28 April 2020, COVID-19 Narratives

By Dr David Nabarro, Strategic Director of 4SD, Special Envoy of 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

LEARNING TO LIVE WITH THE NEW CORONAVIRUS:

ANTICIPATION, ARTICULATION, ADAPTATION AND ACCOUNTABILITY

By Dr David Nabarro and John Atkinson


Summary

  1. The virus is here to stay and will be a constant threat for the foreseeable future;
  2. The impact of both the virus and containment strategies on people’s lives and livelihoods is dramatic and disturbing: the challenges for poorer people and societies are extreme;
  3. The central requirement is the set-up and full functioning of public health capacity that covers all communities everywhere;
  4. Decision-makers within businesses, government, universities, in communities and in households are working out how best they can get ahead of the virus;
  5. Each decision-maker is
    • ANTICIPATING where things might go in terms of potential negative and positive impacts of COVID and its containment – including economic impacts, supply chains;
    • ARTICULATING where it is headed in ways that help people everywhere to make sense of what is happening and how it is expected to evolve: consistency is vital;
    • ADAPTING strategic guidance from the World Health Organization (WHO) and national authorities to fit with local realities; and,
    • ACCOUNTING for what they do to people everywhere who are part of the response.
  6. The WHO and other international bodies are increasingly called on to support these four vital capabilities: they are evolving in each location at the same time;
  7. Spaces, where learnings can be shared openly, are vital and are being established: the vital requirement is for connecting actors, analysing experiences and sharing them openly;
  8. All bodies that have the capacity must now support the development of opportunities to encourage sense-making and collective action;
  9. The international unity of purpose is starting to emerge: we need to work to minimise delays caused by ongoing political discord; and
  10. Nothing should stand in the way of collective learning about how to live with the ever-present threats posed by COVID in our midst.

Detail

The virus will be a threat to societies for the foreseeable future.  Limiting the extent to which it damages people’s health by prompt suppression of new outbreaks as they occur is the only way to contain this threat at this time.  The consequences of suppression strategies, especially in locations with very limited public health capacities at community level, are extreme.  To avoid successive suppressions associated with restrictions on people’s movement there will need to be adaptations to lifestyles everywhere in order to reduce opportunities for the virus to be transmitted.  These adaptations, especially about physical distancing and shielding more vulnerable people, will be substantial.  Decision-makers face profoundly difficult choices because they must weigh up options amidst extraordinary uncertainties.  There is an enormous amount of learning underway but it may take months to resolve some of the unknowns about pattern of spread and effectiveness of alternative suppression strategies.  And we should not assume that the virus will go on behaving as it does now.  

All in authority can act in ways that make it possible for people to reduce their own risk of infection and to shield those who are vulnerable from any risk that they might inadvertently be infected. 

Behaviours are starting to change everywhere: this is happening locally, nationally and internationally, with some synchrony (as COVID is focusing multiple minds simultaneously) but with inevitable discordance.  The changes need to be ushered in, and implemented as systematically as possible, while movement restarts and lockdowns are gradually lifted.  They are changes in people’s behaviour that cannot be directed by authorities: it is necessary for people themselves to see value in making them and sticking to them.  But all in authority can act in ways that make it possible for people to reduce their own risk of infection and to shield those who are vulnerable from any risk that they might inadvertently be infected.  Every person has to make her or his own sense of the threats posed by the virus: not everyone will do this sense-making at the same time, and each individual will do it in her or his own way. 

As they make sense of what is happening people will depend on interpretations of what is known from different local, national and international sources.  They will entertain theories that they suspect to be wrong simply because this is an unprecedented situation.  They will both trust and question the official advice – whether from national experts or the WHO.

They will accompany each other as the new reality of being COVID-Ready emerges everywhere, exchanging their ideas as they evolve, expressing frustration and anger about something that has appeared out of the blue.  But life for all of us will be messy for a period, the more so if there is disunity – for whatever reasons – within communities, nations and internationally.  I anticipate that the need for greater unity will become apparent as the magnitude of the challenges – for people (especially those who are most vulnerable), for institutions (particularly those offering residential care), for local and national governments, and for the collective of nations – becomes increasingly evident. 

The interpretation of WHO guidance needs to reflect the threats posed by the virus in specific contexts: a constant challenge will by the shortage of reliable information about where the virus is, how it is moving and what effects it has on different populations.  There is still much that is not known, for example, about the impact of the virus in poorer societies around the world. 

Four strategic functions are essential to help decision makers (indeed everyone) make sense of what is happening and how they might best contribute as they emerge into the next normal of being ready for COVID.  They are: anticipation, articulation, adaptation and accountability.  Each of them is challenging given the uncertainties.

Anticipation:

Anticipation is about being prepared for what we think might happen as well as for things that we do not know will happen (but we need to prepare for all eventualities).  This means projecting the ways that the virus will affect different societies as infected people transmit it to those who are susceptible.  It means devising ways of living and working that limit opportunities for the virus to be transmitted in this way and to interrupt transmission when it occurs through ensuring that those who might have the disease are promptly kept away from others.  It means everyone being clear on the steps that must be taken rapidly to suppress any outbreaks of disease that build up un-noticed.  All these functions are essential – none is easy given multiple uncertainties about the behaviour of the virus and the effectiveness of different defence and containment measures.  

The anticipation goes beyond public health and hospital systems to the functioning of different settlements, arrangement for residential care, the resilience of systems for producing and distributing food as well as for ensuring people’s access to nutrition, employment, travel, trade.  It involves all of society’s systems: for ensuring access to education, law and order, food and nutrition, employment, social protection and much more.  Businesses, labour unions, governments, institutions…indeed decision-makers within all of society will be anticipating potential challenges and seeking to act together in preparing for them and responding to new eventualities smartly, as they emerge. 

Articulation: 

Overarching values and strategic principles for responding to threats of COVID are likely to remain relatively constant over time. They need to be widely shared and appreciated: this means that they need to be articulated regularly, with both clarity and authority.  A central principle is that those who take their responsibilities for limiting transmission of the virus should be treated with the utmost respect given the roles they are playing in keeping societies safe.  This includes those who choose to self-isolate or who agree to be isolated.  Every possible effort must be made to counter stigma. 

Everyone will need to appreciate that though the principles are constant, the ways in which they are applied in practice are bound to vary from place to place.  Those who are responsible for making decisions about responses will seek public support as they adapt and apply strategic principles in their locations.  Shifts in approach and adjustments to protocols will be a constant feature of responses even if the virus appears to be successfully contained.  This is inevitable given the newness of the threat and uncertainties about how the virus behaves.  

The WHO is establishing frameworks that, if widely used, can assist those who are responsible for making decisions to describe the steps they are taking, to share their experiences and to learn from each other.  These frameworks for action are likely to become increasingly useful as they will be adjusted in the light of experience.  They will be shared as they are being evolved: it is important that they are made available widely as well not least so that people everywhere can work out for themselves the strategic principles of defence and containment. 

COVID-19 is exposing multifaceted challenges at all levels of governance (global, national, local).  The inherent complexity may create concerns (“how can we cope with a such complex situation?”), despair (“we won’t be able to come out”?) and distrust (“the government is hiding things”). Explaining as much as possible is key to mobilizing all energies but also important for the future accountability phase that will assess the respective efforts of all stakeholders. 

Adaptation

Much work is underway to document alternative ways for enabling societies to be defended against the virus and to contain outbreaks of disease.  This involves studies of ways in which the virus behaves among people, how it infects individuals and how it is transmitted between them.  Results are being assessed and put into context: from time to time they lead to changes in guidance which means that strategies have to adapt. 

Strategies for containing outbreaks of disease are evolving as well, with an emphasis on which approaches work best, and how any social and economic consequences can be minimised.  This applies at present, as nations work out how best to respond to the initial outbreaks, as well as in the longer term for maintaining defences against the virus and being ready to respond rapidly in the event that further outbreaks occur. 

A vast amount of experience is emerging and being examined: analysis of experience in specific places is already indicating the value of adapting implementation in response to local circumstances.  Adaptation will need to happen simultaneously and synchronously: this is only possible if there is unity of purpose and effective networking among all involved.  This unity will only be achieved through opportunities for dialogue and debate about options as well as about the factors that influence different choices

Accountability: 

The public is being asked to make significant changes to behaviour and these are having enormous costs for society, for businesses and for governments.  There is a need for constant learning from experience to enable collective adaptation and to serve as the basis for articulating the rationale for guidance and directives.   We need to be able to examine what has been done in ways that recognize that decisions made earlier this year were made on the basis what decision-makers knew at the time, as well as the different options being considered as choices were made.  There is a need to limit the degree to which individuals currently in authority perceive themselves to be blamed for the current situation when it is still expanding and evolving.  Over time, decisions that are currently being criticized could well turn out to have been for the best.  At the same time, we are all accountable for the values that drive our actions and the ways in which they are reflected in what we do.  We should all be ready, always, to be called to account for how we are applying and sharing our values in what we do. 

It will be essential to evaluate what has been done in the early days and months of humanity’s encounter with the virus and to conclude how different actions could have affected its impacts.  All of us will be called to account for decisions made and actions taken.  There will be blame to be taken and shared.  That is why evaluation should involve all actors, not a selection.  It should use the tested procedures of after-action reviewswhich examine key decisions that have been made with a view to improving future alert and response capability. 

In after-action reviews, care is taken to examine the circumstances of each decision: the focus is on the information available at the time and being shared at the time and the context within which each decision was being made.  This means relying on records kept by the different actors, or on recorded written and oral statements made at specific times.  There is a selection of “living histories” of COVID responses being developed: these chronicles will prove invaluable in after-action reviews.  

Perhaps there is one other A-word that should be added to the list: Authenticity.  Whenever decision makers act they need to be constantly reflecting on the extraordinary requests being made of people everywhere and the tremendous contributions that are already being, and will continue to be made, through unprecedented cooperation and collective action. 

People everywhere are working out how they will contribute to a world as everyone works out how to get going again in ways that are equitable and sustainable.  They know that to do this they must establish means to defend themselves against the dangers posed by the virus and its potential to cause serious harm to people everywhere while making sure that whatever has to be done avoids disadvantage and danger for any-one. 

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There are many great sources of advice for governments and healthcare systems and the people who work in them, particularly the World Health Organization website. This is the trusted source for clinical information. Please bookmark it and keep checking it as it is updated.


On 21 February 2020, Dr David Nabarro, Co-Director of the Imperial College Institute of Global Health Innovation at the Imperial College London and Strategic Director of 4SD, was appointed as one of six Special Envoys to the World Health Organization (WHO) Director-General on COVID-19.

In this role, David provides 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.

The COVID-19 Narratives are being written by David and peers to share with those who want more information about the situation and to help raise awareness and readiness of all actors.


Snapshot from WHO COVID-19 Situation Report – 99, as of 10:00 CET 28 April 2020.

→ WHO Risk Assessment Global Level VERY HIGH
→ 2,954,222 confirmed cases (+76,026 new in the last 24 hours)
→ 202,597 deaths (+3,932 in the last 24 hours)
→ WHO publishes an “R&D Blueprint: COVID-19 Experimental Treatments”
→ WHO calls to maintain usual immunisation
→ WHO Director-General Dr. Tedros highlights need to continue to find, isolate, test and treat all cases
→ WHO continues to source millions of dollars of medical equipment and supplies


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