Whole-place approach for a COVID-ready city

By John Atkinson and David Nabarro, originally published online by The MJ on 14 September 2020 and published in print on 17 September 2020.

The first phase of the global COVID-19 pandemic required a national response. Around the world, national Governments saw health services being overwhelmed and infection rates rising exponentially and out of control. They reacted firmly by imposing national lockdowns, shifting funding to support acute services and maintaining basic income for those unable to work. This was a crisis response.

As Governments regained a measure of control, the clamour to ease social and economic restrictions grew. Lockdowns were a way to regain immediate control, but they are no solution for the longer-term. COVID-19 will be with us for the foreseeable future. We need to learn to live with it and find ways to carry on with our lives. If we do not, then inevitably, cases will again proliferate.

COVID-19 does not come in waves of infection; instead it appears in outbreaks. Now the situation in the UK is clearer we can see that.

The data shows us where the virus is, in which places it is at a low level, and where the infection rates begins to rapidly rise. This means a differing response in different places.

Bolton and Leicester have different needs to Banbury and Littlehampton, but they are also different to each other. It takes tireless fieldwork to understand what is going on in each place, and then it takes local relationships and intelligence to find the virus and break the chains of infection.

Where a place has the capacity to do this it is ‘COVID-ready’. With ‘COVID-ready cities’ (and counties and districts), we can be more confident when we see case numbers rising that there is a response that can quickly suppress it. This will be the pattern from now on – uneven spikes of infection that must be suppressed before they become explosive outbreaks. Where we cannot do this, as we are already seeing, tough restrictions will inevitably follow.

Around the world it has been shown that the critical convenor in effective responses to COVID-19 is local leadership. The ability to target testing at very specific groups when they need it most, using well-established relationships with faith and community groups to trace people who may have been infected, getting funds and food to the most disadvantaged when they need to self-isolate – these are things that only local organisations can do effectively. This requires effective political leadership that connects different actors and integrates their efforts.

Local action thrives best with tailored support from national authorities. Where local action cannot be unified and co-ordinated, national direction is essential.

Where national and local authorities are at odds with each other, time is lost, and the effectiveness of the responses diminished enabling the disease to strengthen its presence.

Where national messages lack consistency, clarity and a compelling narrative, confusion and disinformation arises.

Additional funding may well be needed because local authorities cannot constantly maintain the scale of resource needed for rapid containment of an established outbreak. National capacities for virus testing, resourcing hospitals and compensating those unable to work are key. But, critical to the effective deployment of these resources is local intelligence, direction and political oversight.

While the focus on test and trace is important, there is a wider dashboard of measures that, taken as a whole, ensure a place is COVID-ready.

The ‘COVID-ready city’ needs a ‘whole-place’ approach. It starts with a collective understanding amongst all the national and local agencies of what is happening in the specific outbreak in the city. It requires high quality intelligence based on open access to shared data. It means determining where the city sits against this wider dashboard of measures, and agencies, national and local, collectively taking action to ensure readiness. It needs locally co-ordinated responses that target the unique circumstances of the outbreak, working with and alongside local communities to achieve this.

The people in a COVID-ready city stay ahead of the virus and keep it at bay. When they understand what is happening around them in their place, they will make reasoned judgements as to risk that they take both for themselves and their neighbours. They own the response, exchanging openly with their leaders on options, and fashion actions so that they are effective in local contexts.

If the virus is the problem, then locally organised humanity has the solutions.

Characteristics of a COVID-ready city

Ability to detect and break transmission chains:

  • Percentage of cases found by contact tracing
  • Compliance of the community to governmental health directives
  • Testing; percentage positive, capacity per million population, turnaround time

Ability to minimise deaths and severe complications

  • Deaths per million population
  • Ventilator capacity per million population.

Minimise hospital-acquired COVID-19:

  • Personal protective equipment availability.
  • Healthcare associated infections.

Fiscal support for individuals and companies:

  • Programmes functioning for those in isolation or quarantine.
  • Programmes functioning for those threatened by social restrictions.

Maintenance of food and medicine supply chains:

  • Demonstrable actions in place.

Protection and support for vulnerable and neglected populations in the community:

  • Recent clusters in vulnerable groups.
  • Demonstrable actions in place.

Maintenance of usual health services

  • Essential services are never reduced.
  • Non-essential services are restored promptly.

[Source: The Lancet, Dale Fisher, Yik Ying Teo, David Nabarro, Published online 15 July, 2020. https://doi.org/10.1016/ S0140-6736(20)31601¬9]

David Nabarro is the co-director of the Imperial College Institute of Global Health Innovation at Imperial College London and supports systems leadership for sustainable development through his Switzerland-based social enterprise, 4SD. He is the special envoy for COVID-19 for the WHO director-general covering Europe and North America. John Atkinson is a specialist in large-scale transformational systems change and works with David at 4SD. He is the former managing director of the Leadership Centre for Local Government


Snapshot from WHO COVID-19 Weekly Epidemiological Update, as of 10:00 CET 20 September 2020.

Over 30.6 million COVID-19 cases and 950,000 deaths have been reported to WHO. From 14 through 20 September, there were almost 2 million new cases of COVID-19, which represents a 6% increase compared to the previous week, and the highest number of reported cases in a single week since the beginning of the epidemic.


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