"If a man knows not to which port he sails, no wind is favourable"
The point Seneca was making is that without goals, then it doesn’t really matter what you do, because it won’t be successful. It can’t be. Success has not been defined, and so success cannot be achieved. With no sense of direction, you'll just get tossed about by the waves.
I think that’s a fair description of where the WHO is now with its approach to pandemic risk management. It doesn't seem to know what the solution is, nor where it can be found. But without any stated goals for the world – global or national – and no specific outcomes to target or plan for, both it and the world are drifting aimlessly from one crisis to the next.
It needn’t be this way.
The Pandemic Papers
The WHO has written three major papers on global pandemic influenza preparedness. The most recent was published in 2009, building on the earlier ones from 2005 and 1999.
There is plenty of good advice in these papers (much of which was ignored by policy-makers during Covid-19) but what stands out to me, is that there is no goal. Nowhere in any of these papers does the WHO state the overall outcome that all of this planning and preparation is supposed to achieve.
This is not a trivial point.
Plans exist to achieve goals. The goal is the destination and the plan is the route to it. So how can I build a plan without first knowing what outcome it is supposed to achieve? How can I set a course for a port which has not been determined? I can’t.
All planning must begin with goal-setting, including pandemic planning. So in these papers, there should be a clear, worthwhile goal that the nations world can aim for, and around which they can build their plans (whether the nations go along with it is another matter) but the WHO seems to have missed that point. Instead, we get vague recommendations, pointless exhortations, and consultant-speak.
For example, in the 2009 paper (p11), the WHO says: “Effectively meeting the challenges of the next influenza pandemic will require robust and extraordinary advance planning on the part of WHO and countries worldwide.” I’m sure it will, but what does the WHO mean by ‘effectively meeting the challenges’? What does it mean to be ‘effective’, and by what metrics would I measure it? How would I know whether my planning is on course to be effective? (What am I supposed to do with this advice?)
Other advice is equally vague: “The goal of recommended actions during these phases is to reduce the impact of the pandemic on society.” What does it mean to ‘reduce the impact’? Reduce it from what, and to what? If we were to prevent a single infection then we would have reduced the impact on society. Would that be enough? It’s a bit like saying, ‘the goal is to win’, or ‘the goal is to solve the problem’. (Again, what am I supposed to do with this advice??)
There is much talk of strengthening systems or minimising risks, and more international coordination is always recommended, but nowhere do they state what specific outcome all of this activity is supposed to achieve. How strong do our systems need to be? How do we measure their strength? How should we co-ordinate, both in advance and in the midst of an outbreak? How can we co-ordinate, when we don’t even know what we're trying to achieve?
The lack of a goal around which to orient our risk management plans is a major hindrance to global pandemic prevention. Part of the reason why the WHO has neglected to offer one (aside from politics) is that the organisation is largely populated by medics, and their perspectives on pandemic influenza are shaped by their experiences of seasonal influenza.
Let me explain…
Seasonal Influenza vs Pandemic Influenza: Hurricanes vs Fires
Hurricanes exist independently of our actions. We can't stop them, in other words. All we can aim to do, is to endure them better. So we stockpile resources, board up the windows, head down to our shelter if we have one, or get out of town if not. We understand that the hurricane is going to do whatever it is going to do, and we endeavour to make ourselves as resilient as possible to it.
Fires are different to hurricanes in that they are interdependent. That is, our fire-fighting actions will determine the path of the fire. If we act quickly, the fire can be snuffed out before it gets going. If we stand around looking at each other, then it will spread and grow and become a much bigger problem. A pan fire or a few sparks from a faulty electrical heater can be suppressed with a fire blanket, or it take out a whole apartment block; it all comes down to our risk management response.
The point is that medics treat pandemic influenza like a hurricane, when thy should be treating it like a fire. They take for granted that it will happen and that there’s nothing they can (or should) do to stop it. So they see no specific epidemiological outcome to be achieved, other than a vague sense of ‘doing better’ i.e. fewer cases, less stress on the health service, etc.
There are a few reasons for this.
One is that the virus mutates quickly, so herd immunity isn’t an option as vaccines are only temporarily effective. Another is that medics are trained to cure individuals, so they are more focused on what happens after people get infected, not what could or should happen in advance to prevent it.
A third, less-appreciated reason is that a seasonal influenza virus is not threatening at the population level. Both the R number (less than 1.5) and the IFR (less than 0.1%) are low, so the overall threat it poses to society is bounded. It may cause a lot of deaths in absolute terms, but those deaths are steady from one season to the next, so we know what to expect. Decades of experience has shown us that there is little risk of wider societal disturbance from a seasonal influenza virus. Seasonal influenza has ‘thin tails’, as they say.
Pandemic influenza is more dangerous than seasonal influenza. It generally has a higher R number and a higher IFR, and it may be a novel pathogen too, at least insofar as there is little existing immunity and novel medicines will be required. Pandemic influenza may also exhibit other nasty features such as asymptomatic / pre-symptomatic transmission, unknowable long-term effects, or a high levels of super-spreading (high dispersion ~ the k number) all of which makes it significantly more dangerous at the individual and population levels. Pandemic influenza has ‘fat tails’, making it significantly more dangerous than a regular seasonal influenza.
The problem we have is that the medics at the WHO have taken their passive, medical approach from managing seasonal influenza into their fight against pandemic influenza. But pandemic influenza is a completely different beast, and the passive approach can be suicidal. It's like hoping that the pan fire will burn itself out, when it's far more likely to engulf the kitchen, the apartment, and then the whole tower block.
Pandemic influenza must be treated like a fire, not a hurricane. We must attack it to prevent it, not prepare to endure it. The goal must be to find it and snuff it out ASAP.
Speaking of goals…
Without Goals, We Cannot Co-Ordinate
Co-operation and co-ordination enable us to become more than the sum of our parts. This is as true for ants, herds of animals, and human beings in their communities, as it is for whole nations in a global society. So international co-ordination will be essential if we are to gather and disseminate information, implement travel restrictions, and manage global supplies of medical resources – all of which play essential roles in pandemic prevention.
However, we can’t co-ordinate at the international level unless we first have goals and plans in place at the national level.
Think about it like this… If I don’t know what you’re planning to do when the time comes, then I can’t co-ordinate with you. I can only watch and react. If I don’t know what I’m going to do when the time comes, then I can’t co-ordinate with you, or with anyone! We each need to have some idea of what we would do in these future scenarios before we can make any progress on co-ordinating those future responses.
Exhortations from the WHO for more co-operation and co-ordination do not fall on deaf ears: they are seeds falling on barren ground. ‘Co-operate!’, they say. But with who, and on what, and to achieve what outcomes? Without goals and plans at the national level, there is nothing to co-ordinate international level.
It’s going to be very difficult to protect ourselves from PPPs until that changes.
Without Goals, We Cannot Progress
The practical reality is that we can achieve very little at all in pandemic risk management without first stating our goals.
Goals are essential because they streamline our decisions: by stating a goal, we automatically define the infrastructure and resources needed to achieve it. At the same time, we eliminate all other potential decisions and paths. Specific goals thereby create a finite ‘to do’ list for our pandemic prevention efforts.
Goals also serve as a metric against which we can assess our performance. In preparation, we can track our progress against our ‘to do’ list. When the outbreak begins, we can determine whether we are on course to achieve our primary goal, or whether we need to change tack. Goals guide our decision-making at all times.
Without clear goals, preparation efforts will be ignored, deferred, or become box-ticking exercises for apathetic civil servants, while plans will be implemented reactively, amid a media storm, and driven by the political expediency of the day. We’ll have no choice but to respond to events as they happen, instead of taking control and setting our own course. Our attention will be dragged from one thing to the next, and ‘managing the narrative’ will take prominence over managing the outbreak. The Covid-19 pandemic was a case-study in how badly things can go wrong in these scenarios. As things stand, we are on course to repeat it.
Conclusion
A pandemic is a risk management problem. Risk management problems start with goals, and the risk management process is what takes us from where we are, to wherever that goal may be. By first sketching our goals and ambitions, we will naturally create a shared direction of travel, which then forms a basis for greater international co-operation and co-ordination.
We may not agree on the exact details of what we want to achieve at a national level, but we don’t need to either. As long as our national goals have ‘enough’ in common, we can work together in areas of shared interest, and there will be more coherence to the next global response, when the time comes. The WHO has, potentially, an important role to play in helping to shape those goals.
In the WHO’s 2005 pandemic paper, they stated that one of the WHO’s objectives was: “To promote the development of harmonized global, regional and national influenza pandemic preparedness plans.” This was the right idea. We need national plans that align, and that allow for co-operation and co-ordination. However, the next logical step is that we need national goals that align, since the plans are determined by the goals.
The WHO has made attempts to build on this idea, but they still fall short of what is required. A 2018 paper focused on the harmonisation of preparedness and response, but again, it misses the key point: we need to harmonise the goals first, then the plans will fall into place. In the absence of such goals, the WHO is once again left issuing nebulous advice like 'identify priorities' and 'strengthen capacities', which is too vague, lacks purpose, and will only be put on the long-finger by politicians and civil servants alike.
If we are to protect the world from future pandemics, we need to think about clear, ambitious, national and global goals: goals that can align our responses and which all the world’s nations can get behind. As things stand, we don’t appear to have any idea that this is even required, and it is costing us time, resources, and ultimately, lives.
To summarise, we need goals:
- To motivate and inspire us
- To achieve worthwhile outcomes
- To provide an organising structure for our pandemic risk management efforts
- To streamline our decision-making
- To avoid box-ticking and other forms of political waste
- To create metrics for assessing our performance
- To provide a basis for co-ordinating international efforts
- Because we cannot solve these problems without them!