Much can be learnt from the Covid-19 pandemic about how we achieve the future health systems that we need.
Our work chairing the Lancet-FT commission on the Governance of Health Futures points to three lessons. First, new technologies such as artificial intelligence, robotics and genomics have transformed our ability to respond to epidemics. Second, the concerted use of such technologies has been better in Asia than the west, possibly due to different governance. Third, there is a danger that short-term needs will blind us to longer-term risks.
The response to the Covid-19 outbreak in China highlighted the power of technology. From monitoring and tracking of cases, to rapidly analysing viral genomes and generating computational models, the response was built on digital platforms. To contain the outbreak, China leveraged the power of an authoritarian system equipped with cutting-edge digital technology.
Its approach included automated surveillance and tracking via thermal cameras and face recognition; big data epidemiology models to track and predict spread; chatbots and robots to provide advice and services with minimal physical interaction; and AI tools to scan radiology images and nucleic acid tests. These are signs that the concerted application of digital technologies permits unprecedented speed and scale.
The pandemic response was accompanied by a digital “infodemic”. While much useful information circulated, there was a significant surge in misinformation. Inaccurate opinions shared by digital influencers were often strident. There is clearly urgent need for better structures of digital information governance.
Digital governance models are a major focus of the commission. They may be driven by open technology, designed for scaling and growth; authoritarian, with strict rules for social cohesion and security; bourgeois, driven by a sense of minimum acceptable behaviour; or commercial, driven by ownership and monetisation.
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With global organisations insufficiently prepared, it is unclear which approach will prevail, or how they will develop and interact. Non-authoritarian governance systems were lean enough to permit the rapid adoption of available technology, and a balance between commercial and governmental influence proved feasible.
In South Korea, within weeks of the outbreak in China, four companies manufactured tests from an open World Health Organization formula and obtained near-immediate regulatory approval, allowing the country to scale up using drive-through test stations. Open digital data, trust and international co-operation are vital components.
Rapid open availability of genomic, epidemiologic and clinical data enabled fast analysis and insights from around the world. Freely available peer-reviewed online publications made these accessible to all. While much may need to be improved and failures dissected, the spirit of digital co-operation was very much in evidence.
Yet there are also potential risks, with approaches to health emergencies acting as Trojan horses for other agendas. Privacy is a central issue: once eroded, it may not be easily regained. Digital surveillance — via phone tracking, facial recognition, contact tracing and smartphone apps — opens up possibilities of data being used for purposes other than personal or public health.
Beyond declarations of purpose, there must be verifiable tracing of data aggregation, retention and access. Data are also critical to commercially oriented models that see them as property that can be monetised. In other words, privacy may have a monetary cost and free services may have a privacy cost. Free open availability of data and tools are critical for global health emergencies, and provisions to enable them must be built into governance models. New forms of solidarity that also include the sharing of data must be explored.
A neglected aspect of digital health governance is the impact of tele-health on human psyche and wellbeing. For example, the use of chatbots and robots to minimise face-to-face interactions is critical in epidemic control, but the long-term consequences of such distancing could harm both patients and providers.
Health is not simply an absence of illness; it is a state that cannot always be deduced by the absence of symptoms on a list. Greater convenience in healthcare delivery should not undermine a necessary emphasis on wellbeing.
Anurag Agrawal and Ilona Kickbusch are co-chairs of the Lancet-Financial Times commission on Governing Health Futures 2030