ROUTES OUT OF LOCKDOWN

By Dr David Nabarro and John Atkinson

Many Governments are taking tough decisions: they have decided that their countries should slow down their economies and go into lockdown in order to reduce opportunities for the COVID-19 virus to be transmitted between people. The decisions made on when and how to emerge from lockdown are even more difficult: they are also delicate.

Deciding to impose lockdown is a reaction to the mounting threat to people’s health caused by rapidly escalating outbreaks. Reducing opportunities for the virus to be transmitted through enforcing physical distancing is essential not least because of the inevitability that hospital services will be overwhelmed unless decisive action is taken.

Governments are finding that the numbers of people with whom newly infected individuals have been in contact after lockdowns were imposed are many fewer than the numbers of contacts of infected people before lockdowns were imposed. Over time – two to three weeks after the imposition of lockdown – the numbers of infected people, and the fatalities, are starting to fall.

The sequence for easing a lockdown will vary from place to place. Decision makers will be considering multiple factors when deciding how best to do this.

This is certainly happening in Western Europe and in some parts of the US as well. Italy’s Health Minister Roberto Speranza outlined that the next phase of the national response includes more testing and reinforced local health systems with a view to creating the conditions needed to live with the virus. This will make it possible for the lockdown to be eased, gradually.

The routes out of lockdown will be messy. Quality information is at a premium. Decisions will be based on data about the spread of the virus disaggregated by locality. Numbers of people becoming infected will need to be factored into decisions. The goal is to understand the extent of transmission and whether the rate of increase in people infected is starting to reduce.

The sequence for easing a lockdown will vary from place to place. Decision-makers will be considering multiple factors when deciding how best to do this. We try to imagine the kinds of questions they will be asking and here we explore the questions and indicate some of the factors they might consider.

Our seven potential questions

Where are we with our efforts to contain the spread of the virus? Here we would be looking at the national statistics to see if the numbers of newly reported cases and deaths are not only increasing more slowly over time but have started to fall. The outbreak curve has started to plateau and each day there are reduced numbers of cases. We want to be sure that the large outbreaks are being contained. We look at sub-national numbers to see if there might be new clusters of virus transmission emerging in different parts of the country.
What is our health system capacity? Even if new cases are beginning to fall, some of those already very ill need prolonged intensive care. There may be substantial levels of infection among staff and a backlog of people who need care for non-COVID-19 illnesses will be building. Will our health system be able to cope if releasing lockdown results in more patients with COVID-19 who need treatment? Have we put all the elements in place to manage a surge in case numbers? This would include additional bed capacity, adequate ventilators and oxygen etc, as well as protection for health workers and other essential staff in hospitals and care facilities.
Are communities and public health services ‘COVID-19 ready’? Even though the major outbreaks are being suppressed there will still be people with the virus within our communities. Other people may come into the communities and have the virus without knowing it. Communities need to be able to detect new chains of transmission, and clusters of cases, promptly – so that transmission can rapidly be interrupted. In that way, new outbreaks do not build up un-noticed. So, as lockdowns are released there must be procedures in place to ensure early identification of people with COVID-19, their rapid isolation in designated locations, tracing of contacts, as well as controlled quarantine and community support for those who are confined. From the public health perspective, the release of lockdown can be considered when these procedures are established, tested and shown to be functioning properly. Those who devised successful strategies for interrupting transmission in East Asia point out that self-isolation is less effective than requiring persons with COVID to be isolated under supervision. We should consider whether – in the earliest stages after lockdown is released – supervised isolation of cases and contacts should be part of the strategy for COVID-19 readiness.

How will we define and describe gradual release? People will want to understand the steps or phases for the release. How are decisions being made? What is the sequence for opening economic activity? They will want to know when and how they might travel. There will be a need to spell out a clear pathway and develop the story that describes the steps. This will include the criteria for the steps that are being taken, how they will be implemented, and the metrics that will be used to track progress. Making this information available, even if there is controversy, will enable people to understand what is happening. It will increase both acceptance and participation.
Who does the gradual release apply to? The way in which release is implemented is unlikely to be universal or uniform. There will be calls for those who have had COVID-19 to be granted more freedoms because they will have antibodies and are expected to have at least some immunity to being infected again. But the extent of immunity, and whether it varies by a person’s age or medical history, is still not known. Young people respond differently to those who are older, whether it is to the disease or to the conditions of lockdown. Workers in essential sectors have already been exempted from some features of lockdowns: the definition of essential may begin to change. Sections of the population – especially older people – will be deemed to be at greater risk and special precautions will be required to protect them. Women play a vital role in lockdowns and in efforts to reduce transmission. The variations in the way gradual release is applied will need to be explained and shifts in practice are inevitable in the light of new understanding about where the virus is being transmitted and how it behaves.
How does gradual release apply in different places? Geographical areas are differently affected by the virus. The ways in which release criteria are applied in specific locations will vary. Openness about the way decisions are being made, as well as any uncertainties, is critical when explaining how lockdown is being released in different places. This could contribute to avoidance of grievance and reducing the risk of unrest.

Whose interests will be served? Many governments have taken on extraordinary powers in order to deal with an extraordinary situation. Populations have understood this and been tolerant of it. In using these powers, leaders will be mindful that their legitimacy comes from being seen to respond to their people’s needs. Maintaining health, avoiding impoverishment and reducing the pain will all be priorities. Governments will be expected to demonstrate a balanced and proportionate response, and always to take account of the needs of those who are most vulnerable.
What level of government decides on the release? Nations have widely differing levels of local autonomy and power. How will national governments work with their sub-national authorities in determining the most appropriate sequencing and management of a lockdown release? Consistency is essential: any variation that appears to be the result of political or organizational fragmentation will not be accepted. This is a time when coordination and consistency really matters: that is key to a managed transition from lockdown to the COVID-19 ready state.

How are leaders and scientists working together? National leaders turn to experts in public health to help them explore options and make complex decisions quickly. They depend on the experts to appreciate how quickly the virus is spreading, where it is going and the impacts it might have on people, health services and more. They are acutely conscious that the sudden imposition of a robust containment plan will be hard to explain to their people and even harder to implement. So they have to make tough choices. They ask the experts to explore the potential impacts of different options. The experts base their advice on evidence and projections, and estimate the efficacy – and risks – associated with each. The choices being made by leaders are difficult to make: even harder if they are politically contested. That is why in many countries a formal or informal political truce has arisen between ruling parties and oppositions. It appears because the situation demands it. There are always those who will criticise decisions made in the rapidly evolving conditions as COVID-19 advances. They feel strongly that alternative approaches would yield better results. They question the advice of scientists who are doing their best despite multiple uncertainties.
Should we be surprised when decisions change? Those who make decisions will inevitably need to be able to change their positions as a result of new evidence, which will be interpreted for them by the World Health Organization (WHO) as it maintains oversight of the rapidly evolving situation – locally, nationally and globally. Hence the absolute need for WHO to receive whatever information individual nations are able to provide, as it comes available.
Why emerging issues should be debated? Once lockdowns start to ease a whole number of deeply political issues might start to surface. These issues need to be met and debated, and not suppressed, with a view to their being resolved for the good of all. If not, the differences will undermine the coherence of actions taken during the release.
Can legitimate interests be expressed? The process of releasing lockdown will also create a contested environment as different groups fear being disadvantaged. Emotional levels will be high after periods of containment. Using extraordinary powers dampens normal political discourse. It is critical to recognise this and provide appropriate ways for legitimate interests to be expressed.
When to hold leaders to account? Decision makers are weighing up options and making tough choices. Everyone will be called to account when the emergency is over: now is not the time for blame and finger-pointing. At this time what matters is openness about how choices are made and why specific options are selected.

Which groups of people are most affected by lockdowns? In all countries, lockdown has supressed the economy. In some sectors such as leisure and travel the impact has been dramatic. In countries and sub-regions dependant on tourism the impact on people’s livelihoods has been catastrophic. People on daily wages and in the informal economy are impacted severely and they will need immediate help. This must be made available without conditions or regrets.
Who are especially vulnerable?The consequencesof lockdown are particularly severe for those who are poorer, especially those on daily wages, in the informal economy, unemployed, in single headed households or with special needs. They worry about accessing the essentials they need for life, especially food. They are concerned about the loss of their savings, about their children’s education, about whether they will be able to keep earning. They may feel insecure and anxious, and face threats that they have not encountered before.
How can they be supported? All authorities are finding ways to soften the blow for the most vulnerable, as well as the self-employed and both small and medium enterprises. Rapid support must reach those with greatest needs. Key sectors of the economy are identified and specific fiscal measures are introduced to support them. The way this is done might encourage a shift in economic activity. Where some sub-national areas or sectors may be kept in lockdown while others are gradually released, it will be necessary to consider how different incentives and support measures such as levels of taxations, grants and loans are applied.

What challenges might businesses face? Businesses will have an acute interest in the patterns of gradual release and will be concerned with their own continuity, the viability of their supply chains, their ability to market their products and the well-being of their employees. They will have a legitimate interest in the rationale for decisions being made. They will be challenged by political instability.
Will there be support measures for businesses? Business may well be relying on a variety of support measures to keep going and as the lockdown is gradually released, there may be some considerable lag before their markets pick up. They will want to know how long any support (such as emergency lending, foregoing of debt or repayment windows) that is currently in place will last in order to plan effectively for the months ahead.
Might there be legal implications? If a release is phased, when is a lockdown not a lockdown? This will affect validity of force majeure in contracts, whether staff can now operate normally at a place of work, the terms and premiums for business continuity insurance in some ‘half-way house’. Expectations of governments and legislation may not align, local and national authorities will have much to work through.

How will individual freedom and collective responsibility be balanced? If there is a gradual release, with different allowances for different groups, there is potential to infringe on individual freedoms for selected groups of people. Paying attention to the balance between liberty and responsibility in such a rapidly evolving environment will be important.

Managing the messiness

The situation of a gradual release from lockdown as we have described it is clearly rather messy. Judgements will need to be made rapidly and will have many unforeseen consequences. The strategy will need to be highly adaptive and rapidly responsive to what is actually happening. That may be fresh outbreaks, or it may be citizen responses to changes in lockdown conditions. This means a built-in process of learning that takes into account the inevitability of differences in perspectives and responses to each change that is brought forward. Without this capacity for fast and high-quality feedback, things can rapidly begin to unravel. We think there are three areas to focus on.

Information. To date, information about the disease and the virus itself has been patchy and people have been slow to pay attention to it. To safely manage a gradual release from lockdown we need much better information about the disease itself, levels of immunity or otherwise, and differences in the behaviour of the virus. We need to know much more about case rates through far higher volumes of testing. We need to greatly increase our capacity for contact tracing so that we know how and where it is spreading and what actions will stop it. We need high quality, real-time information on health supplies and hospital capacity so that we can rapidly switch responses. We need good business barometers that point to shifts in markets. We need accurate assessments of compliance in populations in order to judge what is driving behaviour.
Transparency. Tolerance of exceptional use of executive power will last as long as it is still perceived to be in the public good. Gaining high-quality information is necessary to make good decisions but making it open and available allows public scrutiny of those decisions and reduces unhelpful opposition. Being clear on the criteria used at each stage in a gradual release from lockdown and where this phase fits within a longer-term view is also vital. Leaders need to tell the story of the journey ahead, describe the route they are taking.
Solidarity. It is easy for leaders under pressure to attempt to diffuse scrutiny through apportioning blame elsewhere. There will be a time when everyone will be held accountable for their actions. Pitching community against community, nation against nation or sector against sector undermines the solidarity needed to engage the legitimate voices of dissent during lockdown. Frustrations and grievances can easily turn to social disorder without this sense of the importance of solidarity. For solidarity to hold and to allow a gradual release of lockdowns to occur, a balance needs to be found. That balance is between building a strong sense of togetherness and hearing the hurt and anger. Maintaining this solidarity requires constant and sensitive attention. Simply repeating slogans (we’re all in it together) is not enough. Communication needs to be nuanced to each situation through carefully chosen language and attitude in each and every leader.

Focusing on these three areas gives leaders the chance to sense what is both legitimate and proportionate at every point in time. Things will change rapidly and differ by geography, sector or community.

This is the moment for leaders to feel into the pace, rhythm and readiness of the situation as they make their decisions.

Responses based on high-quality information, made transparently and with a view to maintaining solidarity, will succeed.

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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 – 80, as of 10:00 CET 9 April 2020.

→ WHO Risk Assessment Global Level VERY HIGH
→ 1,436,198 confirmed cases (+82,837 new in the last 24 hours)
→ 85,522 deaths (+6,287 in the last 24 hours)
→ Transmission scenarios for each country are now included in the daily situation report
→ WHO releases guidance for religious leaders and faith-based communities

6 Comments

William Gore 24th April 2020, 8:39 am

A first and comanding priority is to find a low total cost treatment for th worst manifetations of COVID 19 .

WE have a number of probable posibilities form the Cuban Interderon to old fashioned serology

WHO must provide real fovus and leadership !!

Also the west needs to understand in detail how Germany and China have contained the disease and kept low death rates

Waiting for a vaccine is like waiting for Godot !! If we can control. the real motality rate it must be the priority.

Rojan 14th April 2020, 9:16 am

Now, I think we have to accept the virus and live up with it by maintaining physical distancing, handwashing, wearing Mask and avoiding crowded places. Developing counties cannot afford this lockdown, Many people in developing countries are finding difficult to cope with starvation and hunger. They are caught in the tug of war between their hopes and despair, their frustration and anger. Children are further pushed to malnutrition. It is highly likely to have more crime, famine, rape, depression, riot, civil unrest in the coming days which is going to be catastrophic consequences in the developing world. The political will use this weakness as a means to violate the basic human right.

Loy Rego 13th April 2020, 7:11 pm

who are the other five COVID commissioners or special envoys? have they met virtually at least. have they developed a common agenda? Do consider this.

- Thuy Nguyen 15th April 2020, 11:57 am
  
  Dear Loy, the WHO announcement of the six Special Envoys on COVID-19 can be found here: https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19-on-21-february-2020. They are Professor Dr Maha El Rabbat, former Minister of Health of Egypt; Dr David Nabarro, former special adviser to the United Nations Secretary-General on the 2030 Agenda for Sustainable Development and Climate Change; 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. They provide strategic advice and high-level political advocacy and engagement in different parts of the world. Yes indeed, they do meet regularly, virtually. Best regards, Thuy (4SD team)
  
Pramod 13th April 2020, 1:24 pm

Well articulated response, need to add dynamism in our response mechanism, rightly because situation would be quite at variance from geographical zone to zone and also with passing time. World also need to fathom that gradual lifting of lockdown will have to be resorted to sooner or later. When industries and other economic activities could function, albeit not to their full potential, during the great wars, understandably can function now too.
Having said that, the dynamics of the present catastrophe is different and would demand a very calibrated and multifaceted response, be it social distancing, hygiene, speedy research and development of vaccine, concurrent and gradual upscaling of industrial, agricultural and other economic activities.
Honestly there is very little window of opportunity to wait for COVID-19 to subside before commencement of other spheres to get rolling.

karol sikora 12th April 2020, 9:42 pm

This is spot on. There’s no easy way out of it. We need to closely monitor what’s happening after any liberation from lockdown. It needs to be staged. The UK NHS has not been overwhelmed and everybody here is relieved. But the next stage is more difficult. I’ve begun an antibody testing strategy on all my clinic staff. I tested negative today to IgM and IgG so i haven’t had the virus which is a pain. The problem is the individual variability.

Governments need to be completely transparent about their plans.

9 April 2020, COVID-19 Narrative Seventeen

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