Covid-19 aftermath requires as much focus as the start

Routine immunisation programmes, sickness care for children and adults, surgery capacity and mental health services have all been disrupted

By Atul Gawande

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Published: Sun 19 Mar 2023, 9:17 PM

Last updated: Sun 19 Mar 2023, 9:39 PM

By the end of 2021, Americans were dying three years sooner, on average, than they were before Covid-19, with life expectancy falling from 79 years to 76 years, according to the Centres for Disease Control and Prevention’s most recent statistics.

Such astonishing declines have occurred planet-wide — the first global reduction in life expectancy since World War II. Total deaths jumped 13 per cent in the first two years of the pandemic. Estimates indicates that about 15 million more people died than would have been expected. Human development has been pushed into reverse.


Most of these deaths have been a direct result of the coronavirus. But the pandemic also killed people by damaging health care more broadly, which will itself have enduring consequences. Years of gains and investment have been wiped away. And we have only started to see the effects.

We can reclaim our lost ground and resume the past decades of advancement in human survival and health. But that requires holding on to our sense of urgency and doing more than simply hoping things will turn around. The aftermath of pandemics requires as much focus and response as the start. And the United States’ leadership is crucial. We rallied the world to invest in emergency relief. Now we must rally the world to invest in recovery.


Across the globe, including here at home, the pandemic diverted resources from essential health needs of all kinds. Routine immunisation programmes, sickness care for children and adults, cancer treatment, ambulance services, surgery capacity and mental health services have all been disrupted. Covid inflicted economic harm that led governments to slash even meagre health budgets. It disrupted supply chains for basic medical supplies. And it has driven health workers, already in short supply, from the profession here and abroad.

The harm to health care has been wide, but the repair must start with the decimated and under-resourced ranks of primary health care workers — our first-line, community-based doctors, nurses and outreach workers. Attention in crisis tends to focus on hospitals and emergency responders. However, primary health workers deliver the vast majority of the services responsible for longer lives, including for stopping the next pandemic. They are the backbone of a functional and effective health system.

Decades of evidence show that primary care teams are also capable of remarkable improvements in health when they’re appropriately trained, paid and — this is crucial — given the capacity to reach out regularly to every household that they serve. Keeping people connected to the most important services for their health and survival, and working to make sure no one falls through the cracks, adds years of life.

When researchers in Ghana tested, in a randomised trial, the impact of financing neighbourhood health clinics that included outreach workers and nurses who provided first-level care and offered preventive measures such as malaria nets and family planning, the results were dramatic. Child mortality fell by over 50 per cent in three years and by nearly 70 per cent in seven years. Women also markedly increased the spacing between births, which significantly reduces maternal mortality risk. In Costa Rica, investment over decades in such a primary care system has delivered an 80-plus-year life expectancy — one of the longest in the Americas despite Costa Rica having just one-sixth of the United States’ income per capita.

Here at home, during the pandemic, health leaders came to recognise the importance of investments incorporating, for the first time, large numbers of community health workers into local health systems, particularly where life expectancy is lowest. These workers were essential in getting 95 per cent of older Americans vaccinated against Covid. Now they can also play a vital role in ensuring that gaps in access to other kinds of lifesaving care are closed.

The global primary care work force also provides critical capacity to detect future public health threats and deliver a response. When people have a weird rash, a nasty cough or a bad fever, it’s a local doctor or nurse whom they most depend on to recognise that it could be mpox (as monkeypox is now called), a new coronavirus variant or a deadly avian flu breaking out. And then it’s those same primary care professionals who deliver the needed testing, vaccinations and treatments to the community at large. Yet around the world, they are routinely among the most neglected and underfinanced part of the health care work force.

Which brings us back to the conditions that have driven the first global decline in life expectancy in generations. A doubling of human life span in less than a century, one of the greatest accomplishments in history, was achieved through worldwide cooperation on sustained efforts to address many individual causes of death and sickness — polio, HIV/AIDS, diarrheal illness, malaria and childbirth risks, to name just a few. These efforts have saved millions upon millions of lives, but they depend on primary health workers to achieve their impact. This workforce is the same one we now must count on to incorporate management of future coronavirus variants into routine care.

A little over a year ago, when I took up my role at the US Agency for International Development, where I oversee foreign assistance for global health, one of my great hopes was to help repair the systemic damage that’s been done. So I was thrilled when President Biden requested funding from Congress last year not only for these critical disease-driven programmes and to prepare for future pandemics but also for a Global Health Worker Initiative. It would provide targeted investments abroad, such as in training and in digital tools, that advance the world’s efforts to rebuild the work force needed to restore health and survival. The omnibus budget that passed in the final weeks of the last Congress dropped this funding, however.

Last week, the president again put forward a budget to back this vital effort. Recovery has received far too little attention and resources, and Congress must do its part to change that.

In the meantime, I have worked with my USAID team to do what we can. Starting with governments in seven countries that we assist — Ivory Coast, Ghana, Indonesia, Kenya, Malawi, Nigeria and the Philippines — we have set a goal to marshal resources to restore death rates to better than pre-pandemic levels by 2025 for, at minimum, children under 5 and women under 50. To accomplish this, we’re working country by country to analyse the gaps in essential health services and the underlying weaknesses in the primary health care work force upon which those services rest. We are also working to partner with governments and international institutions to focus resources on closing those gaps over the next two years.

As the World Health Organization has put it, we need countries “to make a radical reorientation of their health systems toward primary care.” This is how we will make a real recovery from the pandemic — and be prepared for the next one. And it is the only path we have back to a world of longer and healthier lives.

Atul Gawande is the assistant administrator for global health at the United States Agency for International Development.

This article originally appeared in The New York Times.

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