Nearly two years into the COVID-19 pandemic, the world remains “dangerously unprepared” for the next major outbreak, according to a new report.

The 2021 Global Health Security Index, released on Wednesday, ranks 195 countries according to their capacity to respond to epidemics and pandemics. The inaugural version of the index, published just months before the first COVID-19 cases were detected, concluded that no nation was ready for such a crisis.

Overall, the world is not any better prepared today, according to the 2021 index, which was created by the Nuclear Threat Initiative, a global security nonprofit group, and the Johns Hopkins Center for Health Security at the Johns Hopkins University Bloombeag School of Public Health.

“I would call this a damning report,” said Dr. Rick Bright, the chief executive of the Rockefeller Foundation’s Pandemic Prevention Institute, who was not involved in creating the index. “The world is not ready.”

More than 90% of countries have no plan for distributing vaccines or medications during an emergency, while 70% lack sufficient capacity in hospitals, clinics and health centers, the report found. Political and security risks have risen worldwide, and public confidence in government is declining.

Although many nations have funneled resources into addressing the acute COVID-19 crisis, few have made dedicated investments in improving overall emergency preparedness, the report found.

“We documented the places where improvements for COVID were made,” said Jennifer Nuzzo, an epidemiologist at the Bloomberg School and one of the two lead authors of the report.

But, she said, unless political leaders “act to ensure that what we’ve worked hard to develop in the midst of COVID doesn’t just erode after the event is over, we could find ourselves back where we started, or worse.”

The researchers rated each country on a variety of factors, evaluating their health care systems, workforces, laboratories, supply chains, infrastructure, trust in government and more. Each nation was assigned a score from 0 to 100.

The average score was 38.9, roughly the same as the 2019 average of 40.2, and no country broke into the top preparedness tier, which began at 80.1 points.

The United States, which was ranked first in the 2019 index, retained its position atop the rankings, with a score of 75.9, while Australia, Finland, Canada and Thailand rounded out the top five.

The top ranking surprised some experts, given what has been widely regarded as a failed pandemic response.

“Really, U.S. No. 1?” said Dr. Ezekiel J. Emanuel, a bioethicist at the University of Pennsylvania who was a member of President Joe Biden’s COVID-19 Advisory Board during the transition between presidential administrations. “I don’t think that’s a credible ranking.”

But Nuzzo noted that the index was designed to measure the tools and resources that a nation has at its disposal and could not predict how effectively those resources would be used in an emergency.

“Just because it exists on paper doesn’t mean it’s going to function,” she said.

The United States had “the lowest possible score on public confidence in the government,” the report noted. Other vulnerabilities include financial barriers to health care and fewer hospital beds per capita than other high-income countries, which could compromise the United States’ ability to respond to future emergencies. “Any missing capacity could be crippling,” Nuzzo said.

Rebecca Katz, who directs the Center for Global Health Science and Security at Georgetown University, said she agreed with the assessment that the world was not ready for another pandemic. And she was not surprised that the scores had not improved since 2019.

“We’re still in the middle of a pandemic,” Katz said. “Everything’s on fire. So there hasn’t been a lot of longer-term, strategic-capacity building.”

The report recommends that countries include funding for health security in their national budgets and review their performance in the current pandemic so they can learn from the experience, among other actions.

Given the events that have unfolded over the past two years, it might also be smart to focus on elements of pandemic preparedness that go beyond technical capacities and capabilities, said Dr. Nahid Bhadelia, founding director of the Boston University Center for Emerging Infectious Diseases Policy and Research.

“We need to think about our ability to sustain healthy communities when a crisis becomes prolonged,” she said. “What’s important to communities is not just the pandemic response, but also how well you’re managing everyday business when you have that crisis.”

This article originally appeared in The New York Times.

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