1 PANDEMICS: Past, Present, Future

Published in 2021 by the Mahatma Gandhi Institute of Education for Peace and Challenges & Opportunities Sustainable Development, 35 Ferozshah Road, New Delhi 110001, India

© UNESCO MGIEP

This publication is available in Open Access under the Attribution-ShareAlike Coordinating Lead Authors: 3.0 IGO (CC-BY-SA 3.0 IGO) license (http://creativecommons.org/licenses/ ANANTHA KUMAR DURAIAPPAH by-sa/3.0/ igo/). By using the content of this publication, the users accept to be Director, UNESCO MGIEP bound by the terms of use of the UNESCO Open Access Repository (http:// www.unesco.org/openaccess/terms-use-ccbysa-en). KRITI SINGH Research Officer, UNESCO MGIEP The designations employed and the presentation of material throughout this publication do not imply the expression of any opinion whatsoever on the part of UNESCO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries.

The ideas and opinions expressed in this publication are those of the authors; they Lead Authors: NANDINI CHATTERJEE SINGH are not necessarily those of UNESCO and do not commit the Organization. Senior Programme Officer, UNESCO MGIEP

The publication can be cited as: Duraiappah, A. K., Singh, K., Mochizuki, Y. YOKO MOCHIZUKI (Eds.) (2021). Pandemics: Past, Present and Future Challenges and Opportunities. Head of Policy, UNESCO MGIEP New Delhi. UNESCO MGIEP. SHAHID JAMEEL Coordinating Lead Authors: Director, Trivedi School of Biosciences, Ashoka University Anantha Kumar Duraiappah, Director, UNESCO MGIEP Kriti Singh, Research Officer, UNESCO MGIEP

Lead Authors: Nandini Chatterjee Singh, Senior Programme Officer, UNESCO MGIEP Contributing Authors: CHARLES PERRINGS Yoko Mochizuki, Head of Policy, UNESCO MGIEP Global Institute of Sustainability, Arizona State University Shahid Jameel, Director, Trivedi School of Biosciences, Ashoka University W. IAN LIPKIN Contributing Authors: John Snow Professor of Epidemiology, Charles Perrings, Professor of Environmental Economics, Vice-Chair, Diversitas, Mailman School of Public Health, Columbia University; Global Institute of Sustainability, Arizona State University W. Ian Lipkin, John Snow Professor of Epidemiology, Mailman School of Public Professor of Neurology and Pathology, Health, Columbia University; Professor of Neurology and Pathology, College of College of Physicians and Surgeons, Columbia University Physicians and Surgeons, Columbia University B.N. Satpathy, Senior Consultant, Office of Principal Scientific Advisor to the B.N. SATPATHY Government of India Senior Consultant, Suneet Mohan, Consultant, Office of Principal Scientific Advisor to the Office of Principal Scientific Advisor to the Government of India Government of India Devesh Kumar, Consultant, UNESCO MGIEP SUNEET MOHAN Designed by Prasun Mazumdar Design, Gurgaon, India Consultant, Printed by Lustra Printing Press Office of Principal Scientific Advisor to the Government of India Printed in India DEVESH KUMAR Consultant, UNESCO MGIEP

3 Preface

Please note: The research, and findings presented in this The booklet took about 6 months till its completion. document are based on data collected until January, 2021. It was a herculean task as the goal posts kept changing, we were flooded with new information on a daily basis As the world continues to grapple with COVID-19, regarding a relatively new phenomena. However, as this booklet comes in handy to answer and reflect upon we sailed through uncharted waters and endured the basic questions encompassing the word “pandemic”- the hurdles, we believe we have a story to tell through this what, where, when and how of it. The genesis of the booklet and hope the readers find it useful primarily as book began when we were approached by the Office of an information note on pandemics in general. It also Principal Scientific Adviser to the Government of highlights some of the complexities we have to face India to produce a document that was not meant to be: when making decisions to combat the disease but at (i) a compendium for training individuals on pandemic the same time oversee the welfare of the people across science; (ii) an exhaustive compilation of do’s and don’ts multiple domains and not just linked with the disease. with respect to a pandemic; and iii) a commentary on global best versus worst practices to combat the We acknowledge that an exhaustive evaluation of the pandemic. current pandemic- COVID-19 and its aftermath might not be possible, given that it is still ongoing and we What this booklet does aim to provide is the following: make no such claims. However, we do try to gauge the (i) basic information about key concepts associated with magnitude of its impact on the world we live in and and procedural understanding of the term “pandemic”; derive preliminary inferences based on facts to enhance (ii) a synopsis of past and present pandemics with our understanding. focus on lessons learnt- primarily from COVID-19 and preparedness for future; iii) a brief overview of If there is one thing that the COVID-19 pandemic has mitigation policies adopted by countries across the globe revealed it is the power of oneness- power of global to combat the pandemic iv) an account of direct and coordination, international scientific collaboration, and indirect impacts of pandemic on various sectors of the aligned action in fighting against the virus. We are all society ranging from health, education, to economic, in this together. As we learn to live with the fact that and v) a preliminary inference of its ramifications COVID-19 is here to stay for a while, and continue to on progress towards Sustainable Development Goals acclimatize to the “new normal”, our aim should be (SDGs). Therefore, this booklet should be considered to trust scientific evidence and align our actions in a as a primer on pandemics with the main objective of manner that maximizes “normal” living and minimizes familiarizing its readers with key concepts, measures, inconveniences caused due to the pandemic. We hope lessons and preparedness on pandemics. this booklet will provide its audience with necessary information to help achieve this goal.

5 04

TABLE OF CONTENTS

Foreword 9 Q5 38 Q10 66 Q15 102 Executive Summary 10 What are the causes What are the health impacts What have been the Introduction 16 of emerging infectious of COVID-19? economic policies in response diseases? to COVID-19?

Q1 18 Q6 42 Q11 74 Q16 106

What is a pandemic and how Which are the main pandemic What health sector specific What have been the overall is a pandemic declared? viruses and what are the key policy responses can be effects of COVID-19 on the differences across them and implemented? SDGs? the type of treatments used?

Q2 22 Q7 48 Q12 78 Q17 112

What is the procedure used What are the main causes How has COVID-19 impacted What are the key lessons we to declare a pandemic? or drivers behind the school education? can learn from the COVID-19 emergence of pandemic pandemic and opportunities diseases? to be explored in preparation for future pandemics? Q3 26 Q8 52 Q13 86

Is it legally binding for all What are the factors What are some key policy References 120 countries to adhere to affecting the spread responses in education? pandemic guidelines? Can of pandemics? a country defy a pandemic declaration? Q4 30 Q9 56 Q14 92

What pandemics have we What measures were What have been the witnessed over the past 100 adopted by countries to economic impacts of years? combat COVID-19 and how COVID-19? successful have they been? Foreword

COVID-19 pandemic is unprecedented in human This document is a collation of facts and figures history. It has brought to the forefront some which are informational in nature. It highlights some unimaginable challenges and has highlighted the need of the complexities we have to face as a nation when for resilient and adaptable health, economic, and social making decisions to combat the disease but the same systems. It is only through an unwavering commitment time oversee the welfare of the people across multiple to COVID appropriate behaviour and adoption of an domains and not just linked with the disease. I hope integrated approach towards vaccine development that that this document will serve as a useful tool not only we can mitigate and recover from damage caused by for policymakers who are at the forefront of devising pandemics like COVID-19. plans to combat the spread of disease, but also for other stakeholders like educators, economists, health care As the world continues to grapple with this pandemic, personnel who are tasked with implementing the plans, it is essential to understand the basic questions and most importantly people by and large who are encompassing the word “pandemic”- the what, where, ultimately responsible for executing the plans, thereby when and how of it. This is the motivation for the deciding success or failure in curtailing the spread of the document. disease.

The primary aim of this document is to provide basic I would like to congratulate Prof Anantha Kumar information about key concepts associated with and Duraiappah, Director UNESCO MGIEP, his entire procedural understanding of the term “pandemic”. It team and the eminent contributors in taking the itiative gives a synopsis of past and present pandemics with and bringing out this document focus on lessons learnt primarily from COVID-19 and preparedness for future. It sheds light on the mitigation Lastly, I thank my team consisting of Shri B.N. policies adopted by countries across the globe to combat Satpathy and Shri Suneet Mohan for coordinating and the pandemic and gives an account of direct and indirect contributing towards building of this document impacts of pandemic on various sectors of the society.

K. VIJAYRAGHAVAN Principle Scientific Advisor to the Govt. of India

9 It is against this background that well as reports from the relevant this document has been prepared. international organizations are What is a The objective of this document is to extensively used in this document. provide basic facts about pandemics, The dates on which the data is pandemic? past, present and future. It is meant presented range from October to be a primer on pandemics. It to December as the numbers are At the time of finalizing this provides a brief overview of some constantly changing as the virus document (10 December 2020), of the key factors that might help works its way through the world. there were 68,165,877 confirmed Executive understand and address pandemics, cases of the COVID-19 pandemic especially the ongoing COVID-19, The document is organized and 1,557,385 confirmed deaths Summary and their impacts across society at around 17 questions beginning across 220 countries, areas and the global scale. This document is with what is a pandemic and the territories.1 The majority of the cases not meant to provide an exhaustive international legal-institutional as of October 1st 2020 have been explanation of pandemics. process to declare a pandemic. the United States of America (USA), n December 2019, References to specific do not reflect These are then followed by India and Brazil and which are still first signs of a the official views of the government. questions on the COVID-19 not seeing a flattening of the curve mitigation policies that have as shown in Figure 1. potentialI pandemic The document is targeted primarily been used to date and the in the form of a new to policymakers tasked with lessons learnt. The next set of Although the WHO does not have handling pandemics but also to questions focus on the direct a binding set of rules for declaring a strain of pneumonia stakeholders in other sectors such as and indirect impacts of the pandemic, the organization uses the emerged in city of education and development who are COVID-19 pandemic across the International Health Regulations Wuhan in the Hubei affected by pandemics. The primary health, education and economic (2005) (IHR) as the global legal data used in this document are from sectors and extrapolating instrument to help protect nations region of China. Due recognized databases such those these on the progress towards from international spread of disease to delayed reporting by the World Health Organization achieving the Sustainable including public health risks and at local levels and (WHO), John Hopkins University Development Goals (SDGs). public health emergencies. The and the Centers for Disease Control The document ends with some key IHR requires countries to report before public health and Prevention (CDC). Peer lessons and recommendations on the public health events and outlines systems could control reviewed published literature as way forward. criteria to determine whether or the localized outbreak, not a particular event constitutes a “public health emergency of similar clusters of COVID-19: CASES international concern” (PHEIC). United States India Brazil Argentina Norway Sweden France Germany South Korea Indonesia China pneumonia started 18,000,000 The bottom line we can learn from appearing in other 16,000,000 COVID-19 is the need to strengthen The pneumonia was attributed On 11 March 2020, the 14,000,000 the rules and legislation within the

parts of the world. 12,000,000 WHO for it to declare a pandemic to a coronavirus. In India, WHO declared the the first case was reported on 30 10,000,000 that is universally accepted by all infectious disease a January 2020. On 11 March 8,000,000 Member States and are obliged to

2020, the WHO declared the pandemic. The disease 6,000,000 act accordingly in a collaborative manner with support from the infectious disease a pandemic. was called Coronavirus 4,000,000 The disease was called 2,000,000 WHO. infectious disease 2019 Coronavirus infectious disease 0 The COVID-19 is not a ‘Black Jul 01 Jan 01 Apr 01 Oct 01 Jun 01 Dec 01 Mar 01 Aug 01 Aug 2019 (COVID-19), and the virus 01 Nov May 01 May (COVID-19), and the virus Sept 01 Swan’ event as many claim it to SARS coronavirus 2 (SARS- SARS coronavirus 2 (SARS- be. A report from the Global- CoV-2). Figure 1. COVID-19 infection rates from 1 March 2020 till 15 December 2020. Source: Graph created byCOVID-19: Devesh Kumar CASES based on PER data MILLION from European Center for Disease Prevention and Preparedness-Monitoring-Board CoV-2). Control (https://www.ecdc.europa.eu/en) United States India Brazil Argentina Norway Sweden France Germany South Korea Indonesia China

Last50,000 updated: 15 December 2020, 08:00 IST (GMT +5:30)

1https://www.who.int/emergencies/diseases/novel-coronavirus-2019 45,0000 40,0000 PANDEMICS: PAST, PRESENT AND LESSONS FOR THE FUTURE 11 35,0000

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15,0000

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0 Jul 01 Jan 01 Apr 01 Oct 01 Jun 01 Dec 01 Mar 01 Aug 01 Aug Nov 01 Nov May 01 May Sept 01 (2019)—a subsidiary body of the COVID-19 decisions, and the essential role Short-term Impacts of Mainly Positive Impact World Health organization— of economics in epidemiological Mixed of Moderately Negative Impact highlighted the imminent danger mitigation processes determines the total COVID-19 on the Highly Negative Impact of a global pandemic and alerted impact a pandemic has on societies. Impact Still Unclear Member States of how little or no policies A key lesson emerging from this Sustainable Development Goals preparations were being made to observation is for policymakers to face such a pandemic (Goodwell Countries across the world adopted have mechanisms that automatically Highly negative impact 2020). a range of measures ranging from kick in during times of disaster such SDG 1 • Increased poverty due to job losses and economic lockdown NO POVERTY lockdowns, containment zones, as a pandemic to reduce the private • Disproportionate impact on vulnerable groups (eg. the poor) It is estimated that around 60% mandatory masks, social distancing costs of illness avoidance. Highly negative impact of all known human pathogens and personal sanitary measures. • Food insecurity due to reduction in global food supplies and trade and 75% of recently emerged It seems that countries which SDG 2 • Hunger due to fall in income and reduce food availability during lockdown infectious diseases are zoonotic. followed a rigorous Test, ZERO HUNGER • Higher food loss and waste due to transportation challenges and reduced labor • Although emerging infectious Impacts of availability Track, Quarantine, Treat • Poorer nutrition due to interruption of school meals disease outbreaks are most (TTQT)—in conjunction with the COVID-19 Highly negative impact likely to occur in the large strict lockdowns in the early • Higher disease incidence and mortaity from Covid 19 cases population centers of Europe, stages of infections followed pandemic SDG 3 • Higher mortality from oother causes because of overburdening systems Slight the USA, and Japan, there is decline in mortality due to reduced economic and social activities (eg. traffic by easing of lockdowns with GOOD HEALTH & accidents) growing body of evidence that COVID-19 has had profound WELL-BEING containment zones established • Potential short-term health gains due to lower environmental pollution those outbreaks are most likely when necessary—and impacts across all segments of society • Negative impact of confinement and lockdown on mental health to have their origin in forested enforced non-pharmaceutical and across all countries. Nobody (eg. anxiety and depression) tropical areas. The spread of newly interventions (social distancing, has been spared. Those countries Mixed or moderately negative impact SDG 4 emerged infectious diseases is very with high levels of infection have • School and day-care closures masks and sanitary measures) QUALITY • Loss in the development of human capital strongly tied to patterns of trade and have weathered the pandemic seen high mortality rates while EDUCATION • Poorer nutrition due to interruption of school meals travel. In the case of COVID-19, much better (see countries others have witnessed the indirect the outbreak prompted immediate with flattened case load rates in impacts through disruptions in the Mixed or moderately negative impact mobility restrictions around Figure 1) than those which had education and human development • Possible disproportionate economic impact on women (eg. job losses, poverty) SDG 5 • Other social impacts on women from the lockdown of (eg. domestic violence) Wuhan. These were followed by the ad-hoc or partial measures but sectors. In this document, we have GENDER EQUALITY • Higher mortality rates from the virus among men (because they suffer from more suspension of international flights without strategic planning. explored the impact the pandemic chronic respiratory diseases due to higher smoking rate) to and from China. Even then, the has on the economic, education and SDG 6 Mixed or moderately negative impact virus spread widely across the globe. The differences in the effectiveness health sectors. We have also used the CLEAN WATER & • Limited access to clean water among disadvantaged groups limits possibility of of such measures applied in different 17 Sustainable Development Goals SANITATION adhering to strict hygiene guidelines countries reflect a fundamental (SDGs) as a relevant benchmark to Mixed or moderately negative impact property of epidemics—that the SDG 7 assess the impacts of COVID-19. AFFORDABLE & • Slowdown in economic growth contributing to a reduction in energy prices (eg.oil), contact between susceptible and Figure 2 provides a snapshot of this CLEAN ENERGY which might increase access to energy but reduce incentives for renewables People’s contact choices infected individuals which leads across the SDGs. Highly negative impact to transmission depends on the reflect the relative costs SDG 8 • Economic crisis in virtually all parts of the world choices made by individuals. Poverty, health, hunger, education, • Trade disruption DECENT WORK of illness and its avoidance • Mass unemployment People’s contact choices reflect gender, unemployment, and & ECONOMIC • Business closures/bankruptcies inequalities can be expected to GROWTH to them—the private the relative costs of illness and • Sharp decline in tourism activities worsen and might take a long time cost. If the private cost of its avoidance to them—the • Massive public deficits to recover if targeted policies are private cost. If the private cost Mixed or moderately negative impact illness is low, or the private not enforced immediately and of illness is low, or the private SDG 9 • Decline in industrial outputs continued post COVID-19. Areas to • Possible nationalization of some industries, and bankruptcies and closures of cost of illness avoidance cost of illness avoidance is high, INDUSTRY, others focus include the green sustainable INNOVATION & people have little incentive to • Scientific collaboration to find treatments and vaccine is high, people have little INFRASTRUCTURE avoid contact. The essentially economy, digitalization, social- • Accelerated uptake of digital technologies, for e-health, e-education, incentive to avoid contact. economic nature of contact welfare programs and governance. e-governance, and e-payments

Figure 2. Impacts of COVID-19 across the SDGs. Source: Adopted from Sachs et al. (2020, pp. 4-5)

PANDEMICS: PAST, PRESENT AND LESSONS FOR THE FUTURE 13 Mainly Positive Impact Key Lessons infection by adopting a Test, Mixed of Moderately Negative Impact Track, Quarantine, Treat Countries which were able (TTQT) strategy. Highly Negative Impact and Future to secure the participation Impact Still Unclear Challenges: Existing mechanisms at all spatial of their citizens—either and institutional levels are ill- by reducing the private Highly negative impact Emerging Infectious Diseases equipped to address and counter the cost of illness avoidance SDG 10 • Disproportionate negative health and economic impacts on vulnerable groups (EID) causing pandemics have effects of pandemics. Healthcare, REDUCED (Including refugees and migrants) especially in countries with low safety nets been found to be distributed non- education, and economic systems or by strict regulatory INEQUALITIES • Loss of jobs of lower skilled lower-wage labor randomly across the globe with across the globe have struggled to Mixed or moderately negative impact enforcement with punitive many dominated by pathogens cope with the direct and indirect SDG 11 • Rise in urban poverty and vulnerability emerging from land conversion, effects of the pandemic, leading to actions—were successful SUSTAINABLE • Shut down of public transport CITIES AND • Lower access to public/green spaces agricultural production methods, many countries witnessing a reversal in stemming the rapid rise COMMUNITIES • Movements of population that vary across countries the trade in wildlife and wildlife in their achievements towards the • Sharp short term reduction in pollution levels in infection by adopting products, and the ecological impacts SDGs. The challenge is to meet the Impact still Unclear of habitat depletion. Pandemics SDG goals with renewed efforts a Test, Track, Quarantine, SDG 12 • Short-term reduction in natural resource use due to reduced economic activity can be expected to occur more after the pandemic. RESPONSIBLE and consumption Treat (TTQT) strategy. • Pressure to loosen up regulations on circular economy and postpone the adoption frequently in the future. Countries CONSUMPTION Transparency, effective leadership and global coordinating centers to AND PRODUCTION of new measures need to prepare themselves for this • Increased plastic pollution (eg, used to produce personal protective equipment) and communication, building ensure privacy of individuals while challenge. trust, solidarity, timely action, increasing efficiency. Impact still Unclear Differences in the effectiveness enhanced use of digital technologies, • Short-term reduction in global GHG emissions Ministries of Education in countries SDG 13 • Pressure to reduce environmental safeguards of pandemic measures applied and internationally coordinated • Lack of clarity on environmental investments supported by multilateral and CLIMATE ACTION in different countries reflect containment efforts are essential to • Slowdown in economic growth contributing to reduction in energy prices (eg. oil) bilateral agencies might explore which might increase access to energy but reduce incentives for renewables a fundamental property of counter pandemics in an efficient transforming education systems pandemics—that the contact and equitable manner. Impact still Unclear to a hybrid model that combines • Short-term reduction in threats to marine biodiversity due to reduced global between susceptible and infected SDG 14 face-to-face and digital learning LIFE BELOW WATER economic activity and consumption individuals, which leads to • Pressure to reduce marine biodiversity and ecosystem safeguards Opportunities: systems, to be better prepared for transmission depends on the choices and responsive to future pandemics Impact still Unclear made by individuals. People’s Explore at the global level, Short term reduction in threats to terrestrial and freshwater biodiversity and other disasters. This means contact choices reflect the relative establishing an international task SDG 15 due to reduced global economic activity and consumption investments in digital infrastructure, Pressure to reduce terrestrial and freshwater biodiversity and ecosystem costs of illness and illness avoidance force comprising of an inter- LIFE ON LAND teacher training and access to digital safeguards, including biodiversity and ecosystem regulations conventions to them—the private cost. If the disciplinary group of experts from (for instance, on deforestation) learning available to all learners. private cost of illness is low, or the across the world to identify ways and Access to internet should be seen as private cost of illness avoidance is means to put in place monitoring Mixed or moderately negative impact a necessity instead of a luxury. • Increased pressure on governments to mitigate the health and economic high, people have little incentive to and coordinating mechanisms SDG 16 consequences of the pandemic avoid contact. The challenge is to for more efficient and effective • Pressure to increxa accessible health care in countries that have not yet achieved Explore the design of automatic PEACE, JUSTICE, bring down the cost of avoidance. mitigation and adaptation pathways. AND STRONG universal health coverage macroeconomic fiscal and monetary INSTITUTIONS • Increased public deficits and debt stabilizers to enable a faster reaction • Disruption of legislative processes and public debates Countries which were able to Leveraging digital technologies— to disasters such as pandemics to • Suspension of freedom-of-information laws and transparency policies secure the participation of their such as artificial intelligence (AI), reduce transaction lost accruing Mixed or moderately negative impact citizens—either by reducing big data and cloud computing, from political and bureaucratic • Possible reduced responsiveness of international aid community to needs of the private cost of illness and blockchain—to test, track, processes of approvals and SDG 17 the poorest countries avoidance or by strict regulatory quarantine and treat COVID-19 can • Possible reduction in international remittances and cross-border financing implementation. PARTNERSHIPS FOR enforcement with punitive curb the spread of the disease across THE GOALS • Closing of borders • Slowdown in international trade actions—were successful in borders. These technologies should • Debt Crisis stemming the rapid rise in ideally be overseen by the national

Figure 2. Impacts of COVID-19 across the SDGs. (Source: Adopted from Sachs et al. 2020, pp. 4-5)

PANDEMICS: PAST, PRESENT AND LESSONS FOR THE FUTURE 15 The ongoing COVID-19 2020, over 100 countries had Which strategy works best? This pandemic has had far-reaching reported COVID-19 cases with The WHO announced on is the quintessential question asked by policymakers all over impacts across the world. over 100,000 cases worldwide. 11 February 2020 that the The rapid spread of the virus has On 11 March 2020, the WHO the world. The results are mixed practically shut down modern in spite of not having any new coronavirus disease because of the large number of society as we knew it. Most formal process to define a will be called COVID-19. confounding variables that prevent economic and social activities pandemic, officially declared strong correlations to be made By 8 March 2020, over 100 were curtailed to different degrees. the COVID-19 as a pandemic— across strategies for flattening the People were requested or ordered defined as the spread of a new countries had reported curve and controlling the outbreak. to stay at home. Empty streets in disease worldwide for which COVID-19 cases with over Answers will definitely emerge as Introduction once buzzing cities like New York, most people do not have more data is collected and analysed 100,000 cases worldwide. London, Milan, Delhi and Paris, to immunity. by researchers across the world. name a few, became the new norm. On 11 March 2020, the These might come late for this As of 10 October 2020, the WHO in spite of not pandemic, but the answers will be o the final lesson The WHO announced on 11 SARS-CoV-2 virus—which valuable in preparing us for the next of 1918, a simple February 2020 that the new causes COVID-19—had spread having any formal process pandemic. coronavirus disease will be of over 213 countries with about to define a pandemic, Sone yet the one most There is little doubt that pandemics called COVID-19. By 8 March 37 million confirmed cases, 25.9 difficult to execute, is officially declared the pose not only serious health impacts that those who occupy COVID-19 as a pandemic— but also have serious economic and COVID-19: CASES social consequences. These impacts defined as the spread of a positions of authority United States India Brazil Argentina Norway Sweden France Germany South Korea Indonesia China can be direct—caused by the health 18,000,000 COVID-19: CASES

United States India Brazil Argentina Norway Sweden France Germany South Korea Indonesia China new disease worldwide for impacts from the disease in the must lessen the panic 16,000,000 18,000,000 form of mortality and/or morbidity 14,000,000 which most people do not that can alienate the 16,000,000 rates. However, we now know 12,000,000 14,000,000 have immunity. members of a society. that pandemics can cause indirect 10,000,000 ... Those in authority 12,000,000 million recovered and over a million impacts to the health, economic 8,000,000 10,000,000 deaths.2 Figure 1 and 2 show the and social sectors through the 6,000,000 must retain the 8,000,000 spread of disease in absolute terms containment policies implemented 4,000,000 public’s trust. The way 6,000,000 and normalized across population by policymakers. 2,000,000 to do that is to distort 4,000,000 respectively for 10 selected countries 0 This report aims to provide a brief 2,000,000 from March 2020 till early Jul 01 Jan 01 Apr 01 Oct 01 Jun 01 Dec 01 Mar 01 Aug 01 Aug Nov 01 Nov May 01 May nothing, to put the Sept 01 but scientific and evidence-based 0 December 2020. understanding of the COVID-19 Jul 01 Jan 01 Apr 01 Oct 01 Jun 01 Dec 01 Mar 01 Aug 01 Aug Nov 01 Nov Figure 1. COVID-19 infection rates 01 May from 1 March 2020 till 15 December 2020. Source: Graph created by Devesh Kumar based on best face on nothing, to Sept 01 data from European Center for Disease Prevention and Control (https://www.ecdc.europa.eu/en) Last updated: 15 December Some countries are still witnessing pandemic. The report is written 2020, 08:00 IST (GMT +5:30) try to manipulate no COVID-19: CASES PER MILLION increasing rates of infection and United States India Brazil Argentina Norway Sweden France Germany South Korea Indonesia China with the objective of providing one.” 50,000 COVID-19: CASES PER MILLION death while some have flattened some clarity on the following aspects United States India Brazil Argentina Norway Sweden France Germany South Korea Indonesia China 45,0000 out these rates. Strategies used by JOHN M. BARRY, 50,000 of pandemics: 40,0000 each of these selected countries 45,0000 (i) what is it and how is it declared; The Great Influenza: 35,0000 40,0000 differ with some imposing strict (ii) what are the key variables that The Epic Story of the 30,0000 35,0000 lockdowns and mandatory determine its severity; 25,0000 Deadliest Plague in History, 30,0000 masking and social distancing (iii) causes; 20,0000 2004, p.462 25,0000 such as China, while others (iv) impacts; 15,0000 20,0000 adopting a policy of voluntary 10,0000 (iv) key containment strategies and 15,0000 lockdowns, social distancing 5,0000 policies; and 10,0000 and the use of masks such as 0 (v) lessons and opportunities for the 5,0000 USA (See Q 8 for an overview Jul 01 Jan 01 Apr 01 Oct 01 Jun 01 Dec 01 Mar 01 Aug 01 Aug Nov 01 Nov May 01 May future. Sept 01 0 of measures adopted by these Jul 01 Jan 01 Apr 01 Oct 01 Jun 01 Dec 01 Mar 01 Aug 01 Aug Nov 01 Nov May 01 May Sept 01 selected countries). 2https://COVID19.who.int/ Figure 2. COVID-19 cases per million from 1 March 2020 till 15 December 2020. Source: Graph created by Devesh Kumar based on data from European Center for Disease Prevention and Control (https://www.ecdc.europa.eu/en) (https://www.ecdc.europa.eu/ en) Last updated: 15 December 2020, 08:00 IST (GMT +5:30) PANDEMICS: PAST, PRESENT AND LESSONS FOR THE FUTURE 17 Pandemics: Past, Present and Lessons for the Future. Question No. 1: What is a Pandemic and How is a Pandemic Declared? Q1 / 17

The following seven key features that might be used to define a pandemic emerge from the literature:

ANSWER WIDE GEOGRAPHIC EXTENSION The term pandemic usually refers to diseases that extend over large geographic areas (Taubenberger & Morens, 2009). There were 178 countries involved during the H1N1 outbreak in 2009 (Rewar et al., 2015) while the COVID-19 has spread over 215 countries and territories.

1 DISEASE MOVEMENT Disease movement includes widespread person-to-person spread of diseases caused by respiratory viruses. such as influenza and SARS. The out-of-season transmission is what ccording to the characterizes an influenza pandemic. World Health OrganizationA (WHO) - “A pandemic is the NOVELTY The term pandemic has been used most commonly to describe diseases that are new, or at worldwide spread of least associated with novel variants of existing organisms. a new disease”.3 According to Centers for Disease Control SEVERITY The term pandemic has been applied to severe or fatal diseases (eg, the Black Death, HIV/ and Prevention AIDS and SARS) much more commonly than it has been applied to mild diseases. Severity is (CDC) of USA, estimated by the case fatality ratio (Donaldson et al., 2009). “Pandemic refers to an epidemic that has spread over HIGH ATTACK RATES AND EXPLOSIVENESS Pandemics are characterised by high rates of attack and explosive spread. However, if the several countries or transmission is non-explosive, even if it is widespread, it is not classified as a pandemic. continents, usually affecting a large number of people.” Also, as stated in A Dictionary there is consensus on: MINIMAL POPULATION IMMUNITY of Epidemiology (John, 2001) (i) its large-scale geographical Although pandemics often have been described in partly immune populations, pandemics are “Pandemic is an epidemic outreach; characterised by almost zero population immunity (Fangriya, 2015; WHO, 2013). occurring worldwide or over a (ii) infecting people beyond national wide area, crossing international boundaries; and boundaries, and usually affecting a (iii) causing significant health large number of people”. INFECTIOUSNESS AND CONTAGIOUSNESS damage and social, economic and political disruptions compared to Pandemic diseases are infectious, so they are transmitted from one person to another person. Although there is no universally This transmission can be direct (person to person) or indirect (person to vector to person) binding definition of a pandemic, a local outbreak or epidemic of an infectious disease. (Morens et al., 2010).

Source: Adapted from Qiu et al. 2017, pp. 4-5 3https://www.who.int/csr/disease/swineflu/frequently_asked_questions/pandemic/en/

PANDEMICS: PAST, PRESENT AND LESSONS FOR THE FUTURE 21 Pandemics: Past, Present and Lessons for the Future.

Question No. 2: What is the Procedure used to Declare a Pandemic? Q2 / 17

sole authority to declare a PHEIC COVID-19 was declared a PHEIC were reported from 114 countries.7 PHASES 5-6/ PANDEMIC (WHO 2016). The PHEIC is the by WHO on 30 January 2020 after It is suspected that WHO’s hesitance PHASE 4 POST PEAK highest level of alert under IHR the second Emergency Committee to characterize COVID-19 as POST PANDEMIC ANSWER PHASES 1-3 that WHO is obliged to declare meeting, at which point 7,736 cases pandemic earlier could be attributed

TIME in order to warn the Member and 179 deaths had been confirmed to its loosely coined definition Predominantly animal infections: Sustained Widespread human Possibility of Disease activity at few human infections human- infection recurrent events seasonal levels States about actions that need to be in mainland China, with 107 cases and to the fear and panic that the to-human 8 transmission taken to curb the spread of disease confirmed in 21 other countries. term induces. The literature offers and to mobilize resources to help Even after declaration as a PHEIC, limited clarity to the question of Figure 3. Pandemic Influenza Phases (2009). Source: Adopted from World Health Organization (2009, pp.24) low-and middle-income countries. the virus continued to spread timing i.e. when it is apt to confirm In the context of COVID-19 be less lethal than was anticipated. It also obligates countries to share globally and was ultimately declared a PHEIC as a pandemic and the there is “no mathematical WHO faced a backlash for the 2 information with WHO. as a pandemic by WHO on 11 relative effectiveness of each term formula, no algorithm,” for declaration when the disease did March 2020, at which point more in triggering combative actions by making a pandemic declaration. not have the wide spread expected than 118,000 cases and 4,291 deaths nation states. orld Health WHO declared COVID-19 as a impact. pandemic on 11 March 2020, at ANNEX 2: DECISION INSTRUMENT FOR THE ASSESSMENT AND NOTIFICATION OF EVENTS THAT MAY Organization Currently, WHO in accordance W which point it had already spread CONSTITUTE A PUBLIC HEALTH EMERGENCY OF OF INTERNATIONAL (WHO), a specialised to over 110 countries.6 WHO’s with the International Health hesitance in declaring a pandemic Regulations (2005) (IHR) EVENTS DETECTED BY NATIONAL SURVEILLANCE SYSTEM (SEE ANNEX 1) agency of the United determines whether an event can highlights the confusion surrounding be designated as Public Health Nations dedicated to the elusive definition of the term and Emergency of International A case of the following diseases is Any event of potential international An event involving the folowing brings forth the recurring debate international public Concern (PHEIC) or not. The unusual or unexpected and may have public health concern, including diseases shall always lead to 4 on when it is apt to call a disease serious public health impact, and this those of unknown causes or sources utilization of the algorithm, because health , is the global IHR-Annex 2 provides a ‘decision outbreak a pandemic (Green 2020). shall be notified1,2: and those involving other events they have demonstrated the ability instrument’ (see Figure 4) that OR OR body with authority Smallpox or diseases than those listed in the to cause serious public health impact to officially declare Prior to COVID-19, the most recent guides States regarding which health Poliomyeliitis die to wild-type box on the left and the box on the and to spread rapidly internationally2: pandemic was the 2009 H1N1 events can potentially turn into poliovirus utilizaton of the algorithm. Cholera 5 a pandemic . Even Influenza or ‘swine flu’. During the PHEICs, thereby requiring reporting Human influenza caused by a new Pneumonic Plague subtype though it is considered spread of swine flu, WHO followed to WHO. The IHR also empowers Yellow Fever Severe acute respiratory syndrome Is the public health impact of the Viral Haemorrhagic Fever (Ebola, Lass, a six- phase procedure (see Figure the WHO Director-General to (SARS) event serious? Marburg) to be the primary convene an Emergency Committee 3) that was applicable worldwide Other diseases that are of special (EC), which provides advice on YES NO body responsible for and provided a global framework to national or regional concern, whether the current situation should announcing when a facilitate preparedness and response eg. dengue fever, Rift Valley fever and planning among countries. be considered a PHEIC, and what meningococcal disease. global outbreak or provisional recommendations should epidemic of disease Phases 1-3 focus on preparedness, be given to governments to support Is the event unusual or unexpected? Is the event unusual or unexpected? that is indulging capacity the response. The EC comprises becomes a pandemic, YES NO YES NO development and response planning international experts convened on intriguingly WHO activities, while Phases 4-6 indicate an ad-hoc basis, and the WHO does not have a the need for response and mitigation Director-General has ultimate and Is there a significant risk of Is there a significant risk of precise definition of efforts. Furthermore, periods international spread international spread after the first pandemic wave are YES NO YES NO a pandemic in its elaborated to facilitate post pandemic The PHEIC is the highest recovery activities (WHO 2009). guidelines. level of alert under IHR Is there a significant risk of international Not notified at this This six-phase approach led that WHO is obliged to travel or trade restriction? stage. Reassess when to declaration of swine flu as a more information pandemic by the WHO in 2009. declare in order to warn YES NO becomes available. However, swine flu turned out to the Member States

4https://www.who.int/about/what-we-do EVENT SHALL BE NOTIFIED TO WHO UNDER THE INTERNATIONAL HEALTH REGULATIONS 5https://www.washingtonpost.com/health/2020/03/11/who-declares-pandemic-coronavirus-disease-COVID-19/ 6https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-COVID-19---11-march-2020 Figure 4. Decision Instrument for assessing PHEIC. PANDEMICS: PAST, PRESENT AND LESSONS FOR THE FUTURE 7https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020 Source: Adopted from International Health Regulations (2005, Annex-2) 25 8https://www.chathamhouse.org/2020/05/coronavirus-public-health-emergency-or-pandemic-does-timing-matter Pandemics: Past, Present and Lessons for the Future.

Question No. 3: Is it Legally Binding for All Countres to Adhere to Pandemic Guidelines? Can a Country Defy a Pandemic Declaration? Q3 / 17

SUBNATIONAL/ NATIONAL IHR FOCAL POINTS OTHER INFORMATION SURVEILLANCE/DETECTION/ NATIONAL ASSESSMENT (NFPS) SOURCES ASSESSMENT ANSWER Local and regional authorities National level confirm events, Countries notify the WHO Nonofficial reports (including identify events that may mounts national response, and within 24 hours, through their media) can be used by the WHO constitute potential PHEICS and performs assessment based NFP, of any event that may to assess if there is a potential report pertinent information on Annex 2 to determine if the constitute a PHEIC. The NFP PHEIC occurring. The WHO can to the national level. Local and event constritutes a potential is also used to respond to any use these unofficial reports to regional authorities also initiate PHEICC follow-up information requests seek verification and to consult response efforts. from the WHO. with states

3 Article 5, Annex 1 Article 5, Annex 1 Article 6-8, 10 Article 9

WHO ASSESSMENT

nternational Health RESPONSE WHO PHEIC DECISION The WHO recieves and assesses notifications. The Who can also Regulations (2005) States develop capacity to respond on their own. States, though, The director-general of the I request additional information may request assistance, include the mobilization of international WHO, in consultation with the (IHR) is the global from NFPs and use reports from experts, and assess risk and the adequacy of control measures Emergency Committee and other sources. legal instrument on-site. The WHO will also coordinate with other relevant affected countries, decides designed to help Internationa Organizations and other States Parties called upon if the event is a PHEIC. The Article 9,10 to support the WHO-coordinated response activites Emergency Committee WHO NOTIFICATION protect nations from provides travel and trade international spread of recommendations. The WHO can make IHR Article 13, 14 Article 12, 17 reporting available to disease including public IHR came into force on 15 June WHO member states. The IHR international organizations when certain criteria related to 2007 as a result of increased requires countries to report public health risks and public severity or international impact international mobility and RESPONSIBLE PARTY health emergencies. health events and outlines criteria are met. These organizations emergence of diseases with potential to determine whether or not a can inform WHO PHEIC Member State NGOs/Media WHO Global to transcend borders. The stated particular event constitutes a “public assessment. purpose and scope of the IHR is “to health emergency of international Article 11 prevent, protect against, control and concern” (PHEIC). A Public Figure 5. IHR Process for Global Governance of Disease. Source: Adopted from Gostin and Katz (2016, pp.272) provide a public health response to Health Emergency of International the international spread of disease Concern is defined in the IHR countries to devise proper focal The process of global governance of recommends critical health measures in ways that are commensurate (2005) as, “an extraordinary event points of communication between the disease and established channel for implementation by member with and restricted to public health which is determined to constitute the nation state and the WHO of communication between nation states during such an emergency. risks, and which avoid unnecessary a public health risk to other States to aid surveillance, international states and WHO is described in Hence, once a PHEIC is declared interference with international traffic through the international spread travel and transport, safeguard Figure 5. The articles and Annexex by WHO, it is implicitly legally and trade” (WHO, 2008). of disease and to potentially the rights of travelers, and ensure refer to IHR (2005) articles and binding for member states to adhere require a coordinated international non-discrimination in the Annexex. to the IHR guidelines and for IHR provides a comprehensive response”10. The IHR also mandates application of health measures countries to implement containment “legal framework that defines under the Regulations. WHO The IHR necessitates countries measures to mitigate the spread of countries’ rights and obligations in ability to- detect, assess and report, The IHR is an instrument plays the coordinating role in IHR the disease. As acknowledged earlier, handling public health events and implementation in nation states and and respond to public health risks apart from the scope of spread there emergencies that have the potential of international law that is support countries to build capacities and emergencies. In the event that is little clarity on when a PHEIC 9 to cross borders.” The IHR is an legally-binding across 196 when a Public Health Emergency IHR determines that a particular is designated as a pandemic, but instrument of international law of International Concern (PHEIC) event constitutes a public health once WHO declares a pandemic, it countries, including the that is legally-binding across occurs.11 emergency of international concern is legally binding for countries to 196 countries, including the 194 194 WHO member states. (PHEIC), WHO develops and adher to its guidelines.

9https://www.who.int/health-topics/international-health-regulations#tab=tab_1 10https://www.who.int/news-room/q-a-detail/emergencies-international-health-regulations-and-emergency-committees

11 https://www.who.int/ihr/procedures/pheic/en/ PANDEMICS: PAST, PRESENT AND LESSONS FOR THE FUTURE 29 Pandemics: Past, Present and Lessons for the Future.

Question No. 4: How many Pandemics have we witnessed over the last 100 years? Q4 / 17

Spanish Flu years age group were particularly susceptible. Most of the 12-18 The Asian flu first reached (1918-20) : million deaths in India took ANSWER place in the three peak months India via Madras in May In the spring of 1918, a mild during the second wave (Barry 1957 and spread across the respiratory disease started at an army 2018). camp in Kansas, USA, attributed country within the next to a soldier who had been cleaning Spanish Flu revealed inequalities due 12 weeks. pig pens (Crosby 1989). The disease to colonial rule and the social divide. spread in the camp, along the In Cape Town and several other a second wave in January 1958. The 4 railway line to other military bases South African cities, influenza killed infection rate was highest in 5- to and US cities, and on troopships to about 4% of the entire population 19-year-olds, where it exceeded Europe. Though highly contagious, in a period of four weeks – 32% 50%. Both waves showed heightened nfectious disease is the first wave caused few deaths and of white South Africans and 46% mortality, with about 116,000 as old as humans, thus received little attention, partly of blacks reportedly had disease – deaths in the US and over 1.1 I million worldwide (Stuart-Harris also due to war-time censorship. with about 0.8% and 3% mortality, but it is only in the respectively (Barry 2018). In Britain 1985). The first cases in UK were last two centuries However, in Spain, a neutral the mortality was 4.7 per 1,000 in late June, and by early 1958 it that we have started country in the War, there was people. In India it was 8.3 per 1,000 was estimated that at least 9 million extensive media coverage and for Europeans but 20.6 per 1,000 people in Great Britain had been understanding its the disease was soon called for Indians. Even among Indians, infected with about 14,000 deaths. microbial basis “Spanish influenza”. The second social divisions were apparent with Five months after the Hong Kong and diversity. wave started in late August, probably mortality rates of 61 and 18.9 per outbreak the virus was reckoned in Western France, from where it Various plagues 1,000 among low caste and high to have traversed the globe. As an spread globally. It peaked during caste Hindus (Kapoor 2020). Besides entirely new strain there was no have inflicted September to November 1918, at poor healthcare infrastructure, there immunity in the populace and the humans through which time about 10,000 people was also a drought in India in 1918, first vaccines were not distributed were dying per week in some US the ages, some of which led to a famine in large parts until August in the US and October cities (Frost 1920). A third wave of of the country that exacerbated the in the UK, and that too on an the major ones equal ferocity struck in late 1918 or disease and associated mortality. extremely limited basis (Jackson shown in Figure 6. early 1919. It was not until 1999 that However, food from India continued 2009). the virus was identified to be a novel to supply Britain’s war efforts. Here we will focus H1N1 virus (Reid 1999). The Asian flu first reached India on the 20th and via Madras in May 1957 and 21st centuries, to Death rates were estimated to be Asian Flu spread across the country within even higher in Africa and Asia. An (1957) : the next 12 weeks. Between 19 seek out common estimated 12-18 million people May 1957 and 8 February 1958 there features in our perished in India – equivalent to This pandemic originated in the were 4.45 million reported cases, understanding of 4% of its population (as per 1911 Guizhou province in southern with 1098 deaths. As elsewhere, disease and our census). The infection was brought China in February 1957, spreading the disease in India generally had a on Allied troopships retuning from to the Hunan province, and to mild course, although nausea and response to it. the War to the ports of Bombay and Hong Kong and Singapore by April. vomiting and symptoms related to Pre 20th century Karachi in May and June 1918. This In May, the causative agent was the nervous system were relatively pandemics are was followed by a far more lethal isolated in Japan and found to be frequently seen. Bombay was the second wave that swept across India a new H2N2 influenza virus. The worst hit with over 1.3 million cases briefly described in from September to early December first wave struck USA and UK in and 315 deaths, but Madras with Annex 1. 1918, in which people in the 20-40 October 1957, and was followed by over 580,000 cases showed only 75

Figure 6. Pandemics through the ages. Source: Adopted from Visual Capitalist (https://www.visualcapitalist.com/history-of-pandemics-deadliest/) PANDEMICS: PAST, PRESENT AND LESSONS FOR THE FUTURE 33 Q4 / 17

Swine Flu one that emerged in 2003. As of The first confirmed case in 10th December 2020, there were (2009) : 68,165,877 confirmed cases of the India was on 30th January COVID-19 disease and 1,557,385 A new H1N1 influenza A virus 2020 - a student from confirmed deaths across 220 that had been circulating in pigs 12 Wuhan University, who countries, areas and territories. for several months, jumped into This case fatality rate (CFR) humans sometime between June came home to Kerala. of 2.28% is almost an order of and November 2008. The outbreak magnitude higher than the seasonal was first recognized in the state of COVID-19 flu. Veracruz, Mexico, and the earliest (2019-continuing) : known human case was traced to The first confirmed COVID-19 9th March 2009 in a 5-year-old The first clusters of the present case in India was on 30 January boy in La Gloria, a rural town in pandemic were observed in the 2020—a student from Wuhan Veracruz. By late April the virus city of Wuhan in the Hubei region University, who came home to had spread enough for WHO to in China around December 2019. Kerala. Till mid-March there were deaths. West Bengal had the highest Kong in July 1968, but there is 100,000 in the US. Most excess declare it a PHEIC, and in June it Researchers from the Chinese only 100 confirmed cases and 2 levels of mortality with 445 dead the unconfirmed possibility of its deaths were in older (65+) people. was declared a “pandemic”. It began Academy of Sciences and the deaths reported from India. There among 300,000 cases. The attack- emergence in mainland China prior to taper off in November 2009 with Chinese Center for Disease Control were 657 confirmed cases with In India the first cases were rates were highest at about 18% in a steep decline in cases by May 2010, identified it as a new coronavirus. 12 confirmed deaths when the reported in Madras on 8 children 0-10 year old, and reduced and WHO declared the pandemic However, due to delayed reporting Government of India imposed a September 1968, having arrived progressively with age; it was 1% In India the first cases to be over on 10th August. During at local levels and the traditional nationwide lockdown on 25 March on the ship S.S. Rajula from or less in those older than 50 years. this period, there were 491,382 lab- large volume of Chinese New Year 2020. However, by the time the were reported in Madras Singapore. During the period (IGK Menon, Bull WHO 1959). As confirmed cases and 18,449 deaths travel caused the early spread of the 68-day lockdown ended on 30 May, on 8 September 1968, 9 September to 31 October, an occupational group, healthcare reported to WHO. Some studies disease beyond Wuhan to the other the number of infections had risen 84,511 patients were treated in the personnel in India showed higher having arrived on the ship estimated that the actual number of parts of China and the World. to about 190,000 with 5400 deaths. hospitals in Madras City, which than average disease incidence. cases including asymptomatic and As of 6 October 2020, India had S.S. Rajula from Singapore. had a population of 2 million. It is The Pasteur Institute, Coonoor, mild cases could be 700 million On 11 March 2020 the Coronavirus the world’s second highest tally of estimated that an equal number of which served as the Government of to 1.4 billion people, equivalent Infectious disease 2019 (COVID-19) almost 6.7 million confirmed cases persons were treated by the private India’s Influenza Centre isolated and to its spread in Hong Kong. By to 11-21% of the world population pandemic was declared by the and the third highest deaths at over practitioners in the city. The attack antigenically characterized the 1957 July, large outbreaks were reported at that time, and about 284,000 World Health Organization. The 100,000. However, the lower CFR rate was therefore 8.4%. The main virus. However, due to rapid spread from Vietnam and Singapore, and deaths (range150,000 to 575,000). In virus causing the disease was called of 1.5% and the lower than world epidemic spread through the Indian of the pandemic, it was not possible by September it had reached India, comparison, it was possibly no worse SARS coronavirus 2 (SARS-CoV-2) average of 2.28% infection per subcontinent within 20 weeks. The to prepare sufficient vaccine from Philippines, northern Australia than seasonal flu, which according in view of its genetic similarity million in India is an observation spread was fastest through the most the new strains in time for adequate and Europe. It reached US via to WHO kills an estimated 250,000 and clinical presentation to the which many scientists are beginning crowded cities and relatively slower field trials or mass immunization of soldiers returning from the Vietnam to 500,000 people annually. to study, understand and learn fort across villages and towns. All age- the population. War, and became widespread by future pandemics. groups were involved, although the In India, the first case of swine flu December. In early 1969 the virus disease appeared to be more severe was reported at Hyderabad airport Since its emergence, COVID-19 has was also seen in Japan, Africa and Hong Kong Flu among children. Persons who had on 13th May in a traveler from shut down the world and devastated South America (Cockburn 1969). an attack of Asian influenza in 1957 USA. Subsequently, more confirmed the global economy unlike the 1958, (1968) : The US Centers for Disease Control generally escaped infection by the cases were reported with the rate of 1968 and the more recent 2009 and Prevention (CDC) estimated Hong Kong influenza virus. The transmission increasing in August, pandemics. A central question is The first signs of a new that from its start in July 1968 until pandemic emerged in the data for how many people became with the first death in Pune on 4th why SARS-CoV2 moved so quickly the outbreak faded in the winter of summer of 1968 in southern Asia. infected or died across India in August. By August 2010, there were compared in a world that is much 1969-70, it killed about 1 million An influenza virus of the H3N2 this pandemic are not available (N 44,987 lab-confirmed cases of swine more technologically advanced in people worldwide, including about subtype was isolated in Hong Veeraraghavan, Bull WHO 1969). flu and 2728 deaths reported from 2020 than it was in 2003. It appears India. that SARS-CoV2 is much better 12https://www.who.int/emergencies/diseases/novel-coronavirus-2019

PANDEMICS: PAST, PRESENT AND LESSONS FOR THE FUTURE 35 Q4 / 17 adapted for human-to-human misuse of frontline drugs leading to transmission and has already shed Caution: the development of antimicrobial (and transmitted) a few days before Pandemic near misses resistance. The world is extremely symptoms appear, unlike SARS- well connected by travel and trade, CoV that sheds only during the The first two decades of the 21st allowing infectious diseases to travel symptomatic phase. The world century have already witnessed two and spread. Moreover, a majority is also more connected in 2020 pandemics – Swine Flu in 2009 and of the world’s people live with through travel and supply chains. Covid-19 that started in December weak public health infrastructures. 2019 and is continuing. However, This does not allow infections to But COVID-19 has also shown there have also been a few pandemic be detected and curtailed in time the power of technology and threats – SARS in 2003, Bird Flu in before efficient human-to human collaboration. The virus was 2005-07, Ebola in 2014-16 and Zika transmission. identified and its genomic sequence in 2015-16. Why is the frequency of became available within a week pandemics increasing? of notification. This allowed the development of diagnostic tests and Outbreaks happen in the world’s real-time mapping of the growth most vulnerable areas – countries with few resources to stem the of the pandemic. It also took only the capital of Guangdong, took health care workers, public health tide of infection before becoming 42 days from availability of the SARS the virus to densely populated and officials and scientists controlled regional outbreaks, public health viral genomic sequence to the first (2002-03) internationally connected Hong it – not through a drug or vaccine, emergencies or pandemics. With vaccine to be made and 63 days Kong, from where SARS-CoV went but simply by testing, isolating and modern travel networks, a pathogen to which human clinical trials On 12th March 2003, WHO global. After infecting 8039 people preventing patients from infecting can travel from a remote village to were initiated. There are over 200 warned of “atypical pneumonia” across 29 countries, of which 774 others. In the end, 21st century major cities on all continents in 36 vaccines currently in development cases from China, Hong Kong died, the outbreak was declared over lab science had little impact on the hours, which is often shorter than with about 50 already being and Vietnam. When three days by 5th July 2003. SARS affected fight against SARS; the disease was its incubation period, i.e. the time clinically tested. The first efficacy later there were suspected cases older adults more severely than stopped using 19th century hygiene it takes from infection to disease. trial results have shown the vaccines in Canada, Singapore, Thailand, younger individuals, almost 50% measures. But the legacy of SARS Many global challenges exist that to be highly effective. Indonesia and the Philippines as of those infected over 65 years is a world better prepared to handle increase the risk that outbreaks well, WHO decided to call this of age died, compared with emerging infectious diseases that Key partnerships among the private will occur and spread rapidly. With first global health threat of the 21st just 1% under 24 years. There have the potential of going global. sector, governments and academic growing populations and demands century as Severe Acute Respiratory were only 3 lab-confirmed and 10 Disease surveillance has improved, institutions have ensured a roll out on land for agriculture and housing, Syndrome or SARS. On 24th suspected cases of SARS, and no and scientific advances make it of more than one vaccine in the wild animal habitats are being March the cause was identified as deaths reported from India. easier to identify pathogens directly first quarter of 2021. Scientists all destroyed, increasing the risk of a new coronavirus – called SARS from clinical materials. SARS also over the world have collaborated infectious pathogens “spilling over” It initially appeared that SARS coronavirus or SARS-CoV. It brought about the introduction of and freely shared both materials and from animals to humans. There is would become a pandemic, sweep was later discovered that SARS new international rules on reporting know-how. The knowledge base the globe and infect millions. But started in November 2002, the and handling disease threats. The on SARS-Cov2 and COVID-19 aggressive countermeasures by first identified case being a 45- International Health Regulations has expanded dramatically since SARS affected older year old man in Foshan, a city in 2005 make it mandatory to have the inception of the pandemic. For adults more severely the Southern Chinese province of There are over 200 dedicated health units at all example, just in six month between Guangdong. Studies also showed international airports, with core the beginning of January and the than younger individuals, vaccines currently in that the virus originated in bats, capacities for undertaking routine end June 2020, 23,634 unique almost 50% of those having infected humans most likely development with about public health measures and the published articles on COVID-19 infected over 65 years of through animals – in this case, surge capacity to deal with Public were indexed on Clarivate 50 already being clinically civet cats in China’s wet animal Health Emergencies of International Analytics’ Web of Science and age died, compared with tested. markets. A doctor from Guangzhou, Concern (PHEICs). Elsevier’s (Teixeira da Silva et al. just 1% under 24 years. 2020).

PANDEMICS: PAST, PRESENT AND LESSONS FOR THE FUTURE 37 Pandemics: Past, Present and Lessons for the Future.

Question No. 5: What were the Main Pathogens Causing the Diseases and What Treatments were Used? Q5 / 17

BOX 1: PATHOGEN DISCOVERY at high concentrations in individuals with disease. It will nonetheless become increasingly Important in chronic Nischay Mishra, Rafal Tokarz and W. Ian Lipkin diseases where the relationships between infections or ANSWER microbiota are less apparent (Center for Infection and Immunity, Mailman School of Public Health of Columbia University) High throughput sequencing has dramatically altered the landscape of microbiology, medicine and public Reviews in the field of pathogen discovery frequently health. One can rapidly and efficiently identify bacteria, focus on the evolution of new from the use of culture fungi, and viruses in clinical samples, determine their and microscopy in the early and mid-1900s to the potential reservoirs and vectors for transmission, and introduction of high throughput sequencing the early 5 design diagnostic assay drugs and vaccines even prior to 2000s. This historical perspective provides insights into cultivation. Sequencing has also enabled identification the power of new platforms for detection of known and of host factors that contribute to pathogenesis and to novel agents. It does not, however, acknowledge that the ccording to susceptibility to disease, as well as to microbial evolution methods we need for microbial characterization, making Jones (2008), (especially in viruses) that may enable cross species A links to desi, and understanding the pathogenesis, transmission. emerging infectious transmission, and epidemiology of infectious diseases disease (EID) events have not much changed Serology has not advanced as rapidly largely because (i) one cannot easily display the entire range of potential between 1940 and Although novel microbes can be found through routine epitopes recognized by antibodies and T cells, and 2004 were dominated surveillance, the primary event in pathogen discovery is (ii) measurements of immune responses can be typically the recognition of an anomaly - a new disease, by pathogens that confounded by cross reactivity. The use of phage or a known disease in a new context - that leads to the expression systems and high density peptide arrays emerge in wild collection of data and samples that, when assayed, yield have addressed these limitations for B cells, at least animals first and a finding that was not anticipated, This underscores for linear epitopes. However, there is no solution yet the importance of recognizing clinicians public health transfer to humans for high throughput analysis of the conformational practitioners, and laboratory scientists as equal partners to cause disease (see or carbohydrate epitopes that can be critical in virus in the process Box 1 on pathogen neutralization and autoimmunity. The identification of a novel sequence is only the first discovery). Such The largest stumbling blocks in achieving the full step in pathogen discovery. Implications in disease potential of pathogen discovery in human health and events have been requires proof of a causal relationship. This can be global biosecurity are social and economic rather than distributed non- achieved through fulfilment of Koch’s postulates technical. The International Health Regulations of 2005 (isolation of a microbe, propagation in culture, and randomly across The CDC estimates that animal as influenza and HIV, both of committed United Nations member states to developing reproduction of disease with introduction into a naive the world and been spillovers account for two-thirds which spilled from animals into the infrastructure and expertise for surveillance, and to host). However, realising this ideal is not feasible if one of all human infectious diseases humans. The pace of emergence freely sharing data so that all nations could prepare for increasing over time. cannot grow the agent in culture or there is no animal and three-fourths of newly of new viruses threatening human microbial threats. model for the disease. Furthermore, some effects, such a emerging diseases, with both wild health has continuously increased neoplasia, neurological or neuropsychiatric damage, or and domesticated animals being able over the past 25 years. Of the 20 The weaknesses in our global infrastructure became autoimmune disease may not be manifest until after the to pass disease to humans. diseases the WHO considers having apparent with the advent of COVID-19. A better agent is no longer present. the potential to develop into future coordinated response would have saved lives and Viruses comprise only 14% of economic devastation. With advances in molecular pandemics, 16 have viruses as the Accordingly, we have developed a more flexible strategy known human pathogens but biology, information technology and social media, causative agents. Understanding the for investigating and establishing causal relationships comprise 44% of new and emerging we have the tools to build a global immune system. biology of viruses, especially RNA that includes the consideration of biological plausibility pathogens. Some of the biggest The challenge now is to equitably distribute write the viruses, is key to both preparedness and seroepidemiology This approach is not required for public health threats of the 20th tools and resources needed to ensure that we we better and mitigation (see Box 1). investigation of outbreaks where a single agent is present century came from viruses such prepared if and when another pandemic threat emerges.

13https://www.cdc.gov/onehealth/basics/zoonotic-diseases.html PANDEMICS: PAST, PRESENT AND LESSONS FOR THE FUTURE 41 Pandemics: Past, Present and Lessons for the Future.

Question No. 6: Which are the Main Pandemic Viruses and What are the Key Differences Across Them and the Type of Treatments Used? Q6 / 17 HUMAN FLU VIRUS

There are 17 different types of HA

(H1 to H17) and 9 different types PB2

PB1

of NA (N1 to N9)—and this is PA ANSWER how influenza viruses are named. HA NP The Spanish Flu (1918) and Swine NA M Flu (2009) viruses were found to NS be H1N1, Asian Flu H2N2, Hong Kong Flu H3N2 and Bird Flu NORTH AMERICAN AVIAN FLU VIRUS CLASSIC/EURASIAN SWINE FLU VIRUS H5N1. Though 17 x 9, i.e. 153 combinations are possible, only a 6 few combinations of H and N genes have caused disease in humans.

PB2 PB2 nfectious disease is 1. Influenza Viruses carrying novel HA and NA PB1 PB1 combinations can spread rapidly as PA PA as old as humans, HA HA I NP NP most of the population is susceptible, but it is only in the Viruses NA NA and can lead to large outbreaks, M M NS NS last two centuries Influenza viruses have been the epidemics or pandemics. Since that we have started cause of major morbidity and influenza viruses circulate in many PB2 mortality worldwide, and large animal species, there is also an PB1 understanding its PA segments of the human population opportunity for animal and human HA microbial basis are affected every year. Additionally, NP influenza viruses to reassort their NA and diversity. these viruses also infect many animal RNA segments, with the population M NS Various plagues species allowing the mixture of having little or no immunity against strains and the emergence of novel 2009 SWINE FLU PANDEMIC VIRUS have inflicted viruses, sometimes with pandemic the new virus. Usually avian and humans through potential. There are three genera human influenza viruses circulate Figure 7. The 2009 swine flu pandemic virus arose by reassortment of human avian and swine influenza A viruses. Figure created by Shaheed Jamal. (types) of influenza viruses—A, within these species. But pigs the ages, some of ion channel activity of the viral Though useful for everyone to B and C, and viruses belonging can get infected by both types of M2 protein; this is essential for prevent disease (not infection), the major ones to each of these types can viruses, and act as “mixing vessels” Note that this virus that the intracellular release of viral these are especially recommended undergo genetic reassortment to produce new influenza viruses. caused a human pandemic shown in Figure 6. RNAs. These are off-patent and for children aged 6 months to 4 and thus readily exchange This is illustrated in Figure 7, which Here we will focus contains only one human very inexpensive drugs. However, years and adults > 50 years as also genetic information, but shows the emergence of the 2009 on the 20th and they have significant side effects in people with chronic ailments reassortment between viruses swine flu pandemic virus. Note that and two avian flu virus and resistance to these drugs arises and immunosuppression. Universal 21st centuries, to belonging to different types has this virus that caused a human genes; the rest of the rapidly. The other class of drugs are influenza A vaccines that protect never been reported. We will pandemic contains only one seek out common genes were derived from virus egress inhibitors—these inhibit against all subtypes of the virus is a focus on influenza A viruses since human and two avian flu virus features in our neuraminidase, which is required highly desirable goal, and an active these are most frequently associated genes; the rest of the genes were swine flu viruses, including to release newly produced virions area of research. understanding of with human disease. derived from swine flu viruses, the HA and NA genes. from the cell surface. These include disease and our including the HA and NA Other strategies. Influenza is a Influenza A virus has a complex This is why humans had no Oseltamivir (Tamiflu), Zanamivir genes. This is why humans had respiratory disease, which is spread response to it. structure with a lipid membrane (Relenza), Peramivir (Rapivab) and no immunity and were highly immunity and were highly by coughing, sneezing and aerosols. Pre 20th century derived from the cell in which Laninamivir. susceptible. susceptible. Barrier protection with masks is it replicated. Embedded in pandemics are Vaccines. Vaccination against desirable in the flu season, especially this envelop are three viral Treatment. Two types of drugs briefly described in cycle. Adamantanes such as seasonal influenza is carried out for those vulnerable due to age or proteins—haemagglutinin (HA), have been used for influenza—both Amantadine and Rimantadine annually based on the major other ailments. Annex 1. neuraminidase (NA), and M2. directed at the virus multiplication are entry inhibitors that block the viral strains circulating that year.

PANDEMICS: PAST, PRESENT AND LESSONS FOR THE FUTURE 45 Q6 / 17

(MERS-CoV), also associated with COVID-19, of which about a dozen respiratory disease. And in late 2019, are used widely with promising or another novel coronavirus, SARS- mixed results. Remdesivir, a RNA CoV2, emerged to cause respiratory virus replication inhibitor initially disease and the ongoing pandemic. developed for Ebola and hepatitis C has shown limited efficacy early The origins of all respiratory in the disease, and so has steroid disease-causing human therapy late in the disease to control coronaviruses have been the ‘cytokine storm’. Plasma therapy traced to bats, having jumped using plasma from recovered patients 3. HIV lineage cells and some populations therapy. The various classes of into human via other animal was used during SARS and is being of dendritic cells (DCs). These are anti-HIV drugs are (1) replication species—SARS-CoV through used widely in critical COVID-19 HIV is a complex virus with also the cells that are important for inhibitors, both nucleoside and civet cats, MERS-CoV through patients with mixed outcomes. a unique virion morphology immune control of other infections; non-nucleoside reverse transcriptase dromedary camels, and SARS- containing cylindrical or conical chronic HIV infections slowly lead (RT) inhibitors; (2) protease CoV2 either directly or through Vaccines. Till very recently there cores. The ~ 10 kilobase genome to immunodeficiency. inhibitors that inhibit viral protein pangolin. Expectedly, the highest were no licensed vaccines against expresses genes found in all processing; (3) integrase inhibitors HIV infects key cells of the nucleotide identity of SARS-CoV2 human coronaviruses. Various retroviruses—gag, pol and env that that prevent provirus formation; and adaptive immune response, is to bat coronaviruses (96%) isolated vaccines were developed against code for the viral core, polymerase (4) fusion inhibitors that block virus explaining the clinical in eastern China in 2018 and to a SARS-CoV, including inactivated and envelope proteins. Additionally, entry into host cells. Since HIV manifestations of immune pangolin virus (91%); it has far less whole virus, viral-vectored single HIV also has a number of accessory undergoes rapid mutation, use of suppression. The time from genetic identity to SARS-CoV protein, recombinant proteins genes—vif, vpr, vpu, tat, rev, single drugs lead to resistance. The 2. Coronaviruses acute infection to AIDS (defined (80%), MERS-CoV (55%) and the and DNA vaccines. However, the and nef that are not required for most successful regimen is to use a as CD4 cell count of < 200 Coronaviruses are enveloped common cold coronaviruses (50%) disease disappeared before any of virus multiplication in vitro but combination of 3 drugs that includes cells per microliter) can be as RNA viruses that are widely these could be tested for efficacy. are essential for disease causation a cocktail of non-nucleoside RT and Treatment. There are no specific rapid as 6 months or as long as distributed among humans, For COVID-19, however, there (Figure 7). The main targets for protease inhibitors. antivirals directed against human 25 years, though most people other mammals and birds. are over 200 different vaccines in HIV are CD4+ T lymphocytes, coronaviruses. During the SARS progress in 5 to 10 years. This Vaccines. Despite decades of Members of this family of viruses development, of which about 50 are CD4+ monocyte/macrophage outbreak, many patients were treated variable disease course depends upon research and several clinical were isolated in the 1930s as in clinical development and six have with Ribavarin, steroids, alpha early events at the time of acute trials, no vaccine has so far been causative agents for infectious received emergency use approval. interferon, and protease inhibitors infection, viral and host genetics. developed. bronchitis in chicken, transmissible This is remarkable speed, with HIV infects key cells of licensed for HIV therapy. According The establishment of latent viral gastroenteritis in pigs and severe at least four COVID-19 vaccines to a large-scale review (Stockman et the adaptive immune reservoirs is key to the success of Other strategies. There are three liver and neurologic disease in reporting efficacy data from Phase al. 2006), none of these treatments response, explaining the HIV as a pathogen. During the major modes of HIV transmission— mice. In the 1960s, some human 3 trials. The earliest approvals are showed a beneficial effect in period of acute infection, a stable sexual, parenteral (via blood) and respiratory viruses were also added expected by the end of 2020, with clinical manifestations of patients. At least 21 different reservoir of HIV-infected rested mother-to-infant. The mitigation to this family; two of these were some vaccines becoming available in treatments are being tried for immune suppression. The memory CD4 cells is established. strategies rest on behaviour change associated with about 20-30% early 2021. As proviruses in this reservoir are such as limiting sexual partners, of common colds. These were time from acute infection Other strategies. Coronaviruses not transcriptionally active, no viral using condoms, and not sharing considered a pretty harmless family The origins of all to AIDS (defined as CD4 cause upper and lower respiratory RNAs or proteins are produced needles (either for injections or of viruses, until the emergence of respiratory disease- infection, which is spread by cell count of < 200 cells and the virus stays hidden from the recreational drug use). Improving severe acute respiratory syndrome coughing, sneezing and aerosols. immune system as well as antiviral the blood supply by testing donors is (SARS), which was found to be causing human per microliter) can be as The virus was shown to be viable therapy. an effective way to reduce infections caused by a new coronavirus, called rapid as 6 months or as coronaviruses have been on surface from about 4 hours to in the community. Mother to SARS coronavirus (SARS-CoV). traced to bats, having 72 hours. Barrier protection with long as 25 years, though Treatments. There are multiple infant transmission can be reduced This was followed in 2012 by the masks, physical distance of about 6 drugs available to treat HIV-infected drastically by treating mothers emergence of the Middle East jumped into human via most people progress in 5 feet and frequent hand washing with people, which has turned AIDS during pregnancy and breastfeeding. Respiratory Syndrome coronavirus to 10 years. other animal species... soap is recommended. into a chronic disease with lifelong

PANDEMICS: PAST, PRESENT AND LESSONS FOR THE FUTURE 47 Pandemics: Past, Present and Lessons for the Future.

Question No. 7: What are the Main Causes or Drivers Behind the Emergence of Pandemic Diseases? (Charles Perrings, Arizona State University) Q7 / 17

to have their origin in forested tropical areas. Specifically, the risk of disease emergence is highest ANSWER in forested areas in the tropics characterized by high levels of mammalian biodiversity (panel a in Figure 8), human population, and the conversion of forest habitat to agricultural production (panel b in 7 Figure 8). The management of emergence involves intervention in the t is estimated that processes of forest conversion. I around 60% of Emergence risks are highest all known human along the edges between forest habitats and agricultural land. pathogens and The more fragmented is the 75% of recently pattern of conversion, the emerged infectious greater is the length of the forest edge, which is where diseases are zoonotic transmission between infected (Bueno-Marí et al. It is helpful to distinguish wild animals and domesticated 2015). There are between the emergence and animals occurs. spread of zoonoses. Currently a common set of while much effort is committed While most studies of the problem factors involved in to the management of spread risk, have argued that the way to reduce both the emergence very little effort is committed to emergence risk is to reduce the rate of deforestation (Dobson et al. and spread of emergence risk. Yet it has been frequently demonstrated that 2020), it is also possible to focus zoonotic diseases. prevention is better than cure This makes it (Leung et al. 2002). A recent study Figure 8. The predicted relative risk distribution of zoonotic EID events. a) shows the predicted distribution of new events b) shows the estimated risk of event locations after factoring out reporting Emergence risks are bias. Source: Adopted from Allen et al. (2017, pp. 4) possible to identify of COVID-19 concludes that the cost of effort aimed at preventing the highest along the edges both likely sources on the edge directly. Risk can be of risk. In all cases emergence is approach increasingly being taken emergence of novel zoonoses would between forest habitats reduced by focusing on the pattern associated with contact between to mitigate emergence risk is styled of new outbreaks, be significantly less than the cost of and agricultural land. The of land conversion. A reduction humans or their domesticates and the ‘One Health’ approach. From a responding to novel zoonoses once and likely patterns of more fragmented is the in the length of the forest edge can particular wild species at forest disciplinary perspective, it integrates spread. they have emerged (Dobson et al. be achieved by ensuring that the edges. virology and parasitology, ecology, 2020). pattern of conversion, pattern of land conversion is more epidemiology, economics, political compact, and less fragmented. It follows that management of science, and anthropology. From Although emerging infectious the greater is the length emergence risks has less to do a policy perspective it integrates disease outbreaks are most of the forest edge, which China has been the source of with epidemiology than with public health, veterinary medicine, likely to occur in the large is where transmission many emerging zoonoses in recent the process of land conversion, animal management, and biological population centers of Europe, decades, but as Figure 8 shows, agricultural production methods, conservation (Cunningham et al. the USA, and Japan, there is a between infected wild countries in South and Southeast the trade in wildlife and wildlife 2017). growing body of evidence that animals and domesticated Asia, Central America, Central and products, and the ecological those outbreaks are most likely animals occurs. West Africa are similarly a source impacts of habitat depletion. The

PANDEMICS: PAST, PRESENT AND LESSONS FOR THE FUTURE 51 Pandemics: Past, Present and Lessons for the Future.

Question No. 8: What are the Factors Affecting the Spread of Pandemics? Q8 / 17

In the last few decades, suspension of international flights to development of the travel and from China. When it became network and growth in the ANSWER volume of travel have been implicated in both the pattern Differences in the and rate of spread of plague, effectiveness of such cholera, HIV-AIDS, H5NI, West measures applied in Nile virus, and SARS (Hufnagel et al. 2004, Tatem et al. 2006, Daszak different countries reflect 2012) . Interventions in the trade a fundamental property 8 and travel network—restrictions on of epidemics—that the movement of both goods and people—are a common first response the contact between he spread of to the appearance of an emerging susceptible and infected T newly emerged infectious disease. infectious diseases individuals which leads In the case of COVID-19, the to transmission depends is very strongly tied outbreak prompted immediate on the choices made by to patterns of trade mobility restrictions around and travel. Studies Wuhan. These were followed by the individuals. of the role of the air transport network in the transmission of the 2003 SARS and 2009 H1N1 clear that the virus had already low, or the private cost of illness taken to compensate those affected. pandemics show spread internationally, individual avoidance is high, people have More of this is discussed in the that spread rates countries (individual states in little incentive to avoid contact. economic impacts of pandemics reflect the time and the U.S.) added internal mobility The essentially economic nature of (see Q14). restrictions together with a range of contact decisions, and the essential distance associated social distancing measures. role of economics in epidemiological The experience of COVID-19 with distinct routes, processes, was understood before has shown how widely public together with the Differences in the effectiveness COVID-19 (Perrings et al. 2014) . health control measures and the of such measures applied in resulting costs differ between volume of traffic different countries reflect The private costs of illness and countries (Fang et al. 2020, Hale along those routes a fundamental property of illness avoidance depend partly et al. 2020). It has also shown (Brockmann and epidemics—that the contact on the characteristics of the how widely the costs that national Helbing 2013). between susceptible and disease, partly on the public health governments were implicitly willing infected individuals which leads control measures implemented to bear vary. The implicit ‘price of to transmission depends on the and the enforcement of those life’ ranges from around $100,000 in choices made by individuals. measures, partly on institutional the U.K., the U.S. and Italy to over People’s contact choices reflect the conditions (the formal and informal $1million in Denmark, Germany, relative costs of illness and illness mechanisms available to support New Zealand and Korea (Balmford avoidance to them—the private those incapacitated by illness), and et al. 2020) . cost. If the private cost of illness is partly on outbreak-specific measures

PANDEMICS: PAST, PRESENT AND LESSONS FOR THE FUTURE 55 Pandemics: Past, Present and Lessons for the Future.

Question No. 9: What Measures were Adopted by Countries to Combat COVID-19 and How Successful Have They Been? Q9 / 17

In Table 1, we present some contrasts. The intention here is of the practices adopted by 10 not to imply that these are the best countries as of 10th October responses to the pandemic but to ANSWER 2020. These countries were selected simply enlist various practices that to highlight either the high case were adopted by these countries to infection and death rates, type of address the spread of the pandemic. 9 measures undertaken, or regional COUNTRY n this section, Iwe shall look USA INDIA CHINA SOUTH AFRICA KENYA BRAZIL at the efficacy of SEVERITY Cases = 7,663,293 Cases = 6,906,151 Cases = 85,557 Cases = 690,896 Cases = 41,158 Cases = 5,055,888 policies implemented IMPACT* Deaths = 213,752 Deaths = 106,490 Deaths = 4,634 Deaths = 17,673 Deaths = 760 Deaths = 149,639 to contain the Declared “State of Nationwide Lockdown Lockdown of Wuhan, Declared a “National Nationwide Curfew from Restricted Operation spread of the virus. Emergency” Hubei Province State of Disaster” 7pm to 5am of Non-Essential Localized Businesses Policies relating Promoting Work- Lockdowns in Adopted Stringent Adopted Containment Suspension of from-Home Containment Zones Enforcement Measures Measures International Flights Schools Closures to mitigating the Extended Extensive Testing to Test, Track, Isolate, economic, education Social Distancing Social Distancing Travel Restrictions Containment Travel Restrictions Treat (TTIT) Covid-19 and health impacts Measures Varied by Travel Bans on Visitors Heightened Restrictions Free Testing State & County Imposed 14-Day TTIT was Implemented Quarantine from High-Risk Countries in Non-Essential Social will be addressed Through Elaborate Use Spaces and Gatherings Travel Bans Post Travel in following of Digital Technologies Quarantine for Nationals Ban on Large School and College ADOPTED like Artificial Returning from High-Risk Encouragement of Gatherings Closures Countries Teleworking Where sections focusing Intelligence (AI), Big MEASURES Possible School Closures Closure of Gyms, Data, Cloud Computing, Screening at Ports of on the key impacts (those that Museums, & Blockchain, and 5G Entry School and College reopened adopted Theatres of the pandemic Closures various instruction Promoting Remote Large-Scale Mobility School Closures approaches-in-person (Q10-Q16). Work Establishment of Isolation instruction, virtual or Restrictions at the Testing Introduced but at Facilities hybrid) Ban On Mass National Level Low Rates Gatherings Limitations on Public Entertainment, Theme Social Distancing Parks & Convention Covid-19 Testing Introduction of Mobile Transportation Passenger Centers Created Technology to Track And Capacity Centers Remain A 14-Day Quarantine Trace Contacts of Those Closed in Some States Nationwide Phased Period For Returning Infected and Inform Reopening Plan in Phased Reopening by Migrant Workers Individuals if They Have Place Most States Been in Close Proximity to a Person Diagnosed with COVID-19

GOVERNMENT RESPONSE STRINGENCY 62.50 73.61 52.31 39.81 64.81 63.43 INDEX** (100 = STRICTEST)

*Figures as of 10 October 2020, based on John Hopkins University, Coronavirus Research Center; World Economic Forum; International Table 1. Severity impact, adopted measures and government response severity index (as of 10 October 2020). Monetary Fund. ** Figures as of 10 October 2020, adopted from Hale et al. (2020). The index ranges from 0-100 (100= strictest) and measures level of PANDEMICS: PAST, PRESENT AND LESSONS FOR THE FUTURE 59 strictness with which government policies were implemented. Q9 / 17

In an attempt to measure a national government’s response to the pandemic, Hale et al. (2020) COUNTRY developed an Oxford COVID-19 Government Response Tracker (OxCGRT). Their team used ARGENTINA NORWAY SWEDEN FRANCE GERMANY SOUTH KOREA INDONESIA data from over 150 countries on 18 indicators14 and aggregated it Cases = 15,388 Cases = 15,388 Cases = 6,906,151 Cases = 732,434 Cases = 320,495 Cases = 24,548 Cases = 324,658 SEVERITY into a set of four common indices, IMPACT* Deaths = 275 Deaths = 275 Deaths = 106,490 Deaths = 32,601 Deaths = 9,599 Deaths = 430 Deaths =11,677 reporting a number between 1 and 100 to reflect the level of Full Closure of Travel Implemented Continuous Hospital Capacity Continued Vigilance Temporary Bans government action on health, Border Restrictions ‘Herd Immunity’ Monitoring Built Up on Domestic and Strategies of Localized International Air and education and state of economy. Extensive Testing Extensive Testing Nation-Wide Quarantine- Clusters with Sea Travel Lockdown After-Travel No Lockdown Outbreaks Awareness Contact Tracing The four indices are as follows: Imposed Requirement Campaigns (Public Screening at Ports School Closures Imposed Voluntary Communication) Isolation of Entry Ban On All 1. OVERALL GOVERNMENT Strict Quarantine Compliance to Transparency Social Distancing Social Distancing Non-Essential Quick Treatment Of School Closures RESPONSE INDEX: Measures In Measures Activities, Border Closures Confirmed Cases This index measures the variation in Outings, Large Place Restrictions on overall government response across Secondary Gatherings And Closure Of Schools Public Events Long-Distance And Non-Essential all indicators, suggesting whether ADOPTED Closures Schools and Of Schools, Universities Travel Businesses Banned Indonesia’s government response has increased MEASURES Universities And Switched Introduction Traditional Annual or decreased since the outbreak. Social Distancing Businesses to Distance Of Night-Time Exodus For Muslim Requirements Learning Curfews In Holidays During Eid Imposed 2. CONTAINMENT AND HEALTH Some Cities Al-Fitr Celebrations Enforcement Of INDEX: Abandon The Mask-Wearing Customary This index encapsulates school “Bise” Ban on Public closures, mobility restriction due to Greeting— Gatherings lockdown and also contact tracing Involving and testing policy to list a few. Kissing Each Other On The Cheek—To 3. ECONOMIC SUPPORT INDEX: Promote Social Distancing This index includes information regarding economic stimulus received, debt relief.

GOVERNMENT 4. STRINGENCY INDEX: RESPONSE This index measures how strictly the STRINGENCY 82.87 28.7 37.04 43.98 46.76 56.48 68.98 lockdown policies restricted human INDEX** (100 = STRICTEST) behavior.

*Figures as of 10 October 2020, based on John Hopkins University, Coronavirus Research Center; World Economic Forum; International 14Containment and closure: 1) School closing 2) Workplace closing 3) Cancel public events 4) Restrictions on gathering size 5) Close public transport 6) Stay at home requirements Monetary Fund. ** Figures as of 10 October 2020, adopted from Hale et al. (2020). The index ranges from 0-100 (100= strictest) and measures 7) Restrictions on internal movement 8) Restrictions on international travel. Economic level of strictness with which government policies were implemented. response: 1) income support 2) debt/contract relief for households 3) fiscal measures 4) giving PANDEMICS: PAST, PRESENT AND LESSONS FOR THE FUTURE international support. Health systems: 1) Public information campaign 2) testing policy 3) 61 contact tracing 4) emergency investment in healthcare 5) investment in COVID-19 vaccines. Miscellaneous: Other responses. Q9 / 17

Figure 10 reveals that ceteris paribus United States O America a higher stringency index during 20000 100 initial months is instrumental 18000 16000 80 in reducing the impact of the 14000 pandemic. However, a drop in 12000 60 10000 the stringency index in later 8000 40 months, which pertains to lifting 6000 of lockdown and containment 4000 Total Cases Per Million 20 STRINGENCY INDEX

TOTAL CASES PER MILLION TOTAL 2000 Stringency Index measures, seems to have contributed 0 0 to the spikes experienced by those Jul Jan Apr Oct Jun Feb Sep Mar Aug May

MONTH respective countries. The French graph indicates that a premature

India lifting of containment measures

10000 100 has contributed to the emergence of a second wave in France. In 8000 80 the case of India, the graphs show

6000 60 a low infection rate with a very high stringency index in the early 4000 40 days but as measures were relaxed,

2000 Total Cases Per Million 20 STRINGENCY INDEX the infection rates increased

TOTAL CASES PER MILLION TOTAL Stringency Index 0 0 exponentially. As the stringency Jul Jan Apr Oct Jun Feb Sep Mar Aug May index is composed on a range of MONTH measures that not only include the health measures but also economic Cina support and government policy 10000 100 implementation, a more detailed

8000 80 analysis will be required to explore which particular measures were the 6000 60 Current Government primary reason for containment. Response Index Level 4000 40 The graphs also reveal that 80 - 100 timing of implementation of 2000 Total Cases Per Million 20 STRINGENCY INDEX 60 - 80 TOTAL CASES PER MILLION TOTAL Stringency Index stringent measures is critical, 40 - 60 0 0 the quicker these measures Jul Jan Apr Oct Jun Feb Sep Mar Aug May

20 - 40 MONTH were implemented, for example 0 - 20 in China, the better chance a country has in curbing the No Data France pandemic. 10000 100

Figure 9. COVID-19 Overall Government Response Index by Country. Source: Adopted from Hale et al. (2020) 8000 80 The findings from Hale et al (2020) insightful to evaluate the spread stringency index calculated by Hale 6000 60 are graphically represented in Figure of the pandemic with respect to et al. (2020) over time for select 9. strictness in implementation of countries. The aim is to examine 4000 40

containment measures. Therefore, in whether those countries with higher 2000 20 STRINGENCY INDEX While Figure 9 represents Total Cases Per Million Figure 10, we graphically represent stringency index were able to CASES PER MILLION TOTAL Stringency Index country performance in terms of the total number of COVID-19 contain the pandemic or not. 0 0 Jul Jan Apr Oct Jun Feb Sep Mar Aug overall government response to May cases (normalized per million) MONTH the pandemic, it might be more and the government response Figure 10. Total COVID-19 Cases per million and Government Response Stringency Index for selected countries from 1 January 2020 till 10 October 2020. Source: Graphs created by Kriti Singh using data from Hale et al. (2020) and Our World in Data (https://ourworldindata.org/covid-cases)

PANDEMICS: PAST, PRESENT AND LESSONS FOR THE FUTURE 63 disruptions in the economic, In this document we shall focus on Key Impacts of education and health sectors (See the health, economic and education COVID-19 Figure 11). A pandemic has to be impacts and through those attempt seen more than just a health issue but to trace how these might affect The impacts of COVID-19 go a societal problem that transcends the progress towards achieving the beyond just health. It affects nearly sectoral boundaries with its impacts Sustainable Development Goals every segment of society causing affecting people on multiple fronts. (SDGs).

COVID-19 HOME RESTRICTIONS TRANSPORT CLOSURE OF INFECTION ISOLATION ON NON-ESSENTIAL RESTRICTIONS EDUCATIONAL WORKERS FACILITIES

Direct Health Fear & Stress & Unemployment or Longer Term Loss of Risk of Impacts Anxiety Boredom Under Employment Economic Education Exploitation Consequences of Children Not in School

Isolation, illness and caring responsibilities for workers

Reduced Loss of Essential Services Additional Costs: Utilitarian Income Stretched - Food, Home Heating, Fewer Staff Walking & Cycling Utilities, etc Childcare, Food, etc Available in Health & Social Care

Substance Vulnerable Long Term Non-presentation Misuse, Online People Isolated Avoidance of for Care of Other Gambling, and with Abusers Public Transport Conditions Unintended Pregnancy

Level of Motorised Traffic

Family Reduced Debt & Air Quality Non-COVID Social Social Physical Violence & Access to Basic Housing Injuries, Noise, Care Displaced Isolation Disorder Inactivity Abuse Necessities Insecurity Greenhouse Gases

Directly Attributable Indirectly Attributable Morbidity & Mortality Morbidity and Mortality

Figure 11. Impacts from COVID-19. Source: Adapted from Douglas et al. (2020)

PANDEMICS: PAST, PRESENT AND LESSONS FOR THE FUTURE 65 Pandemics: Past, Present and Lessons for the Future.

Question No. 10: What are the health impacts of COVID-19? Q10 / 17

million. The Case Fatality Rate have been people with obesity. (CFR)15 for India, USA and In a meta-analysis published in Depending on age, health Brazil were approximately 1.5, Obesity Reviews, which included ANSWER 1.9 and 2.6 respectively as of 399,000 patients, it was found and clinical condition December 13th 2020. that people with obesity who of the patients (Wu et contracted COVID-19 were 113% al. 2020) outcomes of Depending on age, health more likely than people of healthy and clinical condition of weight to land in the hospital, 74% COVID-19 have shown the patients (Wu et al. 2020) more likely to be admitted to an dramatic variation with outcomes of COVID-19 have ICU, and 48% more likely to die more severe outcomes 10 shown dramatic variation with (Simonnet et al. 2020, Hamer et more severe outcomes in the al. 2020). Depending on severity in the elderly patients elderly patients with secondary of infection, existing health with secondary health here are basically health problems like diabetes, conditions and age, recovery problems like diabetes, Ttwo direct health hypertension, lung and heart from COVID-19 is variable with impacts—mortality diseases and cancer. Dozens of some persons recovering easily hypertension, lung and studies have also reported that many while others experiencing longer heart diseases and cancer. and morbidity. The of the sickest COVID-19 patients recuperation time. former refers to the As of December 2020, India number of deaths COVID-19: DEATHS was the third highest country United States India Brazil Argentina Norway Sweden France Germany South Korea Indonesia China while the latter 350,000 with fatalities in absolute terms while it is ranked 83 of over 203 refers to the level of 300,000 countries and territories when health during and 250,000 United States normalized for population. Septemer 12: 193,843 post illness. As of 200,000 Morbidity is overlooked if we focus 13th December 150,000 only on death as a measure of the

2020 there were 100,000 effect of the pandemic. While it approximately over is too early to evaluate morbidity, 50,000 emerging studies report on children 1.5 million deaths 0 who developed a multisystem Jul 01 Jan 01 Apr 01 Oct 01 Jun 01 Dec 01 Mar 01 Aug 01 Aug Nov 01 Nov May 01 May globally with USA, Sept 01 inflammatory syndrome after Brazil and India COVID-19, with potential cardiac damage (Whittaker et al. 2020). with the highest COVID-19: DEATHS PER MILLION United States India Brazil Argentina Norway Sweden France Germany South Korea Indonesia China The severe pulmonary damage has levels of 297,800, 1000 been observed in some adults who 9000 181,123 and 143,019 India as of 13th December 2020 recovered from severe COVID-19. 8000 Brail had mortality rate of 105 per Octoer 1: 681 It is too soon to tell whether this respectively (See The Case Fatality 7000

million increasing from about 6000 will have long-term respiratory Figure 12). Rate (CFR) for India, 75 deaths per million as of 1 5000 implications, but the term

October 2020. The U.S. was USA and Brazil were 4000 “Long COVID” has been used

th 3000 to describe long-term sequelae experiencing 910 deaths as of 13 approximately 1.5, 1.9 December increasing from 625 2000 of COVID-19. It is a situation deaths per million as of 1st October and 2.6 respectively as of 1000 that countries should continue with Brazil having a death rate of December 13th 2020. 0 to monitor as patients recover. Jul 01 Jan 01 Apr 01 Oct 01 Jun 01 Dec 01 Mar 01 Aug 01 Aug Nov 01 Nov May 01 May 864 from approximately 675 per Sept 01 Figure 12. Deaths and deaths per million across selected countries from 1 March 2020 till 15 December 2020. Source: Graphs created by Devesh Kumar based on data from European Centre 15The CFR is the ratio of deaths per number of cases. for Disease Prevention and Control (https://www.ecdc.europa.eu/en) Last updated: 15 December 2020, 08:00 IST (GMT +5:30) PANDEMICS: PAST, PRESENT AND LESSONS FOR THE FUTURE 69 Q10 / 17

difficult choices on how to best meet associated lockdowns was the for cancer, cardiovascular disease reported following the imposition Indirect Health the needs of people. The outbreak negative impact on accessing and diabetes have not been receiving of quarantine in previous outbreaks Impacts of the infection has necessitated the essential health care. For instance, the health services and medicines (Brooks et al. 2020, NZFVC 2020). urgent increase in the number of in India, public transport was barred they needed since the COVID-19 The massive negative effects of Two indirect impacts from beds and intensive care units that for a long time, making it extremely pandemic began. mandatory mass quarantine have COVID-19 have emerged so far in are localised in specifically equipped difficult for individuals with pre- called for serious introspection on SOCIAL STIGMA the literature. The first relates to the wards, with dedicated medical teams existing health problems to access the use of quarantine as a public The fear of being infected with effects of COVID-19 on the health and separate routes and exits. any health care. As a consequence, health measure (Hawryluck et al. COVID-19 has given rise to system and its capacity to deliver The speed, extent and severity of there have been dramatic reductions 2004, Reynolds et al. 2008, Brooks stigma in local communities. health care. The second indirect the infection exposed the lack of in essential public health and clinical et al. 2020). Social stigma was defined as impact pertains to the psychological preparedness of healthcare systems interventions. PSYCHOLOGICAL IMPACT OF Along similar lines a study “an attribute which is deeply implications arising from the disease and made clear the urgent need for Data from India’s National Health COVID-19 comparing post-traumatic stress discrediting” that reduces a itself but also from the confinement countries to develop guidelines for Mission indicates that there was symptoms in parents and children person “from a whole and usual and lockdown policies implemented such pandemic disasters with the a close to 70% drop in children’s The highly infectious nature quarantined with those not person to a tainted, discounted to contain the virus. objective of enhancing the resilience vaccination for measles, mumps, and of the COVID 19 virus have quarantined found that the mean one” (Goffman 1963, p.3; of health systems and integrating rubella, a 50% fall in attendance to demanded hard measures of physical post-traumatic stress scores were Dowdy et al. 2020). Media reports disaster risk reduction into all levels clinic for acute cardiac events, an distancing and the strict imposition much higher (quadrupled) in from around the globe have also of healthcare. over 30% decrease in inpatient care of quarantine. For humans who children who had been quarantined, narrated how frontline health care for pulmonary conditions, and an are social beings, quarantine is a compared to those who were not workers were assaulted, spit on, over 20% reduction in institutional difficult and unpleasant experience. (Sprang and Silman 2013). While denied rides, hit with rocks, sprayed BURDENING THE HEALTHCARE deliveries in March 2020, compared Uncertainty and anxiety about the length of the quarantine with bleach and made homeless SYSTEM with March 2019 (Cash and Patel disease status, curtailed freedom, period (10 days or more) on social because of fears that they would 2020). Other disruptions observed boredom and separation from family and emotional health is unclear, transmit COVID-19 to the people The COVID-19 pandemic stretched ACCESS TO ESSENTIAL in other countries include curtailed and friends can have dramatic maintaining stable social and living around them (Sotgiu and healthcare systems worldwide HEALTHCARE access to antimalarial medicines consequences. Anger runs high, emotional health has emerged as a Dobler 2020). and rapidly revealed the fragility and suspension of polio vaccination. and increases in domestic violence, key factor of psychological health in of healthcare infrastructure and The second rather unfortunate Many people who need treatment divorce rates and suicide have been quarantine conditions. services, forcing countries to make outcome of COVID-19 and

PANDEMICS: PAST, PRESENT AND LESSONS FOR THE FUTURE 71 the immune system gradually loses MINORITY POPULATIONS Factors its resilience, resulting in greater affecting the susceptibility to infection of any Racial/ethnic and minority kind, especially a new one like populations experience worse health magnitude COVID-19 (Valiathan, Ashman & outcomes than do other groups Asthana, 2015). However, this age during and after disasters. A study of direct and gradient needs to be re-examined in on racial and ethnic disparities light of a research study conducted in population level COVID-19 indirect health by Laxminarayan et al. (2020) mortality found that only 28 states that examined COVID-19 cases in the United States reported race impacts of from Southern India. Their study and ethnicity-stratified COVID-19 analyzed data from the Indian states mortality (Gross et al. 2020). The COVID-19 of Tamil Nadu and Andhra Pradesh, increased mortality risk for black and found enhanced transmission compared to the white population was found to be 3.57 (95% CI: A number of factors affect the risk was apparent among children 2.84-4.48). Similarly, the Latino mortality and morbidity levels of and young adults. In their study, population displayed 1.88 (95% the disease. In addition, the degree deaths were concentrated in 50- to CI: 1.61-2.19) times higher risk of to which the indirect impacts 64-year-olds. Their data indicated death than whites. However there will affect individuals will also that incidence of COVID 19 did not is no evidence to suggest that such be influenced by a number of change in older age groups and this disparities are due to genes or how external factors. The key factors are was attributed to adherence to stay- our immune system responds to presented below. at-home orders and social welfare programs or socioeconomic status. viral infections. These disparities instead may be attributed to the AGE disproportionate burden experienced PRE-EXISTING HEALTH by people of color regarding Similar to the 2003 SARS epidemic CONDITIONS (Anderson et al. 2004), but unlike comorbidity, at-risk employment, H1N1 Swine Flu of 2009, the Pre-existing health conditions unstable housing, incarceration, and risk and severity of COVID-19 like diabetes, heart disease, and decreased access to healthcare and increased with age (Dong et al. other chronic illnesses lead to medical resources. 2020; Zhao et al. 2020) with the more intense disease symptoms GENDER most severe health impact seen for and complications. While the adults over the age of 60—with impact of underlying medical Public policy data indicate particularly fatal results for those conditions on COVID 19 differential impact of pandemics 80 years and older. Potential continues to be investigated, across gender with women affected reasons behind this increment in emerging reports suggest that more than men. From a public reported number of cases with age individuals with underlying health perspective, they are: (i) at the onset of COVID-19 (Liu, health conditions might be at disadvantaged by reduced access Xing, & Xue Za, 2020) are lower an increased risk for severe to sexual and reproductive health vulnerability to infection among illness from COVID-19. Some of services (Wenham et al. 2020); (ii) younger populations, reduced these include asthma, hypertension, more severely affected since they chances of tracing infection as the cardiovascular disease, obesity, bear the brunt of care responsibilities cause of disease among children, neurologic conditions such as as schools close and family members and prevalence of underlying dementia, liver disease, smoking, fall ill (Bandiera et al. 2018); and (iii) health conditions present in older and immunocompromised at greater risk of domestic violence populations (Davies et al. 2020). conditions, to name a few. (Peterman et al. 2020, NZFVC Moreover, with increase in age, 2020).

PANDEMICS: PAST, PRESENT AND LESSONS FOR THE FUTURE 73 Pandemics: Past, Present and Lessons for the Future.

Question No. 11: What Health Sector Specific Policy Responses can be Implemented? Q11 / 17

To maintain and build public trust continuous anxiety, extended in public health authorities before, Quarantine is a necessary sadness, or other stressful reactions during and after an influenza that negatively affect their work ANSWER pandemic; preventive measure during or family relationships in order To support coordination and the pandemics. However to provide relief and receive 16 efficient use of limited resources studies have suggested professional counselling. In among local, national, regional and India, psychiatric social workers that length of quarantine international public health partners; quickly set up counselling support for psychological counselling. In To provide relevant public health can have impact on addition, social network support information to the public; to support psychological health and 11 was found to be a great resource in vulnerable populations having the economic growth. managing psychological outcomes information they need to make (Maunder et al, 2003). he pandemic well-informed decisions; economic growth. Two studies T outbreak exposed To take appropriate actions to showed that longer quarantine is Protecting associated with poorer psychological many gaps and protect their health and safety; and to minimize social and economic outcomes. Research suggests that Vulnerable weaknesses in public disruption. restricting the length of quarantine health surveillance, to what is scientifically reasonable Populations To minimize social and economic given the known duration of preparedness and disruption. incubation periods, and not adopting In order to ensure that vulnerable response systems of an overly precautionary approach As a consequence, on ground populations are protected during to this, would minimize the effect countries worldwide. medical infrastructure and Supplies pandemic outbreaks, it is essential The impact on mental on people (Hawryluck et al. 2004, An interesting trained manpower to respond that their vulnerability be Insufficient supplies for daily Reynolds et al. 2008). to the pandemic were absent or health as a consequence of highlighted to policy makers. To feature that emerged needs was found to be one of the do so, public health professionals, was the existence inadequate, which left public health quarantine and lockdown greatest concerns in lockdown and systems vulnerable. The impact of Psychological emergency managers, and other has reiterated once again quarantine situations. Officials of policies in a COVID-19 once again brought to stakeholders need to include the need for psychological therefore need to ensure that enough Support representatives from racial/ number of countries, fore the absence of public health supplies for daily needs which would focus on mental health and the minority/migrant communities following earlier support and counselling be replenished at regular and rapid Psychological crisis intervention urgent need for it. The impact on to inform planning and response as an active component of intervals and provide reassurance to should be part of the public health epidemics and mental health as a consequence and where appropriate, to adapt the public to prevent hoarding of response to a pandemic outbreak. of quarantine and lockdown has the public health support. strategies to the context of diverse pandemics but with such supplies (Manuell et al. 2011). This is important enough to be reiterated once again the need minority communities. Mass health no follow-up action. a pandemic. The purpose of the organized at the city, municipal, and for psychological support and messages for the general population communication is to provide and provincial levels. There is urgent counselling as an active component Length of the may need to be adapted to the cater exchange pertinent information with need for an intervention workforce of the public health support. to language, culture and health the general public and stakeholders Quarantine or that comprises psychological literacy. Both the private sector Some key responses that have been so that they can make well informed outreach teams led by psychiatrists and community support can also observed include: decisions and take appropriate Lockdown and mental health professionals provide active support in keeping measures to protect health and and psychological support hotline themselves, their families, and Quarantine is a necessary teams. The European Federation safety. Communications should be others in the community protected. preventive measure during Communication based on the five principles outlined of Psychologists’ Association Co-ordinated public-private pandemics. However, studies in WHO’s influenza outbreak developed a set of guidelines for partnerships would have been very Providing scientifically accurate have suggested that length of communications planning guide psychologists on how to conduct helpful and governments need to set information to people is not only quarantine can have impact (World Health Organization 2008b), online consultations to provide up data banks of such organisations important but necessary during on psychological health and which are as follows: support for people who experience for future preparedness.

16https://www.covid19healthsystem.org/mainpage.aspx PANDEMICS: PAST, PRESENT AND LESSONS FOR THE FUTURE 77 Pandemics: Past, Present and Lessons for the Future.

Question No. 11: How Has COVID-19 Impacted School Education? Q12 / 17

There is a serious risk that Multiple Roles of Schools Compromised & Challenges of the COVID-19 pandemic will Direct impact Home Learning Magnified undo progress made in terms ANSWER of confinement Disrupted Delivery of Loss of Instructional Time of achieving the ‘Education for Academic Instruction & All’ agenda in recent decades as measures on Exam Execution Direct Impact well as in the context of the current of Confinement Measures on Disrupted Access to Food, ‘Education 2030-SDG 4’ agenda— education Loss of Learning Outcomes Widened Education: School Nutrition & Vital Services Learning Gaps inclusive and equitable quality Closures education and lifelong learning School closures can have negative Stress, Anxiety & Mental opportunities for all. effects on learning by compromising Health Issues Indirect Impact Heightened multiple roles played by schools and Pandemic Teacher Absenteeism, 12 of Confinement Risk of School Attrition, Poor Teaching The disruptions brought on by Measures on Dropout magnifying the challenges of home Disrupted Home Learning Quality the COVID-19 pandemic are learning (see Figure 14). Aside from Education disproportionately affecting the health and safety of the school ith the Education Financing Diminished COVID-19 the marginalized children population, the major impacts of Teacher Compensation W & Job Security and youth and exacerbating a pandemic on education include Curtailed Economic Increased Risks of Exploitation & Compromised outbreak, the Violence for Vulnerable Children (eg. educational inequality both disruptions not only to instructional Activities & Economic Recession child marriage, child labour, grooming world has faced within and across countries as time and exam execution but also to by gangs) an unprecedented illustrated in Figure 13, leading ancillary school-based services. to urgent calls for investment disruption to Figure 14. Impact of a pandemic on school education. Source: Figure created by Yoko Mochizuki in and transformation of Prolonged school closures disrupt education systems. education and learning systems services such as school feeding, School closures have to prevent short-term setbacks immunization, and mental health Further, these disruptions have The longer disadvantaged children from turning into long- and psychosocial support. They disproportionately negative stay out of school, the more likely Further, these disruptions affected nearly all impacts on marginalized they are to drop out. Even in a lasting problems (International can also cause stress and anxiety have disproportionately education systems Commission for the Futures of owing to disrupted routines children, such as those from non-crisis situation, children from negative impacts on around the globe. Education 2020; UN 2020). and the loss of peer interaction. poor households, those living the poorest households are almost As of the middle in conflict-affected countries, five times more likely to be out of marginalized children, migrants, the forcibly displaced, primary school than those from the such as those from poor of April 2020, over minorities, and children wealthiest (UNESCO et al. 2020). 1750 100% with disabilities and learning households, those living

1.5 billion children PERCENTAGE OF LEARNERS AFFECTED Reopened Schools Moreover, the digital divide and youth—more 1575 90% differences. in conflict-affected 1400 80% has made it impractical and Localised Closures DISRUPTED DELIVERY OF unrealistic for many schools to countries, migrants, than 90% of total 1225 70% CURRICULUM-BASED STUDIES/ transition to online classes. For enrolled learners— 1050 60% the forcibly displaced, ACADEMIC INSTRUCTION example, while globally 50% 875 50% were affected as of learners have computers at minorities, and children school and learning 700 40% The pandemic has forced a home and 57% have household with disabilities and institution closures 525 30% massive shift away from face-to- internet connection, these face instruction in the physical learning differences. expanded across 200 350 National Closures 20% figures drop to 11% and 18%, 175 10% classroom. Disruptions to respectively, in sub-Saharan in 2019.18 A high proportion of the 17 countries. 0 0 instructional time in the classroom world’s population, 46.4%, did not NUMBER OF LEARNERS AFFECTED (MILLIONS) Africa (International Commission without adequate quality online on the Futures of Education 2020). have access to the internet in 2019, 01 Apr 16 Apr 15 Jun 30 Jun 15 Jun 16 Feb 02 Mar 17 Mar 01 May 16 May 31 May learning substitutes can have a According to the most recently with most of the offline populations DATE severe impact on children’s learning available data in the World Bank’s residing in least-developed countries Total Share of Low and Upper-middle and especially learning of disadvantaged Learners Affected Lower-Middle High Income online data repository, 34.5% of (LDCs) (See Figure 15). by National Closures Income Countries Countries children. population in India used the Internet

Figure 13. Number of learners affected by school and learning institution closures globally (from pre-primary to higher education). Source: Adopted from United Nations (2020, Figure 2, p.6) 17https://en.unesco.org/covid19/educationresponse 18https://data.worldbank.org/indicator/IT.NET.USER.ZS PANDEMICS: PAST, PRESENT AND LESSONS FOR THE FUTURE 81 Q12 / 17

Key constraining factors include million in mid-August 2020.19 The also see section on health impacts). BOX 2: ‘MANODARPAN’ MENTAL HEALTH loss of school meals therefore puts For children and adolescents INITIATIVE IN INDIA (i) poor or uneven quality of these children at risk of hunger with mental health issues, social existing digital resources, which can and being deprived of key vitamins distancing measures mean a lack of India’s Ministry of Human Resource Development be neither linguistically accessible and micronutrients, which in access to the resources they usually (MHRD) launched a mental health initiative called nor culturally responsive to learner turn negatively affects immunity, have. School routines serve as ‘Manodarpan’ to promote student well-being during the needs especially in developing brain development and learning important coping mechanisms coronavirus pandemic in response to suggestions made countries; and (UNESCO 2020a). for young people with mental by a taskforce it convened. Manodarpan provides a health issues, and school dedicated website, advisory guidelines, skill handbook, (ii) the lack of training and capacity Moreover, disruptions to health closures can therefore add to a national toll-free helpline, interactive online chat of teachers in remote instruction and immunization services expose the deterioration of their mental platform, a database of counsellors and a holistic report or distance teaching, which often children in the most economically health. card. hampers the realization of flexibility, deprived households and the adaptability, customizability, poorest countries to increased risks According to Lee (2020), in a Under this programme, schools are asked to focus on learner-centred approaches and of pneumonia, diarrheal diseases, survey by the mental health charity prevention by creating a safe and calm environment, other promises of digital or blended malaria, HIV and so on, leading to YoungMinds, which included 2,111 teaching students about mental well-being, and learning solutions (UNESCO more child deaths from pneumonia, participants up to age 25 years with reinforcing it through school activities. The programme 2020c, UNESCO MGIEP 2019). which already takes the lives of a mental illness history in the UK, also addresses early detection of mental health issues 800,000 children under the age of 83% responded that the pandemic among children, by making mental health an integral DISRUPTED ACCESS TO FOOD, five annually or 2,200 daily, apart had worsened their conditions, and part of health and physical education and by making NUTRITION AND VITAL SERVICES from COVID-19 (UN CCSA 2020). more than a quarter reported that these components compulsory for teacher education courses. In addition, as part of the National Education School closures due to COVID-19 they were unable to access mental STRESS, ANXIETY AND MENTAL Policy 2020, report cards of students will be redesigned have an impact on the health and health support. HEALTH ISSUES to reflect the “uniqueness of each learner in the nutrition of many learners. The For children and adults living cognitive, affective, socio-emotional and psychomotor World Food Programme (WFP) Infectious disease outbreaks in an abusive home, social domains”. estimated that, due to school have observed increased levels of distancing measures can worsen closures, globally over 365 million anxiety among the population the already difficulty situation primary school children were and increased rates of diagnosable they find themselves in at home, missing out on school meals at NON-CONDUCIVE HOME LEARNING BOX 3: GOVERNMENT INITIATIVES TO SUPPORT mental illnesses (Brooks et al. with abuse likely aggravated at the end of March 2020 and 346 ENVIRONMENT HOME-BASED LEARNING 2020, Rubin and Wessely 2020, times of uncertainty, stress and anxiety. Whereas previous public A number of challenges hamper efforts to create an The French Ministry of Education, in March 2020, health emergencies have witnessed environment conducive to home learning. For children launched an initiative called Nation apprenante 100 100 increased reports of child abuse, from poor households, home learning is typically a (Learning Nation), to facilitate learning at home during 90 86.6 20 82.5 we know little about the long-term challenge due to a general lack of resources, including lockdown. The Kyrgyz Ministry of Education and 90 86.6 80 82.5 77.2 72.2 mental health effects of pandemics digital devices and connectivity, crowded conditions Sciences provided embedded daily instructions to 80 77.2 70 72.2 on children and adolescents, which and poor ability of parents or caregivers to facilitate parents to support their children’s homework that were 70 60 51.6 53.6 is an important gap for research (Lee formal learning at home. broadcast through TV programmes. In addition to 60 50 48.4 47.0 51.6 53.6 2020). As the COVID-19 pandemic online learning, the use of TV and radio, supported by 50 40 48.4 47.0 continues, there is a need to monitor Home learning can be a source of stress for media campaigns and guidance for parents, constitutes 40 30 28.2 learners as well as for families, as it puts extra 19.1 the mental health status of children an effective tool to reach families during school 30 20 28.2 and adolescents. Box 2 provides an pressure on caregivers, sometimes with limited closure. To reach out to students without connectivity 10 19.1 20 capacity, time or resources. Parents who do 0 example of a government initiative or devices, Mauritania and Jamaica have provided 10

CIS not speak the language of instruction or whose

LDCs to monitor young people’s mental families with take-home packages that contain learning Africa World 0 Europe children have special educational needs are likely Developed Developing Arab States Asia Paciific health issues. materials, play kits and practical guidance for parents CIS The Americas LDCs Africa World Europe to face aggravated challenges (UNESCO 2020a). (Alam and Tiwari, 2020). Developed Developing Arab States Asia Paciific

The Americas Box 3 gives examples of government initiatives designed to support home-based learning.

Figure 15. Percentage of individuals using the Internet, by region and development status, 2019 Source: Adopted from https://itu.foleon.com/itu/measuring-digital-development/offline-population/

19World Food Program, 2020. https://cdn.wfp.org/2020/school-feeding-map/?_ga=2.175892834.1147572844.1585583851-1305129353.1538135627 (accessed 25 March 2020 and 16 August 2020) PANDEMICS: PAST, PRESENT AND LESSONS FOR THE FUTURE 83 20https://www.education.gouv.fr/operation-nation-apprenante-303174 Q12 / 17

the income shock of the COVID-19 INCREASED RISKS OF The Gender (3) gendered digital gaps, which can in Sierra Leone found that teenage pandemic alone will push out almost EXPLOITATION AND VIOLENCE be exacerbated during the crisis and pregnancy increased by 65% in some 7 million students from primary FOR CHILDREN AND YOUTH Dimension deepen gender inequality in and communities during the crisis partly and secondary schools worldwide through education. due to school closures.26 (Azevedo et al. 2020). Economic Another important consideration The unprecedented disruption to A recent literature review found The gender divide in digital hardships due to the pandemic will is increased risks of exploitation education linked to COVID-19 has increases in gender-based violence learning during this pandemic have spillover effects on education and violence for vulnerable immediate and longer-term effects (GBV) during past epidemics, can be expected to worsen. as families take into account the children at the times of economic on gender equality. According to including domestic violence and According to the International monetary and opportunity costs of downturns. Lockdowns and other some estimates, nearly 10 million sexual exploitation and abuse (Fraser Telecommunication Union (ITU), educating their children, especially social distancing measures linked to more secondary school age girls 2020). School closures can put more men than women have access in countries where schooling COVID-19 have already increased could be out of school after the adolescent girls at increased risk to and use the internet in all regions is a private good and there are reporting of violence at women and COVID-19 crisis has passed (Malala 22 of early marriage and pregnancy. of the world (see Figure 16). In limited social safety net and social girls. Fund 2020). Public health outbreaks When schools close, learners in 2019, the proportion of women protection measures. have distinct gendered impacts that Confinement measures can disadvantaged households, such as using the internet globally was deserve special attention here.25 aggravate risks affecting already With much uncertainty about how children from migrant and forcibly 48%, compared to 58% of men. ‘at-risk’ teenagers, from persistent the current crisis unfolds, a major In considering the indirect impacts displaced communities, can become In the least developed countries absence from school. The 2020 slowdown of the global economy is of pandemics on education, it is isolated at home and in their (LDCs), only 13.9% of women use report released by the Children’s inevitable, which will consequently important to address communities with diminishing the internet. Moreover, the digital Commissioner for England warns affect government revenues of many protection. This leads to increased gender gap worldwide is widening that the 120,000 teenagers in (1) the burden of unpaid care work, countries and hence the resources risk of abuse, exploitation and in recent years, particularly in England—one in 25 of all teens— gender-based and sexual violence. developing countries, although it Indirect Impact available for education (UNESCO (2) female vulnerability and gender- already at risk before the COVID-19 Research conducted by UNDP on decreased in developed countries.27 2020d, UNESCO 2020b). The based violence, and lockdown could be joined by many of Confinement domestic budget for education as the impact of the Ebola epidemic more who have difficulty returning well as international aid to education to ‘normal’ after six months out of Measures on tend to suffer at the times of school.23 economic recession. These cuts will Education Europe 84.9 have an impact on: The Commissioner’s report calls 80.3 The Americas 77.6 Major epidemics have always been for re-engaging them in society 76.8 (i) teacher training, compensation followed by economic crisis and so as not to let a whole generation CIS 73.6 and job security, leading to teacher 71.0 often accompanied by a period of of vulnerable teens remain at absenteeism, attrition and low Arab States 58.5 economic recession. In times of risk of educational failure and 44.2 teaching quality; Asia Paciific 54.6 recession, government spending unemployment, or crime or 41.3 Africa 33.8 across the board is cut with huge (ii) expenditure on digital exploitation. They are easy prey 22.6 implications for the education sector. infrastructure; and to criminal gangs and are at high 58.3 These budget cuts will have serious risk of becoming so-called ‘NEET’ World 48.4 implications for the well-being (iii) support services such as school (Not in Education, Employment meals. Developed 87.6 of children and youth from the or Training). Given that the share 86.0 vulnerable segments of society. of NEET youth in UK was 10.5% Developing 52.8 The early 2020 estimate of the 40.7 of youth population (2019), as IMPACT OF ECONOMIC financing gap to achieve SDG 4 LDCs 24.4 compared to 30.4 percent in India 13.9 Male RECESSION ON EDUCATION AT in low-income and lower-middle- Female (2018) and 30.5% in South Asia HOUSEHOLD LEVEL AND PUBLIC income countries was $148 billion (2018)24, it is all the more important EXPENDITURE LEVEL annually, and it is estimated that to take measures to mitigate youth 0 10 20 30 40 50 60 70 80 90 100 the this gap will increase by more disengagement from education in The World Bank analysis using data than 30% due to COVID-19 (UN this region, especially during and Figure 16. Internet penetration rate for men and women, 2019. Source: Adopted from https://itu.foleon.com/itu/measuring-digital-development/gender-gap/ from 157 countries estimated that 2020).21 Note: *ITU estimate. Penetration rates in this chart refer to the number of women/men that use the internet, as a percentage of the respective total female/male following the confinement measures. population

21The Incheon Declaration and the Framework of Action for Education 2030 urged countries to adhere to the international benchmark of allocating at least 4-6% of GDP to education or allocating 26 https://www.sl.undp.org/content/sierraleone/en/home/library/crisis_prevention_ at least 15-20% of public expenditures to education. According to the UIS data, 47 out of 141 countries with data between 2014 and 2018 do not meet either of these benchmarks (UNESCO 2020, and_recovery/assessing-sexual-and-gender-based-violence-during-the-ebola-cris.html COVID-19 issue note 7.2). 22See https://www.unwomen.org/en/news/stories/2020/4/statement-ed-phumzile-violence-against-women-during-pandemic 23Coronavirus crisis could see a lost generation 27 According to ITU, “The gender gap represents the difference between the Internet user of vulnerable teenagers falling through gaps in the school and social care systems, 7 July 2020, https://www.childrenscommissioner.gov.uk/2020/07/07/coronavirus-crisis-could-see-a-lost-generation- penetration rates for males and females relative to the Internet user penetration rate PANDEMICS: PAST, PRESENT AND LESSONS FOR THE FUTURE 85 of-vulnerable-teenagers-falling-through-gaps-in-the-school-and-social-care-systems/ 24Share of youth not in education, employment or training, total (% of youth population) https://data.worldbank. for males, expressed as a percentage”. See https://itu.foleon.com/itu/measuring-digital- org/indicator/SL.UEM.NEET.ZS 25This sub-section is based mainly on UNESCO’s COVID-19 response issue note 3.1. development/gender-gap/ Pandemics: Past, Present and Lessons for the Future.

Question No. 13: What are Some Key Policy Responses in Education? Q13 / 17

emotional well-being, given home population, and various community- How do students, teachers and 1. Safe 2. A Framework learning environments, burdens on related risk factors. Some key other school staff travel to and from caregivers and other factors? questions to ask are: school? ANSWER Reopening of for Reopening Do school closures expose children Does the school have necessary Are there community-related risk Schools: Lessons Schools: With to increased risks of exploitation, capacity to maintain safe school factors, given epidemiological from Europe and the Most abuse and violence? operations? factors, the capacity of the health system, density of population, and USA Marginalized There is also a need to consider Does the school population have a observance of social distancing, school readiness for reopening, high level of exposure with higher- personal hygiene and other measures 13 While school children and Children in Mind the level of exposure of the school risk groups? to prevent COVID-19 transmission? adolescents can develop COVID-19, experiences in European Around the world, decision makers TABLE NO. 2: FRAMEWORK FOR REOPENING SCHOOLS chool reopening countries and USA show that are tackling difficult trade-offs as amidst the schools implementing appropriate they consider re-opening schools. S UNESCO, UNICEF, WFP, transmission mitigation measures pandemic involves (e.g. physical distancing, ventilation, UNHCR and the World Bank balancing health masking, hand hygiene, and staying developed a framework to inform the decision-making process on SAFE OPERATIONS LEARNING WELLBEING AND INCLUSION OF THE MOST risks against adverse home with minimal symptoms) PROTECTION MARGINALIZED have not significantly contributed when, where, which schools to impacts of school Develop Provide teachers and Ensure continuous and Direct education funding to spread of the virus among local reopen and how to ensure (1) i) national guidance on school leaders with timely parment of teachers’ to schools hit hardest by closures on children’s communities (Lordan et al. 2020). safe operations, (2) learning, parameters for decision support and training salaries, with attention the crisis (3) wellbeing and protection of making on school on remote learning to those on precarious learning and well- Based on scientific understanding of openings and contracts, to mitigate Adapt school opening school staff, teachers, students and being. SARS-CoV-2, Lordan et al. (2020) ii) protocols on Develop alternative against teacher attrition policies and practices highlight three mitigation strategies communities, and (4) inclusion of physical distancing academic calendars and promote wellbeing to expand access to PRIOR TO and hygiene measures; marginalized groups; for reopening: the most marginalized (UNESCO et REOPENING revise personnel and Take specific measures al. 2020). attendance policies; to mitigate protection 1. To minimize the import of identify response and risks while girls and other infections into the school, restrict Some of the key questions to be recovery financing for marginalized groups are immediate investments out of school in-person learning when infection in asked in terms of addressing the in school water, the local community is controlled. challenges of school closures include sanitation and hygiene

the following. Work towards ensuring Equip tachers to Increasion provision Waive school fees and 2. To minimize the likelihood of all schools have access deal with both of mental health and other costs (school further transmission, implement Is classroom instruction to adequate safe water, learning recovery and psychosocial support uniforms, etc) wherever appropriate mitigation measures indispensable to attain the respective handwashing stations, students social and (MHPSS) services that possible and eliminate cleaning supplies and sex emotional and mental addess atigmatization/ other barries to entry to such as limiting room occupancy, learning outcomes? segregated toilets health needs discrimination and support maximize re-enrolment avoiding activities such as singing children and their families in rates Is high-quality remote learning Train school staff Implement large- coping with the continued and sports, and improving and teachers on scale remedial uncertainties of the Take specific measures ventilation. (including but not limited to online PART OF implementing physical programs to mitigate pandemic. to support girls’ return to learning) accessible to all students? REOPENING distancing and school learning loss and school through increated 3. To minimize outbreaks in school, PROCESS hygiene practices prevent exacerbation Conduct a risk assessment community engagement Are school closures compromising of learning inequality for teachers and other staff limit secondary transmission to the Establish procedures if (considering age, chronic smallest possible number of persons. student access to food, nutrition and students or staff become conditions and other risk other vital services? unwell. Secure space to factors) Cohorts should remain isolated from temporarily separate each other and person-to-person sick students and staff Re-establish regular and Is the current arrangement for contact should be kept minimal without creating stigma safe delivery of essential remote learning sustainable in terms services. Eg. critical to facilitate contact tracing in case of student learning and socio- nutrition, WASH and health outbreaks occur. services

Source: Adapted from UNESCO et al. 2020. For more detailed guidance, consult the original document.

PANDEMICS: PAST, PRESENT AND LESSONS FOR THE FUTURE 89 Q13 / 17

the most vulnerable learners out not a call for transitioning from Strengthening of school. Invest to build system face-to-face to fully online schools, the resilience, resilience and responsiveness, which have so far a poor track focusing on equity and inclusion, record of supporting learning in responsiveness as well as on reinforcing capacities prior research. Evidence from USA for risk management and enhancing suggests that fully virtual schools and flexibility of leadership, coordination, generate much less learning than in- consultation and communication person schools (Harris et al. 2020). the education (see UN 2020). Student experience can be severely system STRONGER ARTICULATION limited in the absence of high-speed BETWEEN DIFFERENT TYPES OF internet connectivity and computers The COVID-19 pandemic has LEARNING at home. Although this cannot highlighted the importance of happen overnight, universalizing building resilient and responsive System resilience also depends digital access for students and education systems to anticipate greatly on its flexibility, which is teachers is an essential step to make and cope with future crises. This partly determined by connections education systems prepared for, and section synthesizes and highlights and linkages between levels and responsive to, current and future recommendations from the two types of education and the capacity health and other crises, including main documents published in to mobilize alternative modes of the looming climate change August 2020: delivery. Hybrid learning can challenges. The United Nations provide quasi-individualized (1) policy recommendations based (2020) has called for expanding the learning pathways for students, on research evidence which were definition of ‘the right to education’ taking advantage of a plethora detailed in an open letter by leading to include connectivity. of digital learning resources. US education researchers (Harris et Stronger articulation between Free and open source technologies al. 2020); and formal and non-formal education is are important to ensure equity. (2) recommendations put forward needed to allow education systems Taking fully into account the issues in the UN Secretary-General’s to become better equipped to of data privacy and implications of policy brief on “Education serve the needs of all learners, their public education being dependent during COVID-19 and Beyond” communities and society at large. on digital platforms controlled by private companies, governments (UN 2020). It also builds on DIGITAL LEARNING recommendations included in a should support open educational resources (OERs) and open digital series of UNESCO Education It is important to capitalize on the access (UNESCO MGIEP 2019; Futures of Education 2020; UN important role in schooling. For (UNESCO MGIEP 2019). It Sector’s COVID-19 response issue momentum of using technology 2020). effective remote instruction, Harris is useful to explore innovative 28 International Commission for the notes and UNICEF Innocenti to innovate teaching and learning, et al. (2020) recommend frequent continuous assessments using 29 Research Briefs on COVID-19 assessment, and school-family Although there is growing evidence interaction combining synchronous technology, such as monitoring published between April and August relationships, and keep up with Hybrid learning that MOOCs and similar approaches and asynchronous instruction. student progress through mobile 2020. innovations after the crisis. to online learning tend to exacerbate phone surveys, utilizing learning can provide quasi- Sustainable solutions should build inequalities in educational outcomes It is important to build platforms or apps which track FOCUS ON EQUITY AND upon lessons learnt from the individualized learning due to socioeconomic status teachers’ capacities to harness student learning, and implementing CAPACITY DEVELOPMENT extensive use of technology—both (Hansen and Reich 2015; Kizilcec pedagogical possibilities opened pathways for students, rapid learning assessments to et al. 2017; Reich and Ito 2017), up by digital technology, such An inequitable education system high tech and low tech—to ensure identify learning gaps (Alam and taking advantage of a there is no doubt that well-designed as ubiquitous learning, active is vulnerable to shocks. Pandemics learning continuity during the Tiwari 2020). online learning can be effective knowledge making, recursive and other disruptions exacerbate pandemic, including for the most plethora of digital learning marginalized. This is however and it will play an increasingly feedback, and collaboration existing inequalities and push resources.

28https://en.unesco.org/covid19/educationresponse/issuenotes#:~:text=UNESCO%20Education%20Sector’s%20issue%20notes,term%20impact%20of%20school%20closures 29https://www.unicef-irc.org/covid-children-library/?contentType=Research+brief PANDEMICS: PAST, PRESENT AND LESSONS FOR THE FUTURE 91 Pandemics: Past, Present and Lessons for the Future.

Question No. 14: How have been the Economic Impacts of COVID-19? Q14 / 17

Global GDP was expected to expand by 4 percent in 2021 The pandemic has also but these numbers have now been caused per capita incomes CHANGE IN GDP GROWTH IN 2020 ANSWER revised to be 5.3 percent below RELATIVE TO BASELINE, PERCENTAGE POINTS the pre-pandemic projections; this to fall in more than 90 China Other G20 North America World Commodity Europe translates to about 4.7 trillion USD percent of Emerging Asia-Pacific Exporters (World Bank 2020). Global Trade is 0.0 projected to contract by 9.5 percent Market and Developing in 2020; a drop witnessed in the Economies (EMDEs) -0.4 14 2009 global recession. forcing millions back into The pandemic has also poverty (World Bank caused per capita incomes 2020). -0.8 he COVID-19 to fall in more than 90 pandemic has percent of Emerging Market progress countries made in achieving T SDG1-reduicng poverty. Equally and Developing Economies caused huge economic -1.2 (EMDEs) forcing millions back important the pandemic has no disruptions. Most into poverty (World Bank 2020). doubt played a key role in worsening the already increasing income and countries have seen This fall is expected to erase about -1.6 their Gross Domestic 10 years of per capita income gains wealth inequality gap across most in these countries. The pandemic countries (Goldin and Muggah Base-case Scenario Broader Contagion Scenario Product (GDP) has no doubt erased much of the 2020). In the United States itself, growth drastically -2.0

fall over the first two BOX 4. PANDEMICS: ECONOMIC IMPACTS Figure 17. OECD forecasts of GDP growth as of March 2020. Source: Adopted from OECD Economic Outlook, Interim Report March 2020. Note: Stimulated impact of weaker domestic demand, lower commodity and equity prices and higher uncertainty. Base- quarters of 2020. 1. The economic impact of the Spanish Flu driven by deflation was case scenario with the virus outbreak centred in China; broader contagion scenario with the outbreak spreading significantly in other parts of the Asia-Pacific region, Europe and North America. See Box 1 for full details of the shocks applied. Commodity exporters include Argentina, Brazil, Chile, Russia, South Africa and other non-OECD oil-producing economies. The contraction computed to be about 6% lower GDP growth (Barro et al. 2020). The has been higher in most recent estimates for the COVID-19 lie in the range from about 3% to 10%. advanced economics over 44 million people lost The high degree of uncertainty and than in emerging 2. During the Spanish Flu, the real employment impact was the loss of a their jobs and unemployment the manner in which COVID-19 The economic impacts are increased rapidly to 15% while response policies have been and developing large portion of the working population. In the case of COVID-19, the twofold. The first coming unemployment impact seems to be similar to the Great depression (GDP at the same time the combined implemented across the globe has economies. Growth fell by over 50% while unemployment rose from 3.2% to 24.9%) due to wealth of US billionaires also had an impact on individuals’ directly from the disease forecasts are being stoppage of supply chains and reduction in demand due to lockdown increased by over $637 billion perceptions and subsequently itself and the second continuously revised policies and worker layoffs. resulting in a total wealth of behaviour (Baldwin and Mauro 3.6 trillion-more than the 2020). resulting from the various downwards as the 3. The 1957 Asian Flu pandemicis estimated to have cost one to two entire wealth of over 54 African policies implemented to million lives globally. The 1968 Hong Kong Flu is estimated to have 30 Unlike the Spanish Flu which economic impacts countries . contain the virus. caused one to four million deaths. No major policies affecting economic caused a major deflation, the of COVID-19 and Lockdowns and confinement COVID-19 is causing the activity were imposed. 1968 (see Box 4). The economic the corresponding policies have had impacts on the greatest recession31 since the impacts are twofold. The first 4. The COVID-19 policy responses have for the first time shut down supply side effecting production and Great Depression of the 1930s. policies addressing coming directly from the the economic system across the world. The final fatality count will tell consumption respectively. These The economic dynamics of the the COVID-19 disease itself and the second us if the social and economic costs of these polices outweigh the benefits have subsequently had impacts on COVID-19 pandemic is very resulting from the various materialize. accrued in potentially saved lives and minimizing reduction in labour the demand side with declining different from the previous three policies implemented to contain productivity caused by the health-related after-effects of the virus. consumer confidence and spending. pandemics of 1918, 1957 and the virus.

30https://www.weforum.org/agenda/2020/10/covid-19-is-increasing-multiple-kinds-of-inequality-here-s-what-we-can-do-about-it/ 31An economy is declared to be in a recession when it experiences negative real GDP growth for two consecutive quarters. However, more recent definitions for a recession include other factors such as unemployment, real income, industrial production and wholesale-retail sales (NBER 2020). PANDEMICS: PAST, PRESENT AND LESSONS FOR THE FUTURE 95 Q14 / 17

The tools used to implement macroeconomic policies for addressing the downturn caused by the pandemic will differ across countries depending on the structure and maturity of the respective economies. (Hevia and Neumeyer 2020 PROJECTED CHANGE IN GDP 2020, Djankov and Panizza 2020). The most important amplifying factors include:

A RELATIVELY UNSTABLE PRE-EXISTING HIGH LEVELS OF POLITICAL AND GOVERNANCE POVERTY AND INEQUALITY STRUCTURE Spain France Italy Kingdom United Republic Czech Area Euro Portugal Belgium Iceland Republic Slovak Lithuania Latvia Argentina New ealand Russia Estonia Switzerland Netherlands Hungary Greece Poland Canada OECD Finland Brazil Slovenia Germany Ireland Mexico States United Israel South Africa Turkey Colombia Sweden Luxembourg Word Austria Norway Japan India Chile Denmark Australia Rica Costa Indonesia China Korea 0%

DECLINE IN REMITTANCES AND -2% POOR HEALTH RELATIVELY SMALL PUBLIC

-4% INFRASTRUCTURE SECTORS AND TAX REVENUE BASES -6%

-8% A LARGE INFORMAL ECONOMY LIMITED FISCAL AND MONETARY AND LABOUR MARKET OPTIONS -10%

-12% A LARGE SHARE OF THE -14% PRECARIOUS ACCESS TO Additional Decline in Double-hit Scenario ECONOMY DEPENDS ON WORK INTERNATIONAL FINANCIAL Single-hit Scenario FROM CENTRALISED LOCATIONS -16% MARKETS AND NOT FROM HOME

Figure 18. OECD forecast of GDP growth as of June 2020. Source: Adopted from OECD Economic Outlook (2020) A LARGE SHARE OF THE An early forecast by the OECD that previous, post-war pandemics The value added production chain DROP IN COMMODITY PRICES ECONOMY COMES FROM THE in March 2020 (see Figure 17) have generally affected much less of today’s global economic system DUE TO DROP IN DEMAND. put the global change in GDP at economically important nations; will translate to distortions in the TOURISM SECTOR approximately negative 1.4% in a this is not the case for COVID-19 chain having a ripple effect across broader contagion scenario. These (Baldwin and Tomuira 2020). For the whole production chain spread figures we very quickly surpassed example, the cluster of US, China, across the world. BOX 5. VALUE OF LIFE AND COST BENEFIT ANALYSIS. with outlooks now much bleaker Japan, Germany, Britain, France and as the second level impacts of the Italy—each having high infection To undertake a social cost-benefit analysis, calculations imputing the cost of life lost is inevitable. Although In a globalized and policies to contain the virus ripple and mortality levels account for steeped in controversy over the use of such estimates, some ball park figures are needed to guide policymakers through the economic systems approximately 60% of the world connected world of today, on making decisions based on trade-offs between cost of lives lost versus the economic costs of saving lives. across the globe. The more recent GDP, 65% of world manufacturing the impacts of policies Estimates understandably range over a wide spectrum, each based on a set of different assumption; an average forecast by the OECD in June and 41% of manufacturing exports estimate is around US$10 million per person (Viscusi and Masterman 2017). 2020 shown in Figure 18 puts GDP (Baldwin and Mauro 2020). in many of these major In addition to the statistical value of life, economists have attempted to calculate the impact of illness through change ranging from negative 6 to economies to minimize the Disability Adjusted Life Years (DALY). The DALY measures the number of years lost to illnesses, negative 7.6% depending on if there In a globalized and connected mortality (deaths) and disability or early death. The indicator therefore computes both mortality and morbidity into a single metric is a second surge of infections in world of today, the impacts (Murray 1994). countries. of policies in many of these morbidity (illness and major economies to minimize inability to work) will The virus has affected a total of mortality (deaths) and 123 countries with some of the morbidity (illness and inability have significant impacts We know that lockdowns and confinement policies can have substantial benefits by reducing the mortality rate. worst effected being also some of to work) will have significant on their own economies However, eradicating the virus through a “crush the curve” or “flattening the curve” policies can have considerable economic costs (Hsiang et al. 2020, Fang et al. 2020, Deb et al. 2020, Torrejon Perez et al. 2020). Therefore, the the most economically advanced impacts on their own economies as well as the rest of the countries. It is important to note as well as the rest of the world. decision to implement any policy should ideally be guided by a Social Cost-Benefit Analysis (SCBA). world.

PANDEMICS: PAST, PRESENT AND LESSONS FOR THE FUTURE 97 Q14 / 17

economic system. illness and the after-effects of the DEMAND SIDE COSTS OF THE we will look at the following four Costs of illness. This cost will be inversely PANDEMIC WILL COME FROM: Benefits main policy strategies: SUPPLY SIDE COSTS ARE dependent on the rigidity of the Lives Saved: The key benefit from Pandemic PRIMARILY: (i) Lower purchases of goods and No action taken: The Business As policy implemented; the more any pandemic policy will be the Usual (BAU); stringent the policy of lockdown services by consumers because of Policies (i) Costs to the economy due to lives saved. It is a philosophically and confinement, the higher the absolute loss of people due to high Voluntary measures of social deaths. The supply of labour for difficult topic to address but at The total economic costs from cost of lost days. However, this cost mortality rates. This can be assumed distancing and face masks combined economic production is disrupted the end of any decision making, the COVID-19 pandemic can will have a time dimension whereby to be negligible in the case of with some regulatory measures and in fact a smaller pool of labour economists have always used cost- be analysed from the supply and the short-term costs will have to be COVID-19 because of the relatively overseeing public gatherings and is available. However, in the case benefit analysis to understand if any low mortality rates in nearly all activities (VR); demand perspective. The extent weighed against the long-term gain additional measure will produce a of COVID-19, the majority of countries. The total number of of these costs will be very of lower infections. net positive or negative benefit; in An aggressive Test, Trace, mortalities were people in the 70 global deaths as of 10th December much dependent on the type of other words, the additional benefit Quarantine, Treat policy (TTQT); and above age group. Therefore, (iii) Third cost is overall reduction 2020 was approximately 1.5 million; pandemic policy being adopted. experienced by society exceeds the A tightly enforced lockdown with the impact on labour supply to the in output (supply shock) due to about 0.02% of global population. These costs will come from: costs incurred. On the other hand, confinement of population to their economy might not be as large as it restricted flow of inputs across and (ii) Reduced demand arising from it might also reduce to a moral homes, shutdown of all economic (i) Supply side disruptions: Costs might have been in the 1918 Spanish within countries, supply chain loss in disposable income caused by question whereby policymakers’ and social activities (SR). related to disruption in production Flu when 50 odd million people disruptions caused by lockdown unemployment, cut in wages and/ objective is to minimize the lives caused by the disease; were lost to the flu from a global and confinement policies. Figure 19 or loss of income for many small lost at whatever cost. This will Turning the coin on its head, population of 1.5 billion. Another tells it all. The three main supply business owners. primarily then imply imposing the success of pandemic policies (ii) Supply chain disruptions: Costs factor that differentiates COVID-19 centers are Germany, China and stringent lockdowns with complete put in place in turn will largely related to trade and supply chains from the Spanish Flu is that most of the U.S.A. The size of the node (iii) A drop in demand because confinement for the time period be influenced by the underlying disruption; and the causalities in the latter were in and the thickness of the arrows of a wait and see behaviour by that is necessary for the virus to be economics. The reproduction their 30’s to 40’s. indicate the value and volume of (iii) Demand side disruptions: Costs consumers and firms. Previous eradicated. number—R0—is in fact influenced trade respectively. Disruptions to of a drop in demand caused by a (ii) Another supply side production recessions and economic crisis such by the confinement policy in place. these there centers will have adverse Environment: An interesting and drop in disposable income and fear cost that will be incurred in a as the Great Trade Collapse in We shall not present actual numbers economic impacts across nearly all unexpected benefit in the case of of uncertainty about future income pandemic is the drop in labour 2008-2009, saw both consumers in this document as we do not have nations across the world. the COVID-19 lockdown policy stream caused by disruption in productivity due to days lost during and firms postponed or delayed the data or models to run these purchases and investment till much has been the improvement of many scenarios but what this document later when confidence in both fiscal environmental conditions across suggests is a SCBA framework for and monetary policies returned to the world. Pollution levels have policymakers to consider when the market. dropped due to the shutdown of designing policies. most economic activities. The actual PSYCHOLOGICAL AND MENTAL benefits of improved environmental Under a BAU scenario, the RO HEALTH COSTS conditions has yet to be calculated factor can be assumed to be high; but initial observations suggest present estimates suggest a RO of 4 An often overlooked or ignored significant improvements. under a BAU. This implies higher costs accruing from pandemics is mortality and morbidity rates. the mental health and psychological Using the statistical value of life, trauma that emerge during a A Social Cost- we can compute the cost of lives pandemic crisis. The direct impacts lost, and the cost of productivity of the pandemic through the loss Benefit Analysis drop from the illness caused. The of family members and friends can To gain a better understanding costs of production and demand have a huge psychological impact of the effectiveness of any policy changes will be minimized in this leading to depression and in some response to the COVID-19 crisis scenario as production chains would cases suicides. The economic will require us to identify the have not been affected due to no valuation of these are usually various costs and benefits associated lockdowns and confinement policy. computed through the DALY’s with these polices. In this document The life span of the pandemic might (Disability Adjusted Life Years).

Figure 19. Three interconnected hubs in the world’s supply chain for ICT goods: Germany, China and USA. Source: Adopted from Baldwin and Mauro (2020, Figure 3, pp. 15)

PANDEMICS: PAST, PRESENT AND LESSONS FOR THE FUTURE 99 Q14 / 17 continue till a vaccine is found or (Gomez e.al 2020). First, there However, it is not an indicator to be herd immunity sets in across all is less compliance with used as a welfare indicator. countries in the globe. Countries containment measures by that might be considered following citizens in low\middle income Many alternate indicators have a BAU could be Sweden, USA, and countries. Second, individuals been suggested to be used if the Brazil. from these countries feel objective of the exercise is to that their governments were monitor the overall welfare of A highly regulated policy will untrustworthy and unreliable. citizens (Stiglitz, Sen and Fitoussi ideally produce a R0 of below 1 for Third, individuals from these 2007, Rogers and Duraiappah et.al the COVID-19 virus. This would low\middle income countries 2012). These range from the Gross yield high benefits from the lives demonstrated higher levels of National Happiness indicator, the saved and also the benefits from an anxiety and depression with Human Development Index, the improved environment. However, females being affected the most. Gini coefficient for inequality, the the costs of a highly regulated policy sustainability Index to the Inclusive would imply high production and These atitudes, behaviour and Wealth Index. Each of these have demand costs incurred from the perceptions will influence the their strengths and weaknesses. The lockdown and confinement policies success of the policy implemented final choice therefore might require put in place. Countries in this and in particular policies which a suite of indicators used together category could be China, Germany, will rely on trust and responsibility synergistically to provide an overall India, Norway, and South Korea. on the part of individuals. A strict indication of the welfare of citizens enforcement of a full lockdown and and how this these have changed Ideally, the lockdown intensity or confinement as in the case of China over time as well as changes from a degree of confinement should be worked well in curbing the spread stress factor such as the pandemic. determined by the compromise of the disease. However, similar between the short-term benefits lockdowns and confinement policies of easing the lockdown and the First, there is less have had less success. What were long-term costs of a longer duration the main factors contributing to compliance with of the pandemic or seen in another this difference is an area of future way, the compromise between the containment measures research. short term costs of increasing the by citizens in low\ confinement and the long term middle income countries. benefit of reducing the duration of What We the confinement (Gollier 2020). Second, individuals from Measure is What these countries feel The Impact We Manage that their governments were untrustworthy of Behaviour, The economic impacts of the pandemic have primarily revolved and unreliable. Third, Perceptions and using the Gross Domestic Product individuals from these 32 Attitudes (GDP) as the key benchmark. low\middle income It is important to keep in mind A study by Gomez and colleagues what the GDP indicator tells us countries demonstrated using data from the International about the economy and more higher levels of anxiety importantly what it does not. The Coronavirus Survey show distinctly and depression with three key findings with respect GDP is therefore a useful indicator to individual’s behaviours and for measuring the productivity females being affected perceptions towards COVID-19 and efficiency of any economy. the most.

32GDP is defined as the monetary market value of all final products and services produced in a country over any specified time period. It was developed by Simon Kuznets in 1934 and he warned against using it as a welfare indicator. PANDEMICS: PAST, PRESENT AND LESSONS FOR THE FUTURE 101 Pandemics: Past, Present and Lessons for the Future.

Question No. 15: What have been the Economic Policies in Response to COVID-19? Q15 / 17

The key role of economic intervention policies would be to BOX 6. OECD MARCH 2020. POLICY RECOMMENDATIONS. maximize the net benefit or minimize the total costs accruing from policies being implemented to address the pandemic. Therefore, using the First and foremost, additional fiscal support for health services is ANSWER cost-benefit framework we had discussed earlier, the following policies have required, including sufficient resources to ensure adequate staffing emerged from the literature on the economic impacts of the pandemic. and testing facilities, and all necessary prevention containment and mitigation measures 1. INCREASE PUBLIC EXPENDITURE ON HEALTH CARE. Emergency 20hospital space, ventilators, protective medical equipment, Measures can also be taken to cushion adverse effects of the outbreak medical personnel and other health related budget items with the sole on vulnerable social groups. Short time working schemes, where purpose of reducing mortality. This will contribute to maximizing the available, can be utilised to enhance the flexibility of working hours 15 while preserving jobs and take home pay, although such schemes do not benefits accruing from saving lives or minimizing the net costs by reducing the mortality and morbidity rates as much as possible. protect temporary or migrant workers from lay-offs. Governments can also help households by providing temporary assistance, such as cash andemic transfers or unemployment insurance, for workers placed on unpaid P policies focus 2. PROVIDE INCOME SUPPORT TO PEOPLE. The provisioning leave, and by guaranteeing to cover virus-related health costs for all, on mitigating the of safety nets in times of crisis is one of the most effective fiscal policy retrospectively if needed tools in the hands of the government. The type of support will vary by impacts of disease on the target group within each country. Workers in the formal economy In the very short term, the provision of adequate liquidity in the human health. The can be supported by providing extensions of existing unemployment and financial system is also a key policy, allowing banks to provide help to main objective is to leave benefits. These can be distributed through the formal tax and revenue companies with cash-flow problems, particularly small and medium- systems. In addition, loan holidays especially house mortgages might be an sized enterprises, and ensuring that otherwise solvent firms do not minimize the loss of option that could be negotiated with banks. go bankrupt whilst containment measures are in force. Measures that human lives and the reduce or delay tax or debt payments, or lower the costs of inputs such after effects of the For workers in the informal and undocumented economy, distribution as energy, for firms in the most affected regions and sectors should be becomes complex and non-trivial; but this is the population group that will considered. Temporary reductions in ch the level of reserves banks disease. We know really need support. Options include direct cash transfers, food coupons, are required to hold at the central bank could also be implemented if that these pandemic access to health facilities, and loan holidays for mortgages, among other required. Swap lines between major central banks may also need to be policies will have measures, when necessary. utilised, particularly it widespread disruption to trade or a flight to safety socioeconomic by portfolio investors enhances the demand for US dollars. 3. SUPPORT SMALL BUSINESS. Small business and enterprises form impacts as illustrated the backbone of economies of many countries. Financial support in the form In addition to allowing the automatic fiscal stabilisers to work fully, in the preceding of wage subsidies, tax cuts, moratoriums on debt repayments, extending and expanding spending on health services, targeted and temporary paragraphs. The credit lines are some of the key fiscal policy measures governments can fiscal measures could also be implemented to support businesses in implement to diminish financial burdens caused by the pandemic and the sectors particularly exposed to a sharp downturn in travel and tourism. intensity of these associated pandemic policies. Funds established to reintegrate workers who he lost their jobs due impacts will to globalisation could also be utilised In the European Union, other depend on the potential options are to adapt temporarily the state aid framework, as 4. REDUCE STRESS ON FINANCIAL SYSTEM. In parallel with was done at the height of the financial crisis in 2008-09, or to allow type of pandemic fiscal measures, governments also have at their disposal monetary policies more leeway within the EU fiscal rules to affected economies, in policies that are such as cutting interest rate, reducing reserve requirements by banks to recognition of the exceptional circumstances support investments, and adjusting the money supply to meet the needs of implemented. the economy in the short term. The release of government backed bonds More broadly, lower policy interest rates and stronger government and securities to support fiscal policies would need support from financial spending can help boost confidence and assist with the recovery of institutions and in particular authorities overseeing the country’s monetary demand once the outbreak eases and travel restrictions are removed. policies. However, such measures are less effective in dealing with the immediate supply-side disruptions that resut from enforced shutdowns and travel restrictions

PANDEMICS: PAST, PRESENT AND LESSONS FOR THE FUTURE 105 Pandemics: Past, Present and Lessons for the Future.

Question No. 16: What have been the Overall Effects of COVID-19 on the SDGs? Q16 / 17

Short-term Impacts of Mainly Positive Impact Mixed of Moderately Negative Impact Highly Negative Impact ANSWER COVID-19 on the Impact Still Unclear Sustainable Development Goals

Highly negative impact SDG 1 • Increased poverty due to job losses and economic lockdown NO POVERTY • Disproportionate impact on vulnerable groups (eg. the poor)

Highly negative impact 16 • Food insecurity due to reduction in global food supplies and trade SDG 2 • Hunger due to fall in income and reduce food availability during lockdown ZERO HUNGER • Higher food loss and waste due to transportation challenges and reduced labor • availability t is estimated that • Poorer nutrition due to interruption of school meals more than 1 billion I Highly negative impact people could be living • Higher disease incidence and mortaity from Covid 19 cases SDG 3 • Higher mortality from oother causes because of overburdening systems Slight in extreme poverty decline in mortality due to reduced economic and social activities (eg. traffic GOOD HEALTH & accidents) WELL-BEING primarily caused • Potential short-term health gains due to lower environmental pollution by the COVID-19 This implies that even if the progress of achieving the SDG’s • Negative impact of confinement and lockdown on mental health (eg. anxiety and depression) pandemic by 203033. pandemic is contained with (UNDESA 2020). As shown in Mixed or moderately negative impact the next year or so, the after- Figure 21, most of the impacts SDG 4 This number • School and day-care closures effects will persist for many years can be expected to range from QUALITY • Loss in the development of human capital EDUCATION represents the upper post pandemic. Estimates from mixed or moderate to highly • Poorer nutrition due to interruption of school meals the World Bank in its Global negative impact. There are a limit scenario if Mixed or moderately negative impact Economic Prospects show when number of SDGs where there is no dedicated and • Possible disproportionate economic impact on women (eg. job losses, poverty) compared with pre-crisis forecasts no data available yet to make SDG 5 • Other social impacts on women from the lockdown of (eg. domestic violence) GENDER EQUALITY integrated solutions that COVID-19 could push about any comment on the impact • Higher mortality rates from the virus among men (because they suffer from more chronic respiratory diseases due to higher smoking rate) are implemented to 100 million people into extreme COVID-19 might have on them. counter the effects poverty in 202034. A study by SDG 6 Mixed or moderately negative impact Sumner et al. (2020) expects poverty CLEAN WATER & • Limited access to clean water among disadvantaged groups limits possibility of At the global level, a SANITATION adhering to strict hygiene guidelines of the pandemic. levels to increase by 25 to 30% This implies that with about half of these in South recent study provided a SDG 7 Mixed or moderately negative impact • Slowdown in economic growth contributing to a reduction in energy prices (eg.oil), Asia. The same bleak prospects snapshot of the impacts AFFORDABLE & even if the pandemic CLEAN ENERGY which might increase access to energy but reduce incentives for renewables hold for SDGs 2, 3, 4, 5, 8, 9 and is contained with COVID-19 can be expected 10. These estimates show the high Highly negative impact the next year or so, degree of variability in projections to have on the progress SDG 8 • Economic crisis in virtually all parts of the world • Trade disruption DECENT WORK the after-effects will which are understandable due to • Mass unemployment of achieving the SDG’s & ECONOMIC the complexity of issues and more • Business closures/bankruptcies persist for many (UNDESA 2020). As shown GROWTH importantly the inter-dependencies • Sharp decline in tourism activities • Massive public deficits years post pandemic. that lie across these SDGs. in Figure 21, most of the Mixed or moderately negative impact impacts can be expected At the global level, a recent SDG 9 • Decline in industrial outputs • Possible nationalization of some industries, and bankruptcies and closures of INDUSTRY, study provided a snapshot of to range from mixed others INNOVATION & • Scientific collaboration to find treatments and vaccine the impacts COVID-19 can or moderate to highly INFRASTRUCTURE be expected to have on the • Accelerated uptake of digital technologies, for e-health, e-education, negative impact. e-governance, and e-payments

33https://sdgintegration.undp.org/accelerating-development-progressduring-covid-19 Figure 20. Short-term impact of COVID-19 on the SDGs. 34https://www.worldbank.org/en/topic/poverty/brief/projected-poverty-impacts-of-COVID-19 Source: Adopted from Sachs et al. (2020, pp. 4-5) PANDEMICS: PAST, PRESENT AND LESSONS FOR THE FUTURE 109 Q16 / 17

Mainly Positive Impact UN’s Sustainable Development Goals Report (2020) states that even before the pandemic, progress towards SDG 2 Mixed of Moderately Negative Impact ZERO HUNGER Highly Negative Impact SDGs was slow and uneven with some visible gains. The probability of achieving the targets by 2030 were SDG 3 Impact Still Unclear HEALTH GOOD HEALTH & grim. COVID-19 aggravated the challenges and made WELL-BEING the SDGs even more difficult to achieve.35 While the Highly negative impact SDGs are intertwined and their achievement is inter- SDG 6 CLEAN WATER & SANITATION SDG 10 • Disproportionate negative health and economic impacts on vulnerable groups dependent on one another, in this report we focus on REDUCED (Including refugees and migrants) especially in countries with low safety nets INEQUALITIES • Loss of jobs of lower skilled lower-wage labor the SDGs that are closely linked to health, education, SDG 4 and economics (the three major domains of this report). QUALITY EDUCATION Mixed or moderately negative impact EDUCATION We intend to understand the impact of COVID-19 on SDG 11 • Rise in urban poverty and vulnerability these SDGs and shed light on targeted interventions SDG 5 SUSTAINABLE • Shut down of public transport GENDER EQUALITY CITIES AND • Lower access to public/green spaces that could be useful in mitigating the damage caused by COMMUNITIES • Movements of population that vary across countries • Sharp short term reduction in pollution levels COVID-19. SDG 1 NO POVERTY Impact still Unclear Targeted interventions refer to “SDG push”36 • Short-term reduction in natural resource use due to reduced economic activity SDG 8 SDG 12 measures which includes focused investments in DECENT WORK & ECONOMIC RESPONSIBLE and consumption social welfare programs, green sustainable economy, GROWTH CONSUMPTION • Pressure to loosen up regulations on circular economy and postpone the adoption ECONOMICS AND PRODUCTION of new measures interventions to strengthen governance and SDG 9 • Increased plastic pollution (eg, used to produce personal protective equipment) digitalization to recover from the impacts caused by INDUSTRY, INNOVATION & INFRASTRUCTURE Impact still Unclear COVID-19 and to get back on-track with achieving • Short-term reduction in global GHG emissions the SDGs. Pardee Center and UNDP (2020) study assets SDG 10 SDG 13 • Pressure to reduce environmental safeguards that “SDG push” interventions, if implemented, could REDUCED INEQUALITIES CLIMATE ACTION • Lack of clarity on environmental investments • Slowdown in economic growth contributing to reduction in energy prices (eg. oil) uplift 146 million people out of extreme poverty, and Note: SDGs are interwoven and inter-dependent across three domains which might increase access to energy but reduce incentives for renewables could reduce gender poverty gap after accounting for

Impact still Unclear damage caused by COVID-19. The good news is that these projections can be SDG 14 • Short-term reduction in threats to marine biodiversity due to reduced global minimized if a focused set of SDG investments in social LIFE BELOW WATER economic activity and consumption A key point to take away from this analysis is the protection-welfare programs, governance, digitalization • Pressure to reduce marine biodiversity and ecosystem safeguards cross-over effects of impacts across the various sectors and a sustainable green economy are implemented. Impact still Unclear in society. For example, curtailed economic activities The report further goes on to stress the importance of Short term reduction in threats to terrestrial and freshwater biodiversity have dire impacts on employment leading to poverty global collaboration if the optimistic scenario whereby SDG 15 due to reduced global economic activity and consumption Pressure to reduce terrestrial and freshwater biodiversity and ecosystem and access to food, health and education. Depending the immediate impacts of the pandemic are reversed LIFE ON LAND safeguards, including biodiversity and ecosystem regulations conventions on the socioeconomic strata, individuals will be and the trajectory to achieve the SDGs are back on (for instance, on deforestation) differently affected with the most vulnerable suffering track (Hughes et.al 2020). For example, we can predict the most leading to growing inequalities. This is further Mixed or moderately negative impact that SDG 12, 14 and 15 to actually see improvements • Increased pressure on governments to mitigate the health and economic exacerbated for women leading to greater gender if a sustainable green economy strategy is implemented SDG 16 consequences of the pandemic inequality. which mirrors the reduced environmental impact we • Pressure to increxa accessible health care in countries that have not yet achieved PEACE, JUSTICE, had observed when traditional economic activities AND STRONG universal health coverage Another ripple effect occurs from confinement INSTITUTIONS • Increased public deficits and debt were curtailed. Another key take away is that the and mental health. Individuals confined in closed • Disruption of legislative processes and public debates countries must take a system approach as opposed to • Suspension of freedom-of-information laws and transparency policies spaces for extended periods of time can suffer a sector approach in implementing the “SDG push” from depression, anxiety and stress. It has been Mixed or moderately negative impact measures because the SDGs are inter-linked and their reported that household violence has increased • Possible reduced responsiveness of international aid community to needs of achievement is inter-dependent on one another. Hence, the poorest countries in particular against children and women. Many SDG 17 only an integrated approach would ensure recovery PARTNERSHIPS FOR • Possible reduction in international remittances and cross-border financing communities and countries are reporting higher THE GOALS • Closing of borders from damage caused by COVID-19 and accelerate pace levels of suicides stemming from the confinement • Slowdown in international trade towards achieving SDGs. • Debt Crisis policies implemented by authorities across countries.

35https://unstats.un.org/sdgs/report/2020/The-Sustainable-Development-Goals-Report-2020.pdf 36https://sdgintegration.undp.org/sites/default/files/Impact_of _COVID-19_on_the_SDGs.pdf PANDEMICS: PAST, PRESENT AND LESSONS FOR THE FUTURE 111 Pandemics: Past, Present and Lessons for the Future.

Question No. 17: What are the Key Lessons We Can Learn from the COVID-19 Pandemic and Opportunities to be Explored in Preparation for Future Pandemics? Q17 / 17

ANSWER 17

ey lessons Kemerging from the ongoing COVID19 pandemic include:

Emerging Infectious Diseases individuals which leads to Countries that were able Existing mechanisms at all internationally coordinated (EID) causing pandemics have transmission depends on the choices spatial and institutional levels containment efforts are essential been found to be distributed made by individuals. People’s to secure the participation are ill-equipped to address and to counter pandemics in an non-randomly across the contact choices reflect the relative of their citizens-either counter the effects of pandemics. efficient and equitable manner. globe with many dominated Healthcare systems, education, costs of illness and illness avoidance by reducing the private by pathogens emerging from to them—the private cost. If the and economics systems across the Stringency in implementation land conversion, agricultural private cost of illness is low, or the cost of illness avoidance globe have struggled to cope with of containment measures such as production methods, the trade private cost of illness avoidance is or by strict regulatory the direct and indirect effects of lockdowns, school and college in wildlife and wildlife products, high, people have little incentive to the pandemic leading to many closures could prove to be enforcement with and the ecological impacts of avoid contact. countries witnessing a reversal in instrumental in reducing the spread habitat depletion. Pandemics punitive punishments-had their achievements towards the of the pandemic. Timing at which Countries that were able these measures are implemented is can be expected to occur at more successfully stemmed the Sustainable Development Goals frequent rates in the future. to secure the participation (SDGs). also crucial- the quicker the better. of their citizens-either by rapid rise in infection by International coordination and Differences in the effectiveness reducing the private cost of Transparency, effective adopting a Test, Track, cooperation may yet prevent the of pandemic measures applied illness avoidance or by strict leadership, effective worst effects of the COVID-19 in different countries reflect regulatory enforcement with Quarantine, Treat (TTQT) communication, building pandemic. a fundamental property of punitive punishments-had strategy. trust and solidarity, timely pandemics—that the contact successfully stemmed the rapid action, enhanced use of Test, Track, Quarantine, Treat between susceptible and infected rise in infection by adopting a digital technologies, and (TTQT) strategy.

PANDEMICS: PAST, PRESENT AND LESSONS FOR THE FUTURE 115 Q17 / 17

EDUCATION

Explore the transformation of education systems to a hybrid model combining face-to-face and digital learning systems, to be prepared for, and responsive to, future pandemics and other crises. This means investment in digital infrastructure, teacher training and making access to digital learning available to all learners. Access to internet should be seen as a necessity like electricity rather than a luxury.

Explore developing global, multi- lingual and AI-powered open repositories of publicly-funded or public-held digital education resources, Open Education Resources (OERs), and other digital content made available by diverse entities for free for educational purposes. Such repositories can build on inspiring examples such as Éduthèque37 by the French Opportunities strengthen the global coordination mechanism that oversees the Government and the Horizon 2020 and sharing of information to management of a pandemic. This project X5GON38 (Cross Modal, to be Explored declare, contain and eradicate body should be overseen again by a Cross Cultural, Cross Lingual, Cross future pandemics in an efficient and multidisciplinary group of experts Domain, and Cross Site Global HEALTH equitable manner.. An international that include not only health experts OER Network) funded by the Collaborating mechanism that but also experts from all relevant European Union. Explore at the global level, might provide: economic, education and social establishing an international task sectors. Explore the force comprising of an inter- - A systematic approach to disciplinary group of experts confinement and lockdowns Explore leveraging digital transformation of from across the world to identify technologies such as artificial - Standardized operating protocols education systems to a ways and means to put in place intelligence (AI), big data and for Testing, Tracing, Quarantine hybrid model combining monitoring and coordinating cloud computing, and blockchain and Treatment (TTQT) mechanisms for more efficient and to test, track, quarantine and treat face-to-face and digital effective mitigation and adaptation - Scientific research and data to be COVID-19 to support curbing learning systems, to pathways. This mechanism under the spread of the disease across shared openly to develop treatment be prepared for, and the leadership of the WHO but protocols, drugs and vaccines more borders. These technologies should in collaboration with other UN effectively, efficiently and equitably. ideally be overseen by the national responsive to, future agencies such as UNESCO, UNDP, and global coordinating centers to pandemics and other UNICEF, WFP and others will Explore at the national level, ensure privacy of individuals while establishing a central disease control increasing efficiency. crises.

37Éduthèque (https://www.edutheque.fr/accueil.html) is a web portal created by the French Ministry of Education, free for all teachers and their students, at primary and secondary school level. Based on a partnership with major cultural and scientific public institutions, Éduthèque gathers the partners’ resources of high scientific quality. More than 80,000 digital educational resources are available on the portal, such as videos, movies, 3D models, documentaries and maps, and their rights are cleared for educational purposes by the government, and they are also accessible to people with disabilities and special needs. 38 X5GON (https://www.x5gon.org/) is developing Artificial Intelligence methods to enable both learners and teachers to identify resources that match their learning PANDEMICS: PAST, PRESENT AND LESSONS FOR THE FUTURE 117 goals. For example, a teacher in Africa might be able to easily find MOOCs or lectures that present a topic based on local and indigenous knowledge that is appropriate for the specific local context. A learner from France interested in understanding specific African challenges might be directed to relevant African content translated from a local language into French. Q17 / 17

marginalized populations and the provisioning of a safe vaccine in the most efficient, effective and equitable manner will always be the key priorities for every government.

Short term solutions that are necessary and which require significant immediate financial resources might have to be accommodated. However, distribution of these resources will need to be equitable and efficient to ensure that the inequality gap is not further widened and transaction costs minimized respectively. This will require major institutional revisions in many countries. In addition, as the crisis abates, efforts must be directed towards ensuring that fiscal and monetary policies are designed in a manner that goes towards supporting the achievement of the SDGs. In addition, the lessons from this pandemic suggest building resiliency within the various ECONOMICS more efficient and transparent access institutions overseeing the to finance especially in the poorest economic, education, health Explore the design of automatic countries. and development sectors. The macroeconomic fiscal and monetary pandemic also shown us how stabilizers to enable a faster reaction Explore the establishment of important digital technology to disasters such as pandemics to unemployment benefit guarantee will be for building this reduce transaction lost accruing reserves. This process would involve resiliency. from political and bureaucratic a partnership between government processes of approvals and and private sector to identify Last but not least, global cooperation implementation. how a negotiated amount of the will be key in addressing many of employment cost can be put aside as the challenges thrown at humanity Explore using or establishing a reserves in the case of a pandemic or when events such as pandemics new international mechanism to any other unseen catastrophic event and other catastrophes like climate coordinate transport protocols to to avoid staff layoffs. change which transcend national minimize travel and supply chain borders happen. The COVID-19 disruptions across countries Pandemic has reminded humanity Conclusion once again the essential role Explore advances in digital Limiting the spread of the virus, multilateralism can and must play in technology in the financial sector providing relief to the population finding solutions to global problems. which could be leveraged to offer in particular to vulnerable and

PANDEMICS: PAST, PRESENT AND LESSONS FOR THE FUTURE 119 References

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127 Acronyms

AI Artificial Intelligence MHPSS Mental Health And Psychosocial Support AIDS Acquired Immune Deficiency Syndrome MHRD Ministry of Human Resource Development BAU Business As Usual NA Neuraminidase CCSA Canadian Centre on Substance Abuse NEET Not in Education, Employment or Training CD4 Cluster Of Differentiation 4 NZFVC New Zealand Family Violence CDC Centers for Disease Control and Clearinghouse Prevention OERs Open Educational Resources CFR Case Fatality Rate OxCGRT Oxford COVID-19 Government CI Confidence Interval Response Tracker

COVID-19 Coronavirus Infectious Disease PHEIC Public Health Emergency of 2019 International Concern

DALY Disability Adjusted Life Years RNA Ribonucleic Acid

DNA Deoxyribonucleic Acid SARS Severe Acute Respiratory Syndrome EID Emerging Infectious Diseases SARS-CoV-2 SARS Coronavirus 2 EU European Union SCBA Social Cost-Benefit Analysis GBV Gender-based Violence SDGs Sustainable Development Goals GDP Gross Domestic Product TTQT Test, Track, Quarantine, Treat H1N1/Swine flu Hemagglutinin Type 1 and Neuraminidase Type 1 TVET Technical and Vocational Education and Training H5N1/ Avian flu Hemagglutinin Type 5 And Neuraminidase Type 1 UN United Nations

HA Haemagglutinin UN DESA United Nations Department of Economic and Social Affairs HIV Human Immunodeficiency Virus infection UNDP United Nations Development Programme IHR International Health Regulations (2005) UNESCO United Nations Education, Scientific and Cultural ILO International Labour Organization Organization

ITU International Telecommunications UNESCO MGIEP UNESCO Mahatma Gandhi Union Institute of Education for Peace and Sustainable Development LDC Least Developed Countries UNICEF United Nations Children’s Fund MERS Middle East Respiratory Syndrome WFP World Food Programme MERS-CoV Middle East Respiratory Syndrome coronavirus WHO World Health Organization 129 Annex 1: WHO Pandemic Phase Descriptions & Main Actions by Phase

1. Inter Pandemic period (low risk of pandemic): Phase 1: No new MAIN ACTIONS

influenza virus subtypes have been PHASE DESCRIPTION PLANNING AND SITUATION REDUCING THE CONTINUITY OF detected in humans. An influenza COORDINATION MONITORING AND COMMUNICATIONS SPREAD OF HEALTH CARE virus subtype that has caused ASSESSMENT DISEASE PROVISION human infection may be present in No animal influenza virus circulating among animals have been Develop, exercise and Develop robust Complete communications PHASE 1 Promote beneficial Prepare the animals. If present in animals, the reported to cause infection in humans periodically revise national surveillance planning and initiate behaviours in health system national influenza systems in communications activities to risk of human infection or disease is individuals for self to scale up. An animal influenza virus circulating in domesticated or wild pandemic preparedness collaboration with communicate real and potential protection. Plan for considered to be low. Phase 2: No PHASE 2 animals is known to have caused infection in humans and is and response plans. national animal health risks. use of pharmaceuticals therefore considered a specific potential pandemic threat. new influenza virus subtypes have authorities, and other and vaccines. relevant sectors. been detected in humans. However, a circulating animal influenza virus An animal or human-animal influenza reassortment virus has PHASE 3 caused sporadic cases or small clusters of disease in people, but subtype poses a substantial risk of has not resulted in human-to-human transmission sufficient to human disease. sustain community-level outbreaks

Direct and coordinate Increase surveillancce. Promote communicate Implement rapid Activate 2. Pandemic Alert Period rapid pandemic Monitor containment recommended interventions to pandemic containment contingency (medium to high risk of Human to human transmission of an animal or human-animal containment acctivities operations. Share prevent and reduce population operations and other plans. in collaboration with findings with WHO and individual risk. activities; collaborate pandemic): Phase 3: Human PHASE 4 influenza reassortment virus able to sustain community-level outbreaks has been verified WHO to limit or delay and the international with WHO and infection(s) with a new subtype the spread of infection. community. the international but no human-to-human spread, community as necessary or at most rare instances of spread The same identified virus has caused sustained community level to a close contact. Phase 4: Small PHASE 5 Provide leadership Actively monitor and Continue providing updates Implement individual, Implement cluster(s) with limited human-to- outbreaks in two or more countries in one WHO region. and ccoordination to assess the evolving to general public and all societal, and contingency multisectoral resources pandemic and its stakeholders on the state of pharmaceutical plans for health human transmission but spread is In addition to the criteria defined in Phase 5, the same virus has to mitigate the soccietal impacts and mitigation pandemic and measures to measures. systems at all highly localized, suggesting that PHASE 6 caused sustained community level outbreaks in at least one other and economic impacts measures mitigate risk. levels. the virus is not well adapted to country in another WHO region humans. Phase 5: Larger cluster(s) Plan and coordinate for Continue serveillance Regularly update the public Evaluate the Rest, restock but human-to-human spread still additional resources to detect subsequent and other stakeholders on any effectiveness of the resources, and capacities during waves. changes to the status of the measures used to revise plans, POST PEAK Levels of pandemic influenza in most countries with adequate localized, suggesting that the virus possible future waves pandemic. update guidelines, and rebuild PERIOD surveillance have dropped peak levels. is becoming increasingly better protocols and essential adapted to humans but may not yet algorithms. services. be fully transmissible (substantial Review lessons learned Evaluate the pandemic Publicly acknowledge Conduct a thorough Evaluate the pandemic risk). and share experiences characteristics and contributions of all evaluation of all response of with the international situation monitoring communities and sectors and interventions the health Levels of influenza activity have returned to the levels seen for POST community. Replenish and assessment tools communities and sectors and implemented. system to the seasonal influenza in most countries with adequate surveillance. 3. Pandemic Period: Phase 6: PANDEMIC resources. for the next pandemic communicate the lessons pandemic PERIOD Pandemic phase: increased and and other public health learned; incorporate lessons and share the emergencies. learning into communications lessons learned. sustained transmission in general activities and planning for the population. next major public health crisis.

Table 3: WHO Pandemic Phase Description and Main Actions by Phase (2009) Source: Pandemic Influenza Phases (2009). Pandemic influenza preparedness and response: a WHO guidance document. World Health Organization. 131 As the world continues to grapple with COVID-19, this booklet comes in handy to answer and reflect upon basic questions encompassing the word “pandemic”- the what, where, when and how of it. If there is one thing that the COVID-19 pandemic has revealed it is the power of oneness- power of global coordination, international scientific collaboration, and aligned action in fighting against the virus. We are all in this together. As we learn to live with the fact that coronavirus is here to stay for a while, and continue to acclimatize to the “new normal”, our aim should be to trust scientific evidence and align our actions in a manner that maximizes “normal” living and minimizes inconveniences caused due to the pandemic. We hope this booklet will provide its audience with necessary information to help achieve this goal.

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