2 April 2020, COVID-19 Narrative Fourteen

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


By Dr David Nabarro and John Atkinson

COVID-19 outbreaks move very, very fast.  The virus does not wait for us: we must get ahead of it together.  It is an epic struggle for all of humanity.  We must use our time well and fight the virus with responses that work, thinking all the time about how best to get ahead. 

Everything we do must be geared to containing outbreaks as they start by interrupting the transmission of the virus between people.  We quickly need capacity everywhere for societies to defend themselves so that outbreaks are picked up and suppressed as soon as they appear.  Any delay quickly leads to intense transmission and increased disease, suffering and death.  Those who might have the virus must be discovered promptly, isolated quickly, and treated with the best possible care.  Contacts must be traced thoroughly, and they must be quarantined promptly.  This requires highly organized public health services, fanned out across all communities.  Services must be strong; they must be on high alert and must be ready to function as soon as a new cluster of cases is suspected.  They must be backed up by hospitals where health workers are protected against infection.  Every country and community must make sure these services are working well as the virus can pop up anywhere. 

As outbreaks advance rapidly, governments act to limit opportunities for transmission, instructing their people to maintain physical distance from each other.  This has meant introducing lockdowns in areas where transmission is occurring.  A lockdown means restrictions on movement and association, with priority given to essential services like food and healthcare whilst dramatically reducing the nature and number of person-to-person interactions. These stringent measures are taken to slow the spread of COVID-19 through cities, towns and villages.

The lockdowns have to be rigorous and comprehensive, long enough for getting ready but as short as possible to reduce damage to people’s livelihoods.  Political leaders are making tough choices: they have to withstand scrutiny and criticism. 

Many governments have introduced lockdowns as soon as they see cases appearing.  This makes sense as a lot must be done quickly to move onto a war footing.  Everyone’s attention is focused on the battle against the virus.  Policies are quickly synchronized within government, at all levels, and across society.  Public health services are strengthened.  Health workers are protected.  Additional hospitals are built.  Societies get ready to defend themselves.  The lockdowns have to be rigorous and comprehensive, long enough for getting ready but as short as possible to reduce damage to people’s livelihoods.  Political leaders are making tough choices: they have to withstand scrutiny and criticism. 

Governments also impose lockdowns during intense outbreaks to help contain them: to reduce transmission and decrease the load on health systems.  They help slow the spread and aid the containment.  Over time they limit the overcrowding of health services. It takes some time for the impact of lockdowns to be seen.  A challenging time for all, especially when not everyone with COVID-19 can be tested.  

At both the national and personal level there are constant challenges in balancing the health benefits with the economic and social impacts. The challenges are laid out in the UN’s report ‘Shared Responsibility, Global Solidarity, responding to the socio-economic impacts of COVID-19’. It is therefore vital that lockdowns are effective and can be kept as short as possible.  Here is what we are learning

  1. Get localities organised. This pandemic will be overcome by people in their communities. The higher the quality of response in every locality, the better the outcome. Countries in South East Asia have shown the absolute necessity for strong local-level public health capacity for detection, isolation, contact tracing and quarantine. It must be done well.  Neighbourhood leaders play a critical role. They take responsibility for ensuring people understand messages around isolation, hygiene and public health. They make sure the vulnerable and elderly are cared for with people bringing food. They pay attention to stress management and mental well-being.  These capacities are needed everywhere.  They are the defensive web of societies and need active encouragement. Furloughed staff and students can make a vital and positive contribution. 
  2. Lockdown promptly and comprehensively. Understand the nature of COVID-19’s exponential growth in cases. Each week is an 8-fold increase. In three weeks, the situation will be 250 times worse. Remember that what you see is the tip of the iceberg. Many cases are not identified. Small outbreaks rapidly become intense and when they connect with each other they are dramatic. If you are seeing COVID-19 in the population, act now! Be very clear with people as to the seriousness of the situation and very clear as to what they can and cannot do. They aren’t seeing what you’re seeing. They’ll make unwise decisions if you are less than explicit.  Try to ensure that the instructions are consistent.  Empower local leaders to adapt to their realities. 
  3. Take good care of those who must carry on. Whilst imposing dramatic restrictions on much of the population, it is vital that key groups are able to continue. Health workers, those involved in food and water supplies, security personnel, all these people fall into this category. They need the best available personal protective equipment, they need to know how to use that equipment safely, they need to be able to get to and from their work safely too. Prioritise them above all others. Make them feel valued. 
  4. Widespread virus testing is ideal. The experience from the South-East Asian countries that have been in lockdown is that it is vital during the lockdown period to ruthlessly suppress the infection. This means testing on the largest scale possible to identify cases. It means rigorous contact tracing once cases are identified. It means ensuring strict quarantine regimes are followed by individuals and households. 
  5. Release in stages: – monitor the situation to check the impact of the lockdown.  See if the number of contacts for each new COVID-19 case are reducing.  Look at hospital numbers: are they falling?  Check whether communities are ready to detect and isolate cases and to avoid repeated outbreaks.  Identify communities with low transmission and let them restart gradually.  Remember – battles against the virus are won in communities and depend on detection, hygiene, isolation, quarantine and personal protection. They require rigorous application in ways that respect people’s autonomy and rights.  The battles are not won when lockdowns are released: that is when societies are particularly vulnerable. Transitioning to the new normal will take time and involve constant engagement with wary and frustrated people. 

Meanwhile, the virus remains a dangerous adversary.

Don’t take it lightly, ever.

Download Narrative Fourteen as PDF
English (89kb)

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 – 72, as of 10:00 CET 1 April 2020.

→ WHO Risk Assessment Global Level VERY HIGH
→ 823,626 confirmed cases (+72,736 new in the last 24 hours)
→ 40,598 deaths (+4,193 in the last 24 hours)
→ 3 new countries/territories/areas have reported cases of COVID-19 in the past 24 hours (Botswana, Burundi, Sierra Leone)
→ WHO releases scientific brief on off-label use of medicines
→ WHO recognises the importance of addressing the needs of refugees and migrants when preparing for or responding to the COVID-19 pandemic
→ WHO has described four levels of COVID-transmission with varying public health and social measures depending on the local evolution of the COVID-19 pandemic

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