THE STATE OF THE PANDEMIC: WHERE THE VIRUS IS, WHAT IMPACT IT HAS, AND HOW THAT CAN BE TACKLED
By David Nabarro and John Atkinson
This article was originally published by British Medical Journal Blogs on July 3, 2020.
We anticipate that the SARS-CoV-2 virus and the resulting disease covid-19 will remain an ever-present threat to the world for the foreseeable future. It makes sense that until now many countries have treated the outbreak of covid-19 as an emergency and tackled it using crisis response approaches. Single authorities have been established to provide command and control in outbreak responses. As responses to covid-19 evolve and decision makers encourage the emergence of covid-ready societies, it will be helpful to modify the approach. Those responsible for managing the outbreak response need to focus on adapting strategies that take account of local level realities. This requires a shift in mindset and a different way of working, but it offers effective means for ensuring granular and locally specific responses.
Unified command and control in emergencies
In emergencies the normal practice is that a centrally directed and coordinated response is established. Someone is taking charge, and providing direction that others can follow. They manage the crisis and control the response so that it reacts to people’s needs as effectively as possible. The sense is that when a leader acts wisely, fairly, and decisively, then people will follow, especially in the initial stages of the response.
The focus is on ensuring that different elements of the response are aligned and working together well. Alignment works best when there is a single point of command, collating and assessing available information, setting the direction of the response, adapting it as necessary over time, and making sure that everyone concerned knows what they have to do. The response is most effective when all the available elements are well controlled and deployed as effectively and efficiently as possible.
In most settings the elements for emergency responses are under a range of different commands and centralising can be difficult unless this practice has been well tested through multiple crises or, at least, rehearsed and modified through simulations. Whoever is given command will constantly need to engage with, listen to, and then explain the rationale for decisions made to all those responsible for implementation. The entitlement to be in command requires adaptability, authenticity, and accountability. The entitlement must be constantly earned even if the person in command is invested with significant authority, even in situations where a quick move to unitary command, during crisis, is the norm.
Why disease outbreaks are different
This pattern for emergency response needs to be adapted by those of us working on infectious diseases outbreaks. The determinants of outbreaks are complex. The shape and intensity of individual outbreaks change over time and vary between locations. Strategies for containment are adapted in light of new knowledge and available resources for the response: these differ from place to place. Control strategies usually involve tracking the pathogen that causes the disease and assessing who is at risk. This means finding out where the pathogen is, who is being affected and why this is happening. Public health workers fan out across communities to detect people with the disease promptly, to interrupt transmission between people, to contain, and then suppress outbreaks quickly, and to protect those who are most at risk.
None of us working on covid-19 has the authority to command with certainty. We recognise that covid is a growing threat with the potential to affect everyone in our world. But our knowledge of the virus and its impact is incomplete: the issues remain complex and are hedged with multiple unknowns, though understanding evolves quickly.
At the same time, none of us has complete control over the range of resources available for the response. Different organisations with different mandates, governance, or political direction must all be factored into the way we operate. The most important task is to coordinate effectively, ensuring that all concerned are fully on board, understand the containment strategies, realise their implications, and are in a position to adjust their actions for the greatest synergy of effort.
Learning from Ebola virus disease 2014-15
As the Ebola virus disease outbreaks in West Africa grew exponentially between 2014 and 2015, incident managers were nominated as focal points for strategy and coordination throughout the region. Because the pattern of disease and capacities for response varied from location to location, incident managers were appointed at national, sub-national, and local levels. The focus was on preventing spread, interrupting transmission of the virus, and ensuring that people with symptoms of disease were tested, isolated, and then treated rapidly.
Multiple groups were involved in the response, each with their own command and control systems. They included national government, local authorities, traditional leadership, local businesses and external entities (non-governmental organisations, emergency medical teams, and different parts of the United Nations system).
The incident managers offered direction on the adaptation of response strategies to specific settings. They engaged with the different response entities to encourage synchronised action, although inevitably responsibilities and jurisdictions overlapped. A lot was expected of the incident managers even though their power to direct action was limited. They tended to set the direction by combining encouragement with instruction.
As the nature of different Ebola outbreaks within the region evolved, the work of the incident managers was more associated with articulating strategic principles than providing firm directives and with coordination of multiple actors rather than seeking to control their assets. To fulfil their responsibilities, the incident managers relied on circles of trust that developed among those who they sought to coordinate. The leadership style was more one of maintaining this trust; it meant paying attention to the relationships between the different responders. Sometimes these relationships needed urgent renegotiation especially when there were differences of view about the way the disease was spreading, or the best tactics for engaging communities in the response.
Applying the lessons to covid-19
Incident managers were appointed within the World Health Organization (WHO) to guide responses to covid-19 early in January 2020 as reports of the new disease started to emerge. They used the available information from different sources to develop analyses and strategies. They consistently stressed the need for rapid and well-coordinated action. National decision-makers varied in their responses; not all grasped the full implications of this dangerous new virus immediately. Over time, both the risks posed by the virus and the need for immediate comprehensive responses are increasingly being factored into national decision-making. As the crisis has grown over the last few months, more and more national decision makers decided to take decisive action. In many countries they went for strong action by unifying command, taking control, and providing clear direction.
This strong action has had several advantages. To limit transmission of the virus, movement limitations have swiftly been put in place. Capacity to provide acute medical care has been rapidly increased and equipment shortages tackled. However, the advice from WHO has been to focus on people being empowered to prevent spreading the virus through hand and cough hygiene, physical distancing, and protecting those who are vulnerable. WHO has also emphasised the importance of locally organised public health services that support people’s efforts to interrupt transmission, with rapid and robust action as soon as there are signs that a new outbreak starts to develop.
If centralised systems for command and control are being used, they need careful adaptation if they are to ensure integrated community-level responses. The focus must be on mobilising people, inspiring professionals and tailoring responses in different places. This means a focus on engaging the many networked actors that are involved in covid prevention or containment – whether in primary-level health services, hospitals, facilities for those with special needs, occupational health, residential care facilities, personnel management, patient transport and more. This networked effort in communities has to be supported by widespread and well-functioning capacity for testing to find who has the virus, for tracing those with whom they have been in contact, and for isolating those who might pass the virus on to others.
It is important that multiple actors involved in a response benefit from clear direction as different implementers are expected to work in synchrony. But the style of direction must empower those being directed so they use their initiative and act to the best of their abilities. And it can be frustrating to stakeholders if they do not feel empowered, especially when trying to resolve difficulties at the local level. They may find themselves dissatisfied with central guidance because it does not address their unresolved issues. They may not feel that their contribution to the response is valued and this limits their ability to engage to the full. In responding to covid, any commands must empower the responders to use their initiative to its best effect.
The countries that are best able to adapt covid responses to local realities, and to coordinate responders, have moved rapidly to develop comprehensive localised strategies. They use well-articulated strategic principles that include testing their populations liberally and empowering local teams to use test results so as to identify clusters of cases early. The countries that have maintained centrally planned, procured, and managed responses are finding it harder to encourage decentralised action. If local knowledge is valued and local capacity is engaged, new outbreaks are more likely to be detected quickly, and local incident managers find their work is increasingly valued. They become more effective, local-level capacity improves, and the covid-ready state starts to emerge at the local level.
Learning lessons from covid-19
There are lessons to be learned from our experiences of tackling covid-19 so far.
First: the command and control approach so often favoured in crisis response has to be modified when it comes to encouraging covid-readiness. There is a need for clear and well-communicated strategic principles, modified in light of new evidence. This should be accompanied by guidance on how the principles can be adapted so they enable all stakeholders to work out for themselves how they can best contribute to the response in their own localities.
Second: those responsible for managing responses should take advantage of opportunities they have to convene, coordinate, curate, and communicate. When these elements are prioritised, power and authority at the local level are used to their best effect. We offer four suggestions about how this can be done:
There must be a narrative. It should describe a clear vision and identifiable pathways for societies to move into the covid-ready state. How to encourage this to emergence from the present situation with widespread movement restrictions?
Information must be locally specific. If people are to be enabled to act at local level, they depend on high quality and specific information about what is happening in their locations. Where is the virus? How many people are infected? Which groups are most at risk?
Responses must make sense to people. This is about people being able to make sense of the narrative and updates in the news. What are the implications of the latest scientific findings? What does that say about safety in schools, on public transport, the wearing of face coverings? Every effort must be taken to avoid stigmatisation.
Values of decision-makers must be explicit. People are bound together in solidarity, getting ahead of the virus, by a sense of what they hold in common. This includes caring for older people and those who are vulnerable. Our values are known because we state them, but they are believed when we live them. We may not be believed if we say we value care workers if it becomes clear that they are unable to be tested for the virus or to access equipment they need for protection. What we do and how we do it is much more powerful than anything we say.
Enabling effective local-level action
Responding to covid-19 involves coordinated local-level action within communities everywhere, supported by well organised public health and primary care services. They need to work hand-in-glove with businesses, transport authorities, and local enforcement. They work together to implement a series of vital steps: these are required of all people everywhere. They include keeping physically separated where possible, maintaining proper hygiene, being alert to the symptoms, knowing what to do if you suspect you – or someone else – has the disease.
Local authorities and local health systems are vitally important. They are intimately connected with each other and with the places in which they operate. They can reach people, respond to what is emerging, and be flexible as to how they respond. They need the local data to do this and, when they have it, they generate much rich learning.
Central government and centralised control cannot match this. They have to work from models and use projections that are fed by incomplete data. Their outputs may be some days behind the reality. They lack the agility of local actors: their ability to adapt in a fluid environment is hampered by their remoteness. Any insistence on exercising control may become a hindrance more than a help.