the borders of the European Economic Area. This could be a shortcoming because pathogens don’t respect national frontiers, and therefore, its remit and function should be expanded. The ECDC should be given more authority for surveillance, preparedness planning, scientific advice, and the response to infectious disease outbreaks across all European countries.
What does Europe need to rethink and improve after the crisis?
The COVID-19 crisis has highlighted the need to improve health data collection and accurately measure the burden of disease. While countries in the EU have established systems for collecting mortality data, many do not capture enough information for a complete picture of population health. In addition to age, gender, ethnic group, and definition of severity of disease, further information should be collected about each case of illness.
Most countries list the underlying cause of death for each mortality case, but since death occurs most frequently among co-morbid, elderly patients, mortality may be the by-product of several causes which won’t be captured in these statistics. Mortality is one important component of the burden of diseases such as COVID-19, but there are also many others—including illness, disability, handicap and more—which are not captured under current systems. This has been demonstrated acutely in the COVID-19 crisis, since in countries without adequate testing capacity, many people with mild-to-moderate symptoms do nοt end up in hospital and are not diagnosed as having the disease. While most countries have mechanisms to track morbidity statistics from hospital data, few can comprehensively record morbidity in the community outside of hospital institutions. Many countries do not use personal identification numbers in their health data systems, which can lead to over-reporting or under-reporting of important information to assess the burden of illness. Furthermore, diagnostic terms used by countries, areas, practices, and even hospitals may vary.
The gaps and inconsistencies in data collection generate challenges in measuring the burden of disease, which in turn causes difficulties in assessing policy impacts and efficiency gains that are essential for public health decision-making. However, it is important to highlight that public-health priority setting is dependent upon many factors, of which disease burden is only one component. Political, social, and behavioural factors also play key roles in public health decision-making. In Europe, the poorest populations generally face the highest risk for ill health, but typically those who are the most vocal players for policy-making do not prioritise poverty alleviation at the tops of their lists. This highlights that modelling the burden of disease under different scenarios is an important tool for public health decision-making, but it is not the only one in the box.