COVID-19
By Dr David Nabarro, Strategic Director of 4SD, Special Envoy to the World Health Organization Director-General on COVID-19 and Co-Director of the Imperial College Institute of Global Health Innovation at the Imperial College London
URGENT NEED FOR RAPID COORDINATED EFFORT
As debates rage about the varied responses to the COVID-19 pandemic in Europe and North America I continue to reflect on the challenges faced by national leaders as they do their best to stabilize the economy and protect jobs while acting in the interests of all people – both locally and globally – amid the pandemic.
The pandemic is advancing as a series of rapidly growing outbreaks around the world. The World Health Organization’s (WHO) Director General urges decision-makers to be extremely cautious about COVID-19. He encourages robust and rigorous efforts to contain an outbreak where it is starting as soon as a first person being suspected of infection and a chain of transmission is developing.
We have only known this virus for 3 months. Although there are models which anticipate what could happen in different settings as they are affected by COVID-19 outbreaks it is difficult to predict how things will evolve in the coming months with certitude.
I have been asked if I have evidence about which containment strategies are likely to be most effective. China, South Korea and Singapore have had to work hard to get on top of their outbreaks and data are available to describe their approaches. We have seen the enormity of suffering and the challenges faced by people as health services in Italy and Iran are stretched to the limit. We believe that similar challenges can be averted through well organized and rapid action.
MULTIPLE ACTIONS SIMULTANEOUSLY
There is no single government action (such as entry bans, movement restrictions, cancellation of large events) that will, when applied alone, stop a COVID-19 outbreak. The World Health Organization encourages multiple actions simultaneously. Governments establish the pathways for action: for the sake of their people they should act with no regrets and err on the side of caution. They should never give up on containing outbreaks even when they are overwhelmed because – if public health and hospital services are well organized and communities are fully involved – outbreaks can be limited.
SAFER BEHAVIOURS
The mainstay of efforts to contain COVID-19 outbreaks involves encouraging safe behaviour. This means everyone practicing good hygiene and cough etiquette. It means maintaining physical separation from others (ideally 2 metres). This includes making tests widely available so that people can know their COVID-19 status. There must be a high suspicion of COVID-19 in people with respiratory symptoms (high fever, cough, short of breath, chest pain). Rapid diagnostic services must be easily accessible. Those with COVID-19 should be counselled, be treated as necessary, and their contacts should be traced. They, in turn, should be kept under surveillance, isolated and supported. Even those with mild symptoms may be highly infectious: physical distancing is important especially around vulnerable people.
POPULAR INVOLVEMENT, COMMUNITY MANAGEMENT AND SOCIAL PROTECTION
Popular involvement in the rapid identification and prompt treatment for people with COVID-19, the community management of close contacts, together with special protection for those who are most vulnerable, is at the centre of successful efforts to contain and limit the pandemic.
DON’T TRY TO CARRY ON AS USUAL
At this time people, local authorities, governments and businesses should not just be carrying on as usual. Although – at first sight – this gives the impression of enabling people to avoid discomfort and anxiety, it can mean societies are unprepared in case there is an undetected build-up of people with COVID-19. Experience from South Asia is that the focus must be on following the virus, finding people with disease, supporting all those at risk (including health personnel) and ensuring that persons with other health care needs can assess heath care. Health workers are the heroes of the hour.
We, public health professionals, have plenty of evidence that COVID is a rapidly spreading and dangerous epidemic that exploits any gaps in our response unless we are rapid, resolute and rigorous in our actions. As has been seen in Italy and Iran, an explosive outbreak with widespread suffering can build up in a few days. Once this dramatic increase has taken place, drastic action (like restricting all movement) is needed to stop it. So, it makes sense to act robustly and rapidly so as to avoid getting to this stage. Once an outbreak has been contained and ended, we should be prepared for it to return.
We should all be using the time we have now to think about how we will organize ourselves when transmission starts in our area, and how we will live through the outbreak and how we will pick ourselves up again. So, keeping on with life as usual even in advance of a major outbreak is unwise.
LOCAL-LEVEL SOLIDARITY
Given that some authorities have been slower than others to get ready for outbreaks I am not surprised to see people in many parts of Europe and North America making decisions for themselves and getting organized in their communities. I see the emergence of local-level solidarity within communities backed by non-formal support networks and increasing evidence of coordination among all societal actors (including health chiefs, local leaders, community organizations, faith groups). People everywhere are getting smart on COVID-19: they use WHO guidance (which is updated each day in the Director-General’s briefings) to make sense of the information they are seeing and so act effectively.
It is sometimes suggested that Europe and the US are not able to respond as effectively as China and other South Asian countries. I have seen how leaders of countries in South Asia recall the outbreak of another Coronavirus Disease, Severe Acute Respiratory Syndrome (SARS) in 2002. They remember the economic damage that occurred and many regretted that it took some months to contain the outbreak. They moved rapidly with whole of government responses at the start of COVID-19 because they knew from experience what was needed. Their people understood too and – in general – worked closely with their authorities.
People in Europe and US do not have the experience of SARS to focus their minds and initially may be more reluctant to change their behaviour: their leaders sense they are walking a political tightrope. Over the last few days, many have come to appreciate the scale and speed of this COVID-19 pandemic and the need for seamless, well-organized efforts by the health services to support communities as they tackle outbreaks, and limit their consequences, in the places where they are happening.
BE READY FOR RESOLUTE ACTIONS
I sense that most people, local authorities and businesses, once they appreciate the scale of this challenge, recognize the need for resolute action. They would prefer to see outbreaks contained robustly as they start rather than continuing to evolve in scale, duration and longer-term impact when confronted with a gradually escalating response. I appreciate that being ready for intensive action requires a continuing investment. It means being on the alert all the time, having social protection in place for poorer people, being able to repurpose health care, carefully looking after health workers, withstanding economic disruption and so on. But that will be the price we have to pay for being able to hold COVID-19 outbreaks at bay and avoiding high loss of life. Limiting the advance of the pandemic is our only option until a vaccine becomes available (likely to be a year). It is the only way in which the world can avoid a long-term pandemic-related recession, with increasing poverty and loss of confidence in governance.
If (and I hope I am wrong) there are multiple explosive outbreaks in advanced nations in the coming weeks this will be very bad news for poorer nations because the risks to their people will be increased as a result of the amplification of the disease. I do hope that governments of poorer nations have the courage to be firm in their response from the moment suspect cases are first detected. This will lead to less confusion and lower risk of explosive outbreaks!
LEARNING CONTINUOUSLY
We are at the start of a complex challenge that affects all nations and is evolving exponentially. Here are some reflections:
People in communities are acting spontaneously, thoughtfully, collectively and rationally. They recognize the complex interconnections between different facets of people’s lives that are being affected by the pandemic. They appreciate that there will be multiple opinions on how best to navigate the complexity.
The world order is changing super-fast with South Asian countries offering support to Europe in their responses.
Middle income and poorer nations are increasingly engaging with the World Health Organization as new supply pathways and funding mechanisms are coming onstream to support their efforts.
This is like a fast-forward version of where we are with the climate crisis. We need to learn from it, quickly: it would be good if we all engage with each other in dialogue about how we tackle major threats and keep journals describing how we ourselves are working together to navigate the challenge of the pandemic.
RESOLUTE ACTION BY ALL
The WHO gets this, of course. Health is an outcome of multiple systems and interacting processes. But the pandemic is a bit special. It is a threat to all and it does not wait till uncertain leaders have finished their dithering. This pandemic thrives on hesitation and it is advancing explosively where leaders are distracted. Complacency in one part of the world leads to dangers for others. WHO knows – and has shown – that the pandemic can be tamed through resolute action now. But it needs resolute action by all, not leaders in one part of the world blaming others and refusing to cooperate. That is shameful, dangerous and irresponsible – and its consequences will be reflected in lives lost. Systems leaders step up and act forcefully despite anxieties, uncertainties and doubts.
BE RESPONSIBLE, ASSERTIVE, ROBUST AND ACCOUNTABLE
Systems leadership to end the COVID-19 pandemic needs people with experience. WHO’s Emergencies Programme has assembled the world’s experts and created space for hyper-fast learning and reflecting on the best ways to go. They tell us that COVID-19 threat is different from influenza. COVID-19 is challenging – just ask the hard-pressed doctors making life-or-death choices in Milan right now. COVID-19 damages life and livelihoods, society and economies. COVID-19 challenges all stakeholders to work together, to be responsible, to be assertive, robust and accountable.
BE AUTHENTIC AND OPEN
It also needs people who are authentic and open. All of us have readjusted our views of the threat over time. The general view now is that it is serious and needs our collective undivided attention with a focus on everyone everywhere. Not the people of one community, one state, one country and one region. We should be honest in admitting that there is much we do not know. If we pretend that we have the answers we will be likely make some serious mistakes. And they could be deadly as people’s lives are on the line.
LEADING MEANS TAKING RESPONSIBILITY FOR THE GOOD OF ALL
It needs people who will take responsibility for the good of all. Massive outbreaks in Europe and the US will seed outbreaks elsewhere. Some will be in poorer countries which are less able to cope. The wealthier nations must do all in their power to contain coronavirus now. No delay. Every person must take action to lessen risks of infection and transmission. This will dampen the pandemic. If not, the world will face a massive tragedy that could, in WHO’s words, be contained. We will demonstrate that humanity is unable to act for the common good even in a crisis. Surely we can do better.
APPLY LESSONS LEARNED
Systems leadership to end the COVID-19 pandemic means being ready to apply lessons learnt. WHO’s Director General told us today what needs to be done. China, Singapore, South Korea, Japan, Iran, Italy and other nations are sharing their experiences. We have much to learn and if leaders apply the learning now the scale of the suffering throughout our world CAN be limited.
ELEMENTS FOR SYSTEMS LEADERSHIP TO END THE COVID-19 PANDEMIC
Here are some elements for systems leadership to end the COVID-19 pandemic. We will need to identify and engage those who are ready to step up and lead this epic struggle.
No regrets strategies that put people first and leave no-one behind. Accessible testing readily available. Highly organized public health action involving people and government working together. Everyone focusing on ways to reduce exposure and support those who are infected. No blaming individuals who are infected themselves or infect others.
Supporting each other through these tough times, especially those whose livelihoods are undermined as a result of control efforts. Sharing and debating our anxieties and concerns in an open and supportive way. Recognizing that even if cases are not being reported from a location or community there may still be transmission underway. COVID-19 is amongst us all, it is not somewhere far away. But we can make a difference to the scale, intensity and impact of the pandemic.
Being strong: this work will last for the next six months at least. It will be a dominant feature of all our lives. We must carry each other through it. Hospitals will become our most precious resource to be nurtured and used with care. Comprehensive, well-organized and collective efforts, backed by adequate finance, are essential. Health workers are key and must receive all our support.
Caring for everyone. What will happen to small businesses that do less well if people prefer to stay at home and not venture out? What are the prospects for those who work in hospitality, retail, caring and service sectors which require contact with people? Life will be hard especially if they have no insurance. The custodial sector will face challenges too. Low-paid people will face economic hardship because of contraction in labour markets. Economies will be stressed: the poorest will face massive challenges as employment tightens. We must be inventive and leave no-one behind.
Being challenged again and again. It is not a simple choice between “fear and panic versus business as usual”. The best leaders will be able to combine their attention on people’s health, wellbeing and livelihoods, and chart a path that has meaning for all. Now is the time for them all to stand up: they will help us all navigate into the future.
Prioritizing together working for the public good. No political point scoring, no falsehoods, no undermining. Fragmentation means more people hurt, more societal damage. Leaders are accountable and the virus will show if they are failing us. The damage caused by this pandemic will be minimised through communication, inclusion, organisation, cooperation, coordination, innovation, openness, transparency and more. The pandemic will be exacerbated if there is name-calling, suspicion, fear, exploitation and obstruction.
Drawing on the strengths of all people and make the best use of all the assets at their collective disposal. Prioritize those most in need. Prevent market manipulation and hoarding. Explain what they do, share their data and encourage others to grow.
Keep learning. The world has never faced an infectious respiratory disease like COVID-19 before. It has only been with us for three months and we are all learning about it quickly. We know it differs from influenza or Ebola virus disease. We see it hurting people, disrupting societies and damaging economies. We have also seen that outbreaks can be contained, limited and stopped. We are helped by generous sharing of experience by countries as well as widespread debate about what to expect in different media. We see a multi-centred research effort underway though it will be some months before safe and effective vaccines or therapies are widely available. Most importantly, we see that people are ready to contribute to the response and want to do so in ways that have the greatest benefit – for them and for society.
Anticipate: think “How will the pandemic evolve? How are we to get ready for what is around the corner? How will we implement the right measures rigorously when they are needed?
Keep checking the things that matter, relentlessly. How to prepare people so they know what to do to be safe? How to organize and test community health services? How to ensure that those in need get the health care they require? How to sustain livelihoods for those whose economies are collapsing? The faster and more robust the action taken, the greater chance of halting the pandemic quickly.
Be international – this virus does the not respect national boundaries. All people of all nations must be involved irrespective of the extent to which their people are touched by this epidemic. Concerted efforts by the leaders of each nation are vital if we are to avert months – even years – of disruption to lives and livelihoods.
Bring people on board and connect with them throughout the pandemic. Tune into people’s hopes and anxieties, regularly and without being defensive. Meet people where they are and sense their rhythm. Seek to understand their perspectives and worldview. Foster trust build confidence and defuse anxiety. Use their voices to unite all sections of society so they act together to contain the pandemic.
Find resources everywhere: from subnational authorities, religious groups, societal organizations, professional bodies, media, sports, entertainment, schools, universities and more. Help them appreciate the importance of hand hygiene, cough etiquette and distancing. Work together in identifying why society-wide measures – such as reducing gatherings or curtailing movement – may need to be introduced. Do it together so that it is our collective effort that halts the pandemic.
Encourage seamless action and reaction: coordinated and robust responses that are implemented seamlessly with a view to maximum impact from the start.Err on the side of caution: the pandemic will win if we are complacent or half-hearted. Ensure thatemergency protocols are activated and working. Check that all involved know what is expected of them and are ready to implement. Set up coordination systems that work. Match response to challenge, repurposing people and money, re-assigning roles and responsibilities.
Encourage all to innovate, take risks and use initiative, not to be scared and risk averse. Treasure front-line responders – especially public health and hospital workers – as they are key to responding. Review progress regularly – together – so that all see the needs and adapt. Encourage – and do not penalize – those who must make difficult judgements using incomplete information even if subsequently they seem to have erred.
Maintain a regular rhythm of information, so that the people are with you. Set up hotlines that work and virtual forums that all can access to share information and reinforce public health services. Ensure people can access COVID-19 diagnostic testing and treatment, as well as treatment for other health conditions. Value health workers who are especially exposed both to the virus and to people’s anxieties.
SO, WHAT MUST WE ALL DO?
As of now there is no requirement for all of us to change behaviour. But we must get the mindset right: as soon as the first person with COVID-19 is found in a community we should care for them (they did not ask for it), treat with dignity and isolate them in a comfortable place. We must do all we can to stop spread and contain quickly. This calls for a collective effort. As we get ready, we should learn and practice cough etiquette: we should remember to wash our hands super-often and well and use sanitisers when there is no water and soap. We should learn to keep a distance from each other. When decisions are made about whether to continue with, or modify, sporting events or conferences we should evaluateeach situation based on local, up-to-date information. We need to know about risk of infection, the capacity of local health services and the parameters of national guidance. Remember: things can change very fast, and guidance may alter at any time.
ROLE OF BUSINESS LEADERS
The key lesson from countries that are successful in handling COVID-19 outbreaks is the need to involve the populace. Enlist them as partners in tackling the disease. Disinformation needs to be countered firmly by business, government and community organizations.
Business leaders could contribute greatly if they keep up to date with national and international guidance (especially from WHO); connect and communicate often with employees, customers and suppliers: communicate frequently, clearly and positively; being open to concerns and respond to them. It may be especially helpful if paid advertising slots are made available for transmitting public service announcements about how people can be safer in the face of COVID-19.
Please keep being positive: do all you can to avoid life coming to a standstill. Prevent livelihoods from collapsing. Make the care, safety and well-being of your employees the highest priority.
COORDINATED BUSINESS EFFORTS ARE UNDERWAY
The World Economic Forum, the Edelman company, the World Business Council for Sustainable Development and the Wellcome Trust are working on a communications plan that involves more than 500 companies. The chairman and founder of the WEF is arranging a weekly update for CEOs and establishing a platform so that companies know what others are doing on employee information, as well as travel, conferences, and office closure.
WHAT MATTERS THE MOST
In the coming weeks it is important that people everywhere are enabled to act for their own and for the public good. They should be able to depend on science, not fantasy, as the basis for their decisions. Businesses can lead for the good of all through connecting people with the science, helping them to stay up to date, and encouraging all to consider “what does this science mean for us”. No-one is finding it easy, but those who depend on reliable information for their survival and growth can make it an awful lot easier for us all.
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