During the opening session of the 2021 ASCO Annual Meeting, Julio Frenk, MD, PhD, MPH, President of the University of Miami, gave a riveting presentation in which he described the devastating effects of the global COVID-19 pandemic on patients with cancer as well as on fragile and fragmented health-care systems that contributed to higher death rates from the virus. Dr. Frenk said the current pandemic is unprecedented and unlike any of the previous four pandemics in which he has had a decision-making role. “Its magnitude, its economic consequences, and the social unrest fueled by the disparities it has laid bare are unparalleled and have generated never-before-seen attention to our common frailty stemming from health risks,” said Dr. Frenk.
“With both climate change and pandemic outbreaks, we need to understand that these threats are shared, and, thus, they require global cooperation to solve.”— Julio Frenk, MD, PhD, MPH
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Rather than returning to the status quo after the current emergency subsides or transitioning to a “new normal” of care that includes a more accessible and patient-centered infrastructure, oncology care beyond the COVID-19 pandemic should encompass a “better normal” of care. It should not only expand on the innovations developed during this crisis, but also address social inequality and strengthen global health security systems, according to Dr. Frenk.
During his ASCO presentation, Dr. Frenk delivered three messages to the oncology community as a bulwark against future health disasters:
Although the global death toll directly attributed to the COVID-19 outbreak is nearly 4,300,000 as of August 2021,1 an untold number of people have died indirectly from delays in the diagnosis and treatment of serious illnesses, including cancer. “When faced with a health emergency, preparedness and response strategies should include not only measures to deal with the imminent threat, but also measures to ensure we do not hamper our ability to deal with other serious diseases and risk factors,” said Dr. Frenk.
The pandemic has accelerated changes in health-care systems that have exposed social inequality, structural weaknesses in health care, and flaws in global health security arrangements; as well as exemplary scientific collaboration, innovations in health-care delivery, and enhanced attention to global interdependence. Strengthening health systems globally and ensuring quality health-care access to all patients with cancer will help reduce disease mortality, especially for those in low-resource countries.
To respond to global health threats more quickly and effectively, countries must develop and execute a new global social compact that includes public health innovations as well as improved legal and institutional frameworks.
In an interview with The ASCO Post, Dr. Frenk expanded on these messages and the urgent need for a new international social compact to be better prepared to combat future global health crises caused by the increasing rates of cancer, climate change, social inequality, and pandemics.
Assessing the Physical and Financial Effects of COVID-19
How is this pandemic different from other global pandemics you have experienced? How has it exposed the weaknesses in global health-care systems, especially the American health-care system?
This is the fifth pandemic I have been involved in; it is truly unlike anything else I have seen because of the depth and breadth of the harm it has produced. COVID-19 quickly engulfed the entire world. The first case of the coronavirus was reported in Wuhan, China, on December 31, 2019, and it was declared a pandemic by the World Health Organization (WHO) just 3 months later on March 11, 2020. So, that is one element of the unprecedented nature of this virus. The second element is how quickly the economic consequences of the initial mitigation measures to contain the pandemic spread throughout the world and the interdependency of the world’s economies, which created a global recession the likes of which we haven’t seen since the Great Depression of the 1930s. The third element is the extent to which these crises triggered various episodes of social unrest, most dramatically in the United States, with new mobilization of protests around racial justice. It is the confluence of these three elements that makes this pandemic unequal to any other health crisis in my lifetime.
Now, on the bright side, the speed in which we were able to sequence the whole genome of the virus and develop a safe and effective vaccine is also unprecedented. We can only imagine the sense of vulnerability and anxiety the 1918 influenza pandemic caused, because there were no tools to know what kind of virus it was or measures to mitigate its impact.
In terms of how this virus exposed vulnerabilities in health-care systems, particularly in the United States, it exposed the fragmentation of the two main health subsystems in the United States: its public health system, which deals with issues on the population level, and the clinical- or health-care system, which deals with disease diagnosis as well as therapeutic rehabilitative and palliative measures for individuals.
“I am very optimistic that most of the elements are in place to make us much better prepared for future pandemics.”— Julio Frenk, MD, PhD, MPH
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What this pandemic exposed in the public health system, which includes a mosaic of local, state, and federal agencies, is health-care fragmentation, which resulted in poor coordination among these agencies and caused delays in testing for the virus. It also resulted in insufficient investment in robust surveillance and preparedness programs.
On the clinical side, mitigation efforts to reduce patients’ exposure to the virus resulted in delays in cancer screening, diagnosis, and treatment. These delays will cause a rise in cancer mortality rates over the next decade.
These two subsystems need to work as one. Instead, we saw a fissure between them.
Lessons Learned in Cancer Care
What will be the long-lasting effect of the COVID-19 pandemic on cancer care? What lessons have been learned to improve care in a future disaster?
When you are dealing with a novel pathogen such as the coronavirus, by definition, we don’t know what will happen in terms of its impact on public health. We can anticipate some potential behaviors of the virus because of our experience with other pandemics, but every novel pathogen is unique, and that uncertainty leads to measures that are understandable.
At the beginning of the COVID-19 pandemic, the United States and countries around the world introduced a moratorium on so-called elective procedures; we didn’t know what was going to happen and needed to have total hospital-bed capacity to care for patients with the coronavirus. We also wanted to protect patients and staff from contracting the virus. The moratorium resulted in delays in the early detection, diagnosis, and treatment of cancer; it also resulted in what epidemiologists call “excess mortality”—the number of deaths from all causes during a crisis above and beyond what could be expected under normal conditions.
For example, a study by Maringe et al investigated the impact of delays in diagnosis on cancer survival outcomes in England due to the COVID-19 pandemic. They reported an estimated 8% to 9.6% increase in breast cancer deaths and a 15% to 16% increase in colorectal cancer deaths compared with figures before the pandemic.2
The moratorium also caused people to see hospitals and clinics as dangerous places. So, people, even those with serious health conditions, including symptoms of cancer and other illnesses such as heart disease, refused to go to the hospital because they did not feel safe there. Thus, the lesson for me is that plans for being able to detect and respond effectively to future pandemics must include actions designed not to compound the death toll from the pandemic in direct excess mortality.
Addressing the Twin Threats of Climate Change and Pandemics
Even though scientists were sounding the alarm about the deadly consequences of this global pandemic, many countries, including the United States, were slow to implement strategies to contain the spread of the virus. How can we ensure greater global cooperation in the future to combat common health threats, including the effects of climate change, on cancer care and other serious illnesses?
We must realize that climate change and pandemics have a common root cause, and that is the abusive way in which humans have treated our planet—the one we share with all other forms of life—although the consequences of their impact are very different. Pandemics are much faster-moving events, and we experience their results immediately. The effects of climate change take longer to manifest and are, therefore, less dramatic, making it more difficult to mobilize people into action, but both disasters are devastating.
People think of pandemics as natural events, but they are not natural. They are as anthropogenic as climate change, because all the pandemics we know are zoonotic diseases; these diseases start in animals and jump the species barrier to humans because of the unsustainable way we produce food and in our inhumanely crowded livestock systems. Past outbreaks of avian flu originated from the crowded living conditions of chickens and then spread to humans. The promiscuous, unsanitary, live-animal markets (wet markets) around the world are also incubators for disease, including the one in Wuhan, China, which is most likely the origin of the current pandemic. Nearly 2 decades ago, an epidemic of severe acute respiratory syndrome (SARS) coronavirus also originated from a wet market in China. It is unbelievable that we did not learn the lesson from SARS and design policies that address the underlying conditions that contribute to pandemic outbreaks, including an increased human population living in proximity to dense animal populations.
The extreme weather events we are seeing from climate change are all manifestations of the same unsustainable ways in which we treat our planet. With both climate change and pandemic outbreaks, we need to understand that these threats are shared, and, thus, they require global cooperation to solve.
Global challenges such as the COVID-19 pandemic can only be addressed with global solutions. Thinking you can erect a barrier around your country and isolate it is not feasible in the world we live in. We must engage globally, but new forms of engagement are needed, ones in which we enforce rules that have been agreed upon by all countries. When any country fails to follow those rules, it puts the rest of the world at risk.
We already have a good set of international regulations, the International Health Regulations instituted by WHO in 2005, which are legally binding in 196 countries. These regulations provide an overarching legal framework that defines countries’ rights and obligations in handling public health emergencies with the potential to cross borders. However, regulations are not useful if we do not have the mechanisms to ensure their enforcement.
We need to create a new global social compact to strengthen our security to meet emerging planetary challenges and incentives for countries to engage in what I would call pedagogical transparency. We also need to develop and impose sanctions when countries defy the rules and put other countries at risk—for example, incentives and sanctions like the ones utilized by the World Trade Organization and the International Atomic Energy Agency.
Accelerating the Use of Technology to Expand Access to Cancer Care
How will technology, including the increased use of telemedicine services during the pandemic, improve care for patients with cancer, especially those in underserved communities and low-resource countries?
Among the bright spots of the pandemic is the large-scale level of cooperation among scientists, which led to the discovery of effective vaccines for the coronavirus. Another bright facet of the pandemic is the way it has spurred innovation in health-care delivery, including the dramatic expansion of telemedicine over the past year, which I think is a game-changer. Although the pandemic didn’t create this technology, it accelerated its widespread adoption.
This technology presents us with an opportunity to continue to develop high-quality tools for the remote delivery of health care, including sophisticated procedures such as remote-controlled robotic surgery and highly sophisticated diagnostic tools that can be used on a remote basis with a huge cost savings and great potential to expand access. One can imagine the potential to expand access to the early imaging detection of cancers, for example, in which you do not need to have a qualified human resource in every country, but you can interpret images remotely and provide guidance from any country in the world. Increasingly, through artificial intelligence applications and working cooperatively, we can expand human capacity—not by replacing human health-care providers, but by enhancing their capacities and expanding their ability to treat patients.
This is one of the exciting technologic frontiers that may be part of the better normal in cancer care that follows the COVID-19 pandemic.
Preparing for the Next Global Pandemic
How hopeful are you that we will be able to more successfully address future global health threats? What is the next greatest health threat that -worries you?
One of the frustrations of those of us in public health is that every time there is a pandemic or health emergency, there are a lot of resources offered during the acute phase of the emergency, but then as soon as the acute phase passes, everyone forgets what happened until we face the next crisis. I think this COVID-19 pandemic has been so oppressive in terms of the depth of harm it has caused that I am very hopeful that, this time, we will put the necessary measures in place to ensure we do not go through this much illness and death again.
“Among the bright spots of the pandemic is the large-scale level of cooperation among scientists, which led to the discovery of effective vaccines for the coronavirus.”— Julio Frenk, MD, PhD, MPH
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There is a lot of discussion going on right now among the 194-member states in the World Health Assembly about the optimal mechanism to draft and negotiate a new international pandemic treaty to increase preparedness and response to overcome the challenges exposed by the COVID-19 pandemic and reinforce global health security. The issue will be taken up at a special session during the United Nations General Assembly in September and during a special session of the World Health Assembly in November.
The technologic platforms used to develop the mRNA vaccines against SARS–CoV-2 can be used to sequence the genome of the next deadly virus and then quickly produce specific tests, treatments, and vaccines in less time and at lower costs than we did this time. So, I am very optimistic that most of the elements are in place to make us much better prepared for future pandemics.
There are also other threats on the horizon. We are seeing the devastating results of extreme weather events, including floods, wildfires, and hurricanes, caused by climate change, and that is concerning. The rise of inequalities in the world is another source of future health insecurity if we do not take steps to implement a new global social compact, as I previously mentioned.
“The rise of inequalities in the world is another source of future health insecurity if we do not take steps to implement a new global social compact.”— Julio Frenk, MD, PhD, MPH
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We must address these issues, which clearly include cancer as a global burden of disease as it grows around the world. We need to make sure that access to the solutions to address these problems is distributed equally around the world.
ASCO and its members can significantly contribute to the construction of a better normal, which our increasingly interconnected world can no longer afford to delay.
DISCLOSURE: Dr. Frenk reported no conflicts of interest.
REFERENCES
1. Johns Hopkins University of Medicine: Coronavirus Resource Center. Available at https://coronavirus.jhu.edu/map.html. Accessed September 1, 2021.
2. Maringe C, Spicer J, Morris M, et al: The impact of the COVID-19 pandemic on cancer deaths due to delays in diagnosis in England, UK: A national, population-based, modelling study. Lancet Oncol 21:1023-1034, 2020.
