15 March 2020, COVID-19 Narrative Five

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


Download Narrative Five as PDF (62kb) English / Français

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.

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. 

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 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. 

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. 

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.   

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!  

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. 

On 21 February 2020, Dr David Nabarro, Strategic Director of 4SD and Co-Director of the Imperial College Institute of Global Health Innovation at the Imperial College London, was appointed as a World Health Organization (WHO) Director-General Special Envoy on COVID-19. In this role, David and five other special envoys are providing strategic advice and high-level political advocacy and engagement in different parts of the world to help WHO coordinate the global response to the epidemic. David joins special envoys Professor Dr Maha El Rabbat, former Minister of Health of Egypt; Dr John Nkengasong, Director of the African Centres for Disease Control and Prevention; Dr Mirta Roses, former Director of the WHO Region of the Americas; Dr Shin Young-soo, former Regional Director of the WHO Region of the Western Pacific and Professor Samba Sow, Director-General of the Center for Vaccine Development in Mali in this collective effort.

Please visit: https://www.who.int/emergencies/diseases/novel-coronavirus-2019 for official guidance from the World Health Organisation on the virus. These Narratives are being written and shared by David for those who want more information and to help raise awareness and readiness of all actors.

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