A practical agenda for incorporating trust into pandemic preparedness and response.

Despite widespread acknowledgement that trust is important in a pandemic, few concrete proposals exist on how to incorporate trust into preparing for the next health crisis. One reason is that building trust is rightly perceived as slow and challenging. Although trust in public institutions and one another is essential in preparing for a pandemic, countries should plan for the possibility that efforts to instil or restore trust may fail. Incorporating trust into pandemic preparedness means acknowledging that polarization, partisanship and misinformation may persist and engaging with communities as they currently are, not as we would wish them to be. This paper presents a practical policy agenda for incorporating mistrust as a risk factor in pandemic preparedness and response planning. We propose two sets of evidence-based strategies: (i) strategies for ensuring the trust that already exists in a community is sustained during a crisis, such as mitigating pandemic fatigue by health interventions and honest and transparent sense-making communication; and (ii) strategies for promoting cooperation in communities where people mistrust their governments and neighbours, sometimes for legitimate, historical reasons. Where there is mistrust, pandemic preparedness and responses must rely less on coercion and more on tailoring local policies and building partnerships with community institutions and leaders to help people overcome difficulties they encounter in cooperating with public health guidance. The regular monitoring of interpersonal and government trust at national and local levels is a way of enabling this context-specific pandemic preparedness and response planning.

Bien qu'il soit largement admis que la confiance est un facteur crucial lors d'une pandémie, peu de propositions concrètes ont été formulées quant aux modalités de son intégration dans la préparation aux prochaines crises sanitaires. L'une des raisons tient au fait qu'établir la confiance est considéré, à juste titre, comme un processus lent et complexe. La confiance mutuelle et celle placée dans les institutions publiques est essentielle dans la préparation aux pandémies, les pays devraient donc tenir compte de la possibilité que leurs efforts pour instaurer ou restaurer cette confiance échouent. Intégrer ce facteur dans la préparation aux pandémies signifie reconnaître que la polarisation, la partialité et la désinformation sont susceptibles de persister. Cela signifie aussi travailler avec les communautés telles qu'elles sont actuellement, et non telles que nous souhaiterions qu'elles soient. Le présent document dévoile un programme politique concret visant à inclure la méfiance comme facteur de risque dans la planification des mesures de préparation et de riposte aux pandémies. Nous suggérons deux types de stratégies fondées sur des données factuelles: (i) des stratégies visant à préserver la confiance préexistante au sein d'une communauté durant une crise, notamment en luttant contre la lassitude face aux pandémies par le biais d'interventions de santé et d'une communication honnête, transparente et sensée; mais aussi (ii) des stratégies qui favorisent la coopération dans les communautés dont les membres se méfient de leur gouvernement et de leurs voisins, parfois pour des raisons historiques légitimes. Lorsque des doutes subsistent, les mesures de préparation et de riposte aux pandémies doivent éviter de recourir à la contrainte et privilégier des politiques locales adaptées ainsi que des partenariats avec les responsables et les institutions de la communauté, afin d'aider les gens à surmonter les difficultés qu'ils rencontrent vis-à-vis des directives de santé publique. Un suivi régulier de la confiance envers les autres et les autorités à l'échelle régionale et nationale permet de planifier une préparation et une riposte spécifiques face aux pandémies.

A pesar del reconocimiento generalizado de que la confianza es importante en una pandemia, existen pocas propuestas concretas sobre cómo incorporarla a la preparación para la próxima crisis sanitaria. Uno de los motivos es que generar confianza se percibe, con razón, como algo lento y difícil. Aunque la confianza en las instituciones públicas y en los demás es esencial en la preparación para una pandemia, los países deben prever la posibilidad de que fracasen los esfuerzos por infundir o restablecer la confianza. Incorporar la confianza a la preparación ante una pandemia significa reconocer que la polarización, el partidismo y la desinformación pueden persistir y comprometerse con las comunidades tal y como son actualmente, no como desearíamos que fueran. Este documento presenta una agenda política práctica para incorporar la desconfianza como factor de riesgo en la planificación de la preparación y respuesta ante una pandemia. Proponemos dos conjuntos de estrategias basadas en la evidencia: (i) estrategias para garantizar que la confianza que ya existe en una comunidad se mantenga durante una crisis, como mitigar la fatiga pandémica mediante intervenciones sanitarias y una comunicación honesta y transparente que haga entrar en razón; y (ii) estrategias para promover la cooperación en comunidades donde las personas desconfían de sus gobiernos y vecinos, a veces por razones legítimas e históricas. Cuando hay desconfianza, la preparación y las respuestas ante una pandemia se deben basar menos en la coerción y más en la adaptación de las políticas locales y la creación de asociaciones con las instituciones y los líderes de la comunidad para ayudar a las personas a superar las dificultades que encuentran en la cooperación con las orientaciones de salud pública. El seguimiento periódico de la confianza interpersonal y gubernamental a nivel nacional y local es una forma de hacer posible esta planificación de la preparación y respuesta ante una pandemia específica para cada contexto.

A US Industrial Policy For Global Health.

Global competition is the wrong strategic lens for an industrial policy involving critical collective health needs. Threats to US health and national security interests in this sector are transnational, and the inputs required for US biopharmaceutical innovation and resilience are globally distributed. To accelerate innovation in the life sciences, the US needs a targeted strategy that invests in domestic self-sufficiency where it is attainable and important and that mobilizes the international collaborations needed to make and deploy medical technologies to promote human health and a more resilient economy worldwide. The US needs an industrial policy for global health.

Assessing COVID-19 pandemic policies and behaviours and their economic and educational trade-offs across US states from Jan 1, 2020, to July 31, 2022: an observational analysis.

BACKGROUND: The USA struggled in responding to the COVID-19 pandemic, but not all states struggled equally. Identifying the factors associated with cross-state variation in infection and mortality rates could help to improve responses to this and future pandemics. We sought to answer five key policy-relevant questions regarding the following: 1) what roles social, economic, and racial inequities had in interstate variation in COVID-19 outcomes; 2) whether states with greater health-care and public health capacity had better outcomes; 3) how politics influenced the results; 4) whether states that imposed more policy mandates and sustained them longer had better outcomes; and 5) whether there were trade-offs between a state having fewer cumulative SARS-CoV-2 infections and total COVID-19 deaths and its economic and educational outcomes. METHODS: Data disaggregated by US state were extracted from public databases, including COVID-19 infection and mortality estimates from the Institute for Health Metrics and Evaluation's (IHME) COVID-19 database; Bureau of Economic Analysis data on state gross domestic product (GDP); Federal Reserve economic data on employment rates; National Center for Education Statistics data on student standardised test scores; and US Census Bureau data on race and ethnicity by state. We standardised infection rates for population density and death rates for age and the prevalence of major comorbidities to facilitate comparison of states' successes in mitigating the effects of COVID-19. We regressed these health outcomes on prepandemic state characteristics (such as educational attainment and health spending per capita), policies adopted by states during the pandemic (such as mask mandates and business closures), and population-level behavioural responses (such as vaccine coverage and mobility). We explored potential mechanisms connecting state-level factors to individual-level behaviours using linear regression. We quantified reductions in state GDP, employment, and student test scores during the pandemic to identify policy and behavioural responses associated with these outcomes and to assess trade-offs between these outcomes and COVID-19 outcomes. Significance was defined as p<0·05. FINDINGS: Standardised cumulative COVID-19 death rates for the period from Jan 1, 2020, to July 31, 2022 varied across the USA (national rate 372 deaths per 100 000 population [95% uncertainty interval [UI] 364-379]), with the lowest standardised rates in Hawaii (147 deaths per 100 000 [127-196]) and New Hampshire (215 per 100 000 [183-271]) and the highest in Arizona (581 per 100 000 [509-672]) and Washington, DC (526 per 100 000 [425-631]). A lower poverty rate, higher mean number of years of education, and a greater proportion of people expressing interpersonal trust were statistically associated with lower infection and death rates, and states where larger percentages of the population identify as Black (non-Hispanic) or Hispanic were associated with higher cumulative death rates. Access to quality health care (measured by the IHME's Healthcare Access and Quality Index) was associated with fewer total COVID-19 deaths and SARS-CoV-2 infections, but higher public health spending and more public health personnel per capita were not, at the state level. The political affiliation of the state governor was not associated with lower SARS-CoV-2 infection or COVID-19 death rates, but worse COVID-19 outcomes were associated with the proportion of a state's voters who voted for the 2020 Republican presidential candidate. State governments' uses of protective mandates were associated with lower infection rates, as were mask use, lower mobility, and higher vaccination rate, while vaccination rates were associated with lower death rates. State GDP and student reading test scores were not associated with state COVD-19 policy responses, infection rates, or death rates. Employment, however, had a statistically significant relationship with restaurant closures and greater infections and deaths: on average, 1574 (95% UI 884-7107) additional infections per 10 000 population were associated in states with a one percentage point increase in employment rate. Several policy mandates and protective behaviours were associated with lower fourth-grade mathematics test scores, but our study results did not find a link to state-level estimates of school closures. INTERPRETATION: COVID-19 magnified the polarisation and persistent social, economic, and racial inequities that already existed across US society, but the next pandemic threat need not do the same. US states that mitigated those structural inequalities, deployed science-based interventions such as vaccination and targeted vaccine mandates, and promoted their adoption across society were able to match the best-performing nations in minimising COVID-19 death rates. These findings could contribute to the design and targeting of clinical and policy interventions to facilitate better health outcomes in future crises. FUNDING: Bill & Melinda Gates Foundation, J Stanton, T Gillespie, J and E Nordstrom, and Bloomberg Philanthropies.

Oral Rehydration Salts, Cholera, and the Unfinished Urban Health Agenda.

Cholera has played an outsized role in the history of how cities have transformed from the victims of disease into great disease conquerors. Yet the current burden of cholera and diarrheal diseases in the fast-urbanizing areas of low-income nations shows the many ways in which the urban health agenda remains unfinished and must continue to evolve.

Growing up and moving out: Migration and the demographic transition in low- and middle-income nations.

International migration has increased since 1990, with increasing numbers of migrants originating from low- and middle-income countries (LMICs). Efforts to explain this compositional shift have focused on wage gaps and other push and pull factors but have not adequately considered the role of demographic factors. In many LMICs, child mortality has fallen without commensurate economic growth and amid high fertility. This combination increases young adult populations and is associated with greater outmigration: in the poorest countries, we estimate that a one-percentage-point increase in the five-year lagged growth rate of the population of 15-24-year-olds was associated with a 15 per cent increase in all-age outmigrants, controlling for other factors. Increases in growth of young adult populations led to 20.4 million additional outmigrants across 80 countries between 1990 and 2015. Understanding the determinants of these migration shifts should help policymakers in origin and destination countries to maximize their potential positive effects.

How COVID-19 vaccine supply chains emerged in the midst of a pandemic.

Many months after COVID-19 vaccines were first authorised for public use, still limited supplies could only partially reduce the devastating loss of life and economic costs caused by the pandemic. Could additional vaccine doses have been manufactured more quickly some other way? Would alternative policy choices have made a difference? This paper provides a simple analytical framework through which to view the contours of the vaccine value chain. It then creates a new database that maps the COVID-19 vaccines of Pfizer/BioNTech, Moderna, AstraZeneca/Oxford, Johnson & Johnson, Novavax and CureVac to the product- and location-specific manufacturing supply chains that emerged in 2020 and 2021. It describes the choppy process through which dozens of other companies at nearly 100 geographically distributed facilities came together to scale up global manufacturing. The paper catalogues major pandemic policy initiatives - such as the United States' Operation Warp Speed - that are likely to have affected the timing and formation of those vaccine supply chains. Given the data, a final section identifies further questions for researchers and policymakers.

Democracies Linked To Greater Universal Health Coverage Compared With Autocracies, Even In An Economic Recession.

Despite widespread recognition that universal health coverage is a political choice, the roles that a country's political system plays in ensuring essential health services and minimizing financial risk remain poorly understood. Identifying the political determinants of universal health coverage is important for continued progress, and understanding the roles of political systems is particularly valuable in a global economic recession, which tests the continued commitment of nations to protecting their health of its citizens and to shielding them from financial risk. We measured the associations that democracy has with universal health coverage and government health spending in 170 countries during the period 1990-2019. We assessed how economic recessions affect those associations (using synthetic control methods) and the mechanisms connecting democracy with government health spending and universal health coverage (using machine learning methods). Our results show that democracy is positively associated with universal health coverage and government health spending and that this association is greatest for low-income countries. Free and fair elections were the mechanism primarily responsible for those positive associations. Democracies are more likely than autocracies to maintain universal health coverage, even amid economic recessions, when access to affordable, effective health services matters most.

Autocratisation and universal health coverage: synthetic control study.

OBJECTIVE: To assess the relation between autocratisation-substantial decreases in democratic traits (free and fair elections, freedom of civil and political association, and freedom of expression)-and countries' population health outcomes and progress toward universal health coverage (UHC). DESIGN: Synthetic control analysis. SETTING AND COUNTRY SELECTION: Global sample of countries for all years from 1989 to 2019, split into two categories: 17 treatment countries that started autocratising during 2000 to 2010, and 119 control countries that never autocratised from 1989 to 2019. The treatment countries comprised low and middle income nations and represent all world regions except North America and western Europe. A weighted combination of control countries was used to construct synthetic controls for each treatment country. This statistical method is especially well suited to population level studies when random assignment is infeasible and sufficiently similar comparators are not available. The method was originally developed in economics and political science to assess the impact of policies and events, and it is now increasingly used in epidemiology. MAIN OUTCOME MEASURES: HIV-free life expectancy at age 5 years, UHC effective coverage index (0-100 point scale), and out-of-pocket spending on health per capita. All outcome variables are for the period 1989 to 2019. RESULTS: Autocratising countries underperformed for all three outcome variables in the 10 years after the onset of autocratisation, despite some improvements in life expectancy, UHC effective coverage index, and out-of-pocket spending on health. On average, HIV-free life expectancy at age 5 years increased by 2.2% (from 64.7 to 66.1 years) during the 10 years after the onset of autocratisation. This study estimated that it would have increased by 3.5% (95% confidence interval 3.3% to 3.6%, P<0.001) (from 64.7 to 66.9 years) in the absence of autocratisation. On average, the UHC effective coverage index increased by 11.9% (from 42.5 to 47.6 points) during the 10 years after the onset of autocratisation. This study estimated that it would have increased by 20.2% (95% confidence interval 19.6% to 21.2%, P<0.001) (from 42.5 to 51.1 points) in the absence of autocratisation. Finally, on average, out-of-pocket spending on health per capita increased by 10.0% (from $4.00 (£3.1; €3.4) to $4.4, log transformed) during the 10 years after the onset of autocratisation. This study estimated that it would have increased by only 4.4% (95% confidence interval 3.9% to 4.6%, P<0.001) (from $4.0 to $4.2, log transformed) in the absence of autocratisation. CONCLUSIONS: Autocratising countries had worse than estimated life expectancy, effective health service coverage, and levels of out-of-pocket spending on health. These results suggest that the noticeable increase in the number of countries that are experiencing democratic erosion in recent years is hindering population health gains and progress toward UHC. Global health institutions will need to adjust their policy recommendations and activities to obtain the best possible results in those countries with a diminishing democratic incentive to provide quality healthcare to populations.

The G20 and development assistance for health: historical trends and crucial questions to inform a new era.

One of the most important gatherings of the world's economic leaders, the G20 Summit and ministerial meetings, takes place in June, 2019. The Summit presents a valuable opportunity to reflect on the provision and receipt of development assistance for health (DAH) and the role the G20 can have in shaping the future of health financing. The participants at the G20 Summit (ie, the world's largest providers of DAH, emerging donors, and DAH recipients) and this Summit's particular focus on global health and the Sustainable Development Goals offers a unique forum to consider the changing DAH context and its pressing questions. In this Health Policy perspective, we examined trends in DAH and its evolution over time, with a particular focus on G20 countries; pointed to persistent and emerging challenges for discussion at the G20 Summit; and highlighted key questions for G20 leaders to address to put the future of DAH on course to meet the expansive Sustainable Development Goals. Key questions include how to best focus DAH for equitable health gains, how to deliver DAH to strengthen health systems, and how to support domestic resource mobilisation and transformative partnerships for sustainable impact. These issues are discussed in the context of the growing effects of climate change, demographic and epidemiological transitions, and a global political shift towards increasing prioritisation of national interests. Although not all these questions are new, novel approaches to allocating DAH that prioritise equity, efficiency, and sustainability, particularly through domestic resource use and mobilisation are needed. Wrestling with difficult questions in a changing landscape is essential to develop a DAH financing system capable of supporting and sustaining crucial global health goals.

The relationships between democratic experience, adult health, and cause-specific mortality in 170 countries between 1980 and 2016: an observational analysis.

BACKGROUND: Previous analyses of democracy and population health have focused on broad measures, such as life expectancy at birth and child and infant mortality, and have shown some contradictory results. We used a panel of data spanning 170 countries to assess the association between democracy and cause-specific mortality and explore the pathways connecting democratic rule to health gains. METHODS: We extracted cause-specific mortality and HIV-free life expectancy estimates from the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 and information on regime type from the Varieties of Democracy project. These data cover 170 countries and 46 years. From the Financing Global Health database, we extracted gross domestic product (GDP) per capita, also covering 46 years, and Development Assistance for Health estimates starting from 1990 and domestic health spending estimates starting from 1995. We used a diverse set of empirical methods-synthetic control, within-country variance decomposition, structural equation models, and fixed-effects regression-which together provide a robust analysis of the association between democratisation and population health. FINDINGS: HIV-free life expectancy at age 15 years improved significantly during the study period (1970-2015) in countries after they transitioned to democracy, on average by 3% after 10 years. Democratic experience explains 22·27% of the variance in mortality within a country from cardiovascular diseases, 16·53% for tuberculosis, and 17·78% for transport injuries, and a smaller percentage for other diseases included in the study. For cardiovascular diseases, transport injuries, cancers, cirrhosis, and other non-communicable diseases, democratic experience explains more of the variation in mortality than GDP. Over the past 20 years, the average country's increase in democratic experience had direct and indirect effects on reducing mortality from cardiovascular disease (-9·64%, 95% CI -6·38 to -12·90), other non-communicable diseases (-9·14%, -4·26 to -14·02), and tuberculosis (-8·93%, -2·08 to -15·77). Increases in a country's democratic experience were not correlated with GDP per capita between 1995 and 2015 (ρ=-0·1036; p=0·1826), but were correlated with declines in mortality from cardiovascular disease (ρ=-0·3873; p<0·0001) and increases in government health spending (ρ=0·4002; p<0·0001). Removal of free and fair elections from the democratic experience variable resulted in loss of association with age-standardised mortality from non-communicable diseases and injuries. INTERPRETATION: When enforced by free and fair elections, democracies are more likely than autocracies to lead to health gains for causes of mortality (eg, cardiovascular diseases and transport injuries) that have not been heavily targeted by foreign aid and require health-care delivery infrastructure. International health agencies and donors might increasingly need to consider the implications of regime type in their efforts to maximise health gains, particularly in the context of ageing populations and the growing burden of non-communicable diseases. FUNDING: Bloomberg Philanthropies and the Bill & Melinda Gates Foundation.

Affordability and availability of off-patent drugs in the United States-the case for importing from abroad: observational study.

OBJECTIVES: To evaluate whether off-patent prescription drugs at risk of sudden price increases or shortages in the United States are available from independent manufacturers approved in other well regulated settings around the world. DESIGN: Observational study. SETTING: Off-patent drugs in the USA and approved by the Food and Drug Administration, up to 10 April 2017. STUDY COHORT: Novel tablet or capsule prescription drugs approved by the FDA since 1939 that were no longer protected by patents or other market exclusivity and had up to three generic versions. MAIN OUTCOME MEASURES: Number of additional manufacturers that had obtained approval from any of seven non-US regulators with similar standards (European Medicines Agency (European Union), HealthCanada (Canada), Therapeutic Goods Association (Australia), Medsafe (New Zealand), Swissmedic (Switzerland), Medicines Control Council (South Africa), and the Israel Health Ministry). Association with drug characteristics including US orphan drug designation for drugs treating rare diseases, World Health Organization essential medicine designation, treatment area, drug product complexity (that is, with attributes that could complicate establishing bioequivalence or manufacturing), and total Medicaid spending in 2015. RESULTS: Of 170 eligible study drugs, more than half (109, 64%) had at least one manufacturer approved by a non-US regulator and 32 (19%) had four or more. Among 44 (26%) drugs with no FDA approved generic versions, 21 (48%) were available from at least one manufacturer approved by one of the seven non-US regulators, and two (5%) by four or more manufacturers. Across all drugs and regulators (including the FDA), 66 (39%) drugs were available from four or more total manufacturers. Of 109 drugs with at least one non-US regulator approved manufacturer, 12 (11%) were approved for patients with rare diseases and 29 (27%) were WHO designated essential medicines; only 12 (11%) were complex products that might be more complicated to import. The highest numbers of drugs were indicated for treating cardiovascular diseases, diabetes, or hyperlipidemia (19, 17%); psychiatric disease (16, 15%); and infectious diseases (15, 14%). In 2015, Medicaid alone spent nearly US$700m (£508m; €570m) on generic drugs without adequate US competition that could have had a manufacturer approved by non-US peer regulatory agencies. CONCLUSION: In this study, more than half the off-patent drugs with no generic competition in the USA had at least one independent manufacturer approved by a non-US peer regulatory agency; slightly fewer than half had four or more total manufacturers. Facilitating US patient access to such manufacturers could help sustain affordable access to essential off-patent drugs.