We Need a Systems-Oriented Approach to Exit the Pandemic

The socioeconomic determinants of an individual’s and group’s well-being are viewed as equally if not more important than medical factors.

The discovery and global spread of SARS-CoV-2 in the last two years brought about a rarely seen focus of public administration, public opinion, and public imagination on this novel coronavirus and the associated disease, COVID-19. A macabre meme on social media shows the gates of heaven with long lineups for the deceased from the common causes of mortality. Only the COVID gate has a red carpet laid out, yet there are few new arrivals. COVID deaths account for a mere fraction of those dying from cardio-vascular diseases and cancer, the two leading causes of mortality. While millions have died from, or with, COVID, the singular focus of public health on one disease is unprecedented and irresponsible. 

Public health is the science and practice of preventing illness and promoting health in communities. Population health is commonly understood in a broad sense, encompassing physical, psychological, and social aspects. In fact, the socioeconomic determinants of an individual’s and group’s well-being are viewed as equally if not more important than medical factors. This shows the importance of thinking in interconnected systems rather than isolated silos when making public health decisions. An example of a severe transgression of this principle is the neglect of collateral damage from mobility restrictions (“lockdowns”) throughout the SARS-CoV-2 pandemic. 

The global pandemic response was heavy on one-size-fits-all measures, decided by politicians and public health bureaucrats in a panic and taken for the sake of “doing something”, when it might have been prudent to calmly assess the situation first. Sweden stands out as a country where top officials took a harder look at the emerging data and considered the long-term implications of restrictions of civil liberties. The measures taken elsewhere quickly expanded the scope of the crisis beyond public health into a society-wide emergency situation with collateral damage inflicted on the economy, education, social life, and indeed public health. 

As early as March 2020, Stephan Kohn, senior civil servant in the crisis management directorate of Germany’s Ministry of the Interior, developed a report characterizing the pandemic response as a global false alarm and argued to activate existing, comprehensive crisis management systems in order to stop the runaway public health measures. In addition to pinpointing the need to collect reliable data and conduct a comprehensive risk assessment, the 80-page report’s author also pinpointed the mainstream media’s failure to serve as a corrective for government activism and forecast collateral health impacts from delayed hospital treatments, the breakdown of long-term care, the broad decline of mental health, and a protracted decline in life expectancy from economic turmoil. Needless to say, the leaked report was ignored by the authorities and the author suspended. 

Similarly, since April 2020, David Redman, retired Lieutenant Colonel of the Canadian Armed Forces and former Head of Emergency Management Alberta, wrote letters to Premier Kenney and many other high-ranked Canadian officials, lobbying for a return to well-established pandemic response plans. For example, both the Alberta’s 2014 Pandemic Influenza Plan and the World Health Organization’s 2009 Pandemic Influenza Preparedness and Response “guidance document” highlight the need for a multi-disciplinary approach and an ethical balance between competing interests in a “whole of society” response—principles that have remained woefully absent from Canada’s SARS-CoV-2 response. One of the tenets of emergency management is to minimize socioeconomic disruption; not to protect hospital capacity at all cost. Consequently, Redman recommended focused protection of seniors and other vulnerable groups while advising against broad-based non-pharmaceutical interventions such as school closures. Importantly, he also argued against using fear in public health messaging to manipulate people’s behaviour. 

In the process of scaling down his two-year advocacy, Redman recently shared a “Post Covid Recovery Plan” via the Frontier Centre for Public Policy. While managing endemic SARS-CoV-2 and recovering from the misguided pandemic response are suggested as the goals of the plan, the author’s fundamental concern manifests in his declaration that “the ultimate aim is to return the [Canadian provinces and territories] to a cognitive behavioural state like existed before January 2020”, complete with reference to the “public’s reaction to COVID-19 with mass formation” and his worry about “threats to the functioning of our democracy”. 

One of the concrete recommendations in Redman’s plan is to replace health-focused advisory bodies with governance task forces that represent all areas of societal activity, including agriculture, education, and finance, to name just three examples. His primary concern is to reduce fear in the population – fear of living, fear of each other, and also fear of the possible return of authoritarian restrictions – and replace these fears with confidence. Other observers are calling for an active “deprogramming” away from our irrational captivation with SARS-CoV-2. Redman also calls for a royal commission to hold politicians, public health officials, and the media accountable for the disastrous COVID response. 

In the meantime, Dr. Irvin Studin, public policy professor, publisher, and president of the Institute for 21st Century Questions, went ahead and established the “Canada Science & Policy Committee to Exit the Pandemic” in early 2022. The committee captures expertise from a selection of disciplines, including medicine, health and life sciences, economics, political science, and criminology, and includes representatives from nearly all provinces and territories. Studin’s premise is that a successful recovery has to cover “the 8 (eight) national systems in crisis”, i.e. COVID-19-related and non-COVID public health; business & the economy; education; institutions; national unity; social fabric; and international dynamics. 

The committee’s national exit plan is presented as a matrix of actions to be taken across these systems, by each of Canada’s four major regions (West, Centre, Atlantic, and North) over the next few months and in the longer term. For example, on the premise that the pandemic is de-facto over, the committee recommends the immediate removal of all mandates and restrictions, followed by funding and incentives for recovery programs geared towards the eight societal areas of attention, and lastly, they too are calling for a royal commission to assess the COVID pandemic preparedness and response. 

The detailed recommendations are comprehensive: From minimum staff/patient ratios in the neglected long-term care homes of Ontario and Quebec, to outreach programs to tackle the opioid crisis out west, tourism and transportation grants for the Atlantic region, and enhanced schooling and vocational training for the North. Overall, the “national exit matrix” contains 160 cells with such concrete recommendations. In addition, a list of eight medium- to long-term goals completes the exit plan. These include aspects of system quality, preparedness for future crises, “recovery of trust in institutions”, and importantly, to “unwind fear [and] re-establish trust & relationships” within the “social fabric” area. 

When we can’t see the forest for the trees, we are missing the bigger picture as we focus on too much detail. Additionally, the forest is a complex system that is more than the sum of its parts, the trees. The elements of a complex system interact with each other – in the case of the forest, trees compete with nearby trees for nutrients and light, while different species may also complement each other’s growth and health. Public health is a wicked problem that will benefit from a systems-oriented approach. Elements of such an approach include established pandemic plans, professional emergency management, and a holistic recovery as outlined above. They all recognize the complexity of public health and its embeddedness in, and dependence on, many other societal functions. For a successful recovery today and mitigation of tomorrow’s crises, we will have to think and act as prudent stewards of these inter-connected systems.