WHEN COVID-19 struck five years ago, hundreds of thousands died because of a lack of oxygen. Even in rich countries, demand for oxygen overwhelmed hospitals in the first wave of the pandemic. In low- and middle-income countries, where nine out of ten hospitals had no medical-oxygen capacity, desperate families went to extraordinary lengths to procure oxygen cylinders to try to save their loved ones. In response, close to $1bn was mobilised to help these countries provide emergency supplies of cylinders and to invest in more scalable and cost-effective approaches, such as pressure swing adsorption (PSA) plants that create medical oxygen from the atmosphere. These investments, alongside training, have constituted the biggest expansion in access to medical oxygen such countries have ever seen. In Nigeria alone, 73 hospitals now have or are on track to have PSA plants creating oxygen that is then piped to hospital beds or used to fill cylinders distributed to other health facilities.
Although the original intent was to save lives threatened by covid-19, these investments are now saving lives in other ways. Many deaths from maternal and neonatal complications, or from traffic accidents or other traumas, can be prevented if medical oxygen is available. Many life-saving surgical procedures require the gas. It has been estimated that investing $4bn in oxygen provision in low- and middle-income countries could save more than 800,000 lives by 2030, including 330,000 children under five.
Having more oxygen to hand also helps with pandemic preparedness. Many of the pathogens monitored by the World Health Organisation for their potential to generate pandemics cause respiratory distress, so immediate access to oxygen can be crucial to reducing the potential death toll from an outbreak.
Better access to oxygen is just one example of how what started as an emergency response to covid-19 has turned into a step-change in health-system capabilities. While the extraordinary speed at which MRNA vaccines were developed got most of the fanfare, the massive impact of these other legacies has received relatively little attention.
Disease surveillance is another example. To track the pandemic and identify the emergence of variants such as Omicron, poorer countries secured support to expand molecular testing, wastewater surveillance and genome-sequencing networks, and to build the systems and human capacities to interpret and respond to the data. For example, by 2023 Uganda’s National Health Laboratory had established wastewater-based surveillance at four sites.
The benefits of these investments go far beyond covid-19. In Malawi, wastewater surveillance helped public-health officials track and ultimately halt an outbreak of wild poliovirus type 1. In Indonesia, genome sequencing played an essential role in fighting covid-19 and will be used to develop more accurate treatment to fight other diseases including tuberculosis (TB), cancer and brain diseases. In Congo, rapid molecular testing tools have played a vital role in understanding the spread of Mpox. While there are still big gaps in being able to detect and identify dangerous pathogens in poorer countries, covid-19 turbocharged progress.
The pandemic also helped dismantle longstanding resistance to at-home testing. Initially, many health authorities hesitated to support self-testing programmes owing to concerns about accuracy and misuse. However, the realisation that overwhelmed health systems could not manage the volume of testing required prompted a shift towards prioritising accessibility. For example, more than 2bn lateral flow tests have been provided across Britain since 2020.
Greater acceptance of self-testing reflects a broader recognition that empowering individuals to take control of their health is a crucial part of any public-health strategy. Arguably, this should have been understood earlier. People engaged in the fight against HIV/AIDS learned long ago that enabling those most affected by the disease to take the lead yields better results. Countries with robust community-health networks can mobilise populations and disseminate information more effectively than those relying on top-down approaches. Many Western countries— constrained by rigid and highly medicalised health-care systems—struggled to implement social distancing, mass testing and vaccination during the pandemic. Many poorer countries, on the other hand, benefited from well-established, more flexible community structures.
As memories of the covid-19 emergency fade, we seem to be sliding back to the cycle of panic and neglect that has typified past approaches to pandemics. It has always been difficult to convince people that it is worth continuing to invest in a more sustained approach to improving global health security when success is measured in nothing happening. Although numerous studies show the potential cost to the global economy of infectious-disease outbreaks, the benefits of avoiding such risks tend to be seen as paling in comparison to the benefits of addressing immediate health issues.
People who work in pandemic preparedness and outbreak response often talk about this arena as if it were a distinct set of health-system capabilities. Yet most of the improvements in infrastructure and capacities required for pandemic preparedness, including improved access to oxygen and better disease surveillance, can also deliver immediate health benefits. Perhaps the trick to securing political and public support for improvements in preparedness would be to frame them more as collateral benefits of investments that more directly meet people’s immediate health needs, rather than as separate priorities.
Increasing investment in fighting TB would serve as an example of such a “double whammy” approach. Now the deadliest infectious disease, killing 1.25m people per year, it puts a huge health and economic burden on the world’s poor. Beating it would save millions of lives and boost productivity. According to the Copenhagen Consensus Centre, a think-tank, every dollar invested in averting TB deaths returns on an average $46 in economic benefits. Moreover, the investments required to combat the disease more effectively—including in surveillance, molecular diagnostics and x-ray screening—would also build capacity and infrastructure vital for pandemic preparedness. It is no accident that some of the countries that did best in responding to covid-19, such as Japan and South Korea, had also invested heavily in fighting TB.
Covid-19 exposed the stark inequities in global health. It also showed that health crises know no borders and that our resilience is only as strong as the weakest health system. With climate change likely to fuel pandemic threats, given the impact of ecological change on zoonotic transmission, we have a shared interest in strengthening our defences. When there are cost-effective approaches to tackling current health problems that also boost pandemic preparedness, we should grab them. ■
Peter Sands is the Executive Director of the Global Fund to Fight AIDS, Tuberculosis and Malaria. He was chief executive of Standard Chartered, a bank, from 2006 to 2015.