The covid-19 pandemic has been a massive international shock to global health, to the world economy, and to the geopolitical order. As we write, reported deaths have exceeded 4.5 million worldwide, with the true total value perhaps several times higher. Many families have been impoverished. Businesses built up over decades have gone under. A generation of children has missed out on education and social contact at critical periods in their development. These events led us into a dark place. But, there is now some light coming through the darkness as we realise the benefits of a greater understanding of how this airborne virus is transmitted, a growing number of vaccines and treatments, and improved models of care. So, as we look to the future, it is time to ask what needs to change. For the past year we have been working with the Pan European Commission on Health and Sustainable Development, endorsed by the Regional Director of WHO Europe, Hans Kluge, and chaired by Mario Monti, a former Italian prime minister and European Commissioner. The report and an accompanying evidence review have now been published. What do these say?

The starting point is a diagnosis of what went wrong. The pandemic was not just predictable, it was predicted by many commentators. Yet governments had failed to invest in preparedness. Even when they had developed and tested plans they had failed to learn the necessary lessons. Political leaders struggled to know what to do, or how seriously to take the threat. And even if they acted decisively—which few did—they often looked in vain for clarity from their scientific advisers, who were themselves trying to make sense of the rapidly expanding, but variable quality evidence. The immediate priority was often to prevent the health systems—in which governments had failed to invest—from collapsing under the pressure. Thus, the first, rather obvious lesson was that we need to strengthen health systems and invest in traditionally neglected areas, such as community health and primary care. Healthcare systems were just about coping before the pandemic, after years of austerity and cost containment. They were stretched to breaking point by the pandemic and had to rely almost exclusively on their most important resource: people. It became obvious that what has been advocated by the health community for years is urgently needed: we need to find ways to recruit and retain a highly trained and motivated workforce. We need to look at the role of different health workers, of patients, and their carers, and of increasingly sophisticated technology, and decide what is the best way to provide care that is responsive to the needs and expectations of patients. We cannot simply go back to doing what we did before. But, is it enough? Will the investment in health systems and allocation of resources be enough for tackling future challenges? The Commission thinks it will not. 

We need to expand our horizons and look ahead. The world has changed during the pandemic. Health systems face massive backlogs, with far too many people missing out on necessary treatment over the past 18 months. On top of this they must care for those who continue to become infected with covid-19 and the large numbers of people with organ damage post infection or long covid. Many health workers, tired and battered, have called it a day. Children have to catch up on missed education. Then there is the economic damage and the loss of trust in politicians, with growing evidence of how ill health creates fertile ground for populist, divisive politicians. But we have also changed the ways that we work, questioning the need for long daily commutes and business travel. And if more of us are to work from home then we may want changes to our physical environment. Just as after previous pandemics, the world will not be the same again and we must acknowledge it. We need a new paradigm. 

One overarching idea underpins all of the report’s recommendations. The spread of SARS-CoV-2 to humans arose, like so many emerging infectious diseases, at the interface between humans, animals, and the natural environment, a place where the concept of One Health resides. Yet our responses continue to inhabit silos, with physicians, vets, and ecologists living in separate communities speaking different languages. We need to bring them together. Much progress has been made in fostering collaboration between the UN agencies involved, the World Health Organization, the Food and Agriculture Organisation, the World Animal Health Organization, and the UN Environment Programme. But much more needs to be done at the national and local level and, above all, in the way we think about these challenges and the solutions we propose to the common challenges. 

The pandemic has shone a light on the fractures that existed in our societies. As politicians began to impose packages of measures necessary to interrupt transmission of the virus, they realized that large numbers of people leading precarious lives after years of austerity were unable to comply with what was being asked of them. Although many governments did release the purse strings, providing salary replacement and other forms of support for those unable to work, many still fell through the gaps. The steep social gradients and risks of infection, hospitalisation, and death are testament to the challenges that many people—especially those whose lives are precarious—have faced. There is no real choice when the options are either to isolate at home or earn the money needed to feed one’s family. Yet, in many countries, these problems are invisible because we simply failed to collect the data, and especially the data required to reveal the stark differences associated with ethnicity. So an essential component of national resilience must be to fix the social safety nets that have been torn asunder.

In the past year we have been reminded of the power of scientific innovation to promote and protect health. Yet we have long known that the way that we organise medical innovation is far from perfect. Too much effort still goes into products that offer little benefit, while those that are needed, in particular antimicrobials to combat the challenge of resistance, attract little investment. We also need to ask why governments take most of the risks, funding basic science, while the pharmaceutical industry reaps the benefits. So we need to look systematically at where further advances are needed, based on the simple criteria of whether they offer the potential to improve One Health and how we can create a true partnership between the public and private sectors in which the risks and the returns are shared. 

None of this will be possible with changes to the global governance of health. The Commission’s report makes several recommendations. These include a new pandemic treaty, a Global Health Board, modelled on the Financial Stability Board created by the G20 after the global financial crisis, and new pan-European structures, including a Health Threats Council to secure high level political commitment and a health surveillance network that spans the entire 53 country European region. And we need new ways of accounting for the money spent, seeing many elements of health spending as an investment, in the same way as we view expenditure on education and physical or digital infrastructure. 

Will any of this actually happen? Too often we have seen how political attention drifts away once the worst of a crisis is over. Yet maybe this time it is different. When there is a strong shock there is also a strong activation of minds—scientific, political and public opinion in search of solutions. The aim is to reap the benefits of this extraordinary movement and make the effects of the shock lasting on our ability to remember the lessons from covid-19. The Commission’s proposals have been welcomed by many governments and have already fed into the thinking of the G20. Above all, the financial sector has realized the cost of failing to invest in health and preparedness. The doors are opening. The fight for health has spread beyond borders of the healthcare systems. The question now is whether the health community will seize the opportunity to enter and engage.

Aleksandra Torbica, Centre for Research on Health and Social Care Management (CERGAS), Bocconi University, Milan, Italy

Competing interests: AT is special adviser to Professor Mario Monti, chair of the Commission

Special thanks to Martin McKee for inspiring contribution to this opinion piece.