LOCAL LEVEL SOLIDARITY IN THE COVID-19 RESPONSE BY DAVID NABARRO AND CAROLINE KENDE-ROBB

Dr David Nabarro, Special Envoy to the World Health Organization Director-General on COVID-19 and Caroline Kende-Robb, Senior Adviser, African Centre for Economic Transformation

The common foe in humanity’s evolving battle is the COVID-19 virus with its capacity to form new foci of transmission that rapidly evolve into outbreaks. It is an unfamiliar foe that has only been with us for four months: some characteristics of its behavior can be predicted and the strategy for early containment and suppression of the outbreak is well understood. In practice though, we all must be ready for surprises as statistics based on counting those who have the disease now are an indication of transmission that took place 14 days ago: it is hard to know the current distribution of the virus in a community without widespread testing in the community.  

Medical approach

The strategy for containing and suppressing outbreaks involves interrupting transmission. This means identifying people likely to have the virus, ensuring they are isolated and requesting that they keep two metres away from those who are uninfected. Their close contacts – from two days before symptoms started – are traced: they are isolated (in quarantine) and kept under surveillance and if they develop symptoms, their isolation continues. These crucial steps are much easier if tests for COVID-19 are available and suspected diagnosis can be confirmed. However, in many settings tests are not widely available and the identification of those with the disease must be undertaken based on symptoms.   

We all must be ready for surprises as statistics based on counting those who have the disease now are an indication of transmission that took place 14 days ago.

The proportion of people who have the infection with minimal symptoms in different settings, and their role in transmitting the virus, is not understood. In addition, there will always be the risk of people passing on the disease before they are diagnosed and isolated. Not all contacts can be traced every time, and newly infected people may have travelled since they were infected and start new outbreaks in distant locations. 

Those who need medical treatment should be detected at community level and cared for in health facilities by staff who are both equipped to treat their patients and able to protect themselves against contracting the disease. In settings with advanced outbreaks the health facilities quickly become overwhelmed and it becomes difficult to ensure that people with non-COVID-19 ailments can receive the treatment they need. Health care professionals are at particular risk because they are frequently exposed to people with the virus and may not have the required personal protective clothing (PPE).

In many settings, interrupting transmission is challenging because households are too small for the infected person to be isolated from other family members plus the household members need to go out for daily necessities. Sometimes the request is for whole households to be isolated and they must then be supported by other members of their community.

Local authorities and community leaders face multiple challenges when deciding how to implement lockdowns in ways that prioritize public health, maintain essential services and protect those most at risk of impoverishment, social isolation and deprivation. 

When there is established transmission in communities with a risk of intense outbreaks, all people in the community are asked to maintain two metres physical distance from each other, often referred to as social distancing. Movements are strictly regulated, and gatherings are prevented. Governments achieve this through directing people to stay in place (including through lockdowns). Currently worldwide more than 2.2 billion people are under lockdown. The lockdown will be shorter if it can be implemented at an early stage in an outbreak and if there is strong capacity for interrupting transmission when an outbreak starts up at the community level. 

This COVID-ready state will be an essential characteristic of all communities as long as the virus remains a threat, and the sooner this ready state is established everywhere the better. If a lockdown is released before communities are COVID-ready, it is highly likely that there will be a sudden increase in the numbers of people potentially able to start outbreaks. However, a lengthy lockdown has immediate and serious implications for the continuation of essential services and for the well-being of poorer and more vulnerable people. Local authorities and community leaders face multiple challenges when deciding how to implement lockdowns in ways that prioritize public health, maintain essential services and protect those most at risk of impoverishment, social isolation and deprivation. 

Collective responses

People everywhere are reshaping their lives in response to the threats posed by COVID-19. The new reality for billions of people has emerged suddenly and makes unforeseen demands on social and political systems as new norms are being established. This is impacting on the well-being of individuals, households, communities, local authorities and countries. The lockdowns are for the good of all. The requirement for new norms to be adopted is sudden.  Countries, societies and communities are being reshaped. This demands a collective response that includes us all, focusing on public health, societal integrity and resilient livelihoods.

The need for physical distancing puts responsibilities on individuals to protect each other and communities to help sustain their most vulnerable citizens. How can individuals separate from each other while coming together in their communities and neighborhoods to develop sustainable and equitable response mechanisms? There are three interrelated elements.

ELEMENT 1: Public health response

The first, and most important element of response, is to interrupt transmission. Identifying cases (by testing for virus if possible, and by symptoms if not), isolation and contact tracing form the heart of the public health response. In settings where possible, treatment – particularly for severe cases – must be accessible. Some of the world’s most intensively resourced health systems in Europe and the USA are buckling under the strain of coronavirus, both with community response and with in-patient care.

This makes the challenges in low income countries with already fragile public health systems immense, the consequences of failure unfathomable. In poorer countries, people’s malnutrition, coupled with endemic diseases, constitute risk factors, which could lead to far higher levels of COVID-19 mortality. Poorer countries – many of which are experiencing early stage outbreaks – will depend on a properly resourced comprehensive strategy that will stimulate community engagement, ensure a fully knowledgeable populace as well as get testing kits, technical support, personal protective equipment and vital equipment to as many communities as possible. Establishing and implementing a comprehensive global plan is an urgent task. 

ELEMENT TWO – Fiscal response

Every government now recognizes the dire economic effects of the crisis.Appropriate fiscal support to the poorest countries is needed to prevent the current health crisis fueling an economic collapse with multiple adverse impacts.

We have seen significant contributions from nations and multilateral institutions: The G20 established its position last week. The World Bank has put in place a $6 billion fast-track facility for health system strengthening; the International Monetary Fund is aiming to increase its resources, and the UN has launched a $2 billion humanitarian appeal. It is likely that more will be needed, as reflected in the additional measures already being contemplated, including coronavirus bonds, increases in the IMF’s emergency credit facilities and new Special Drawing Rights as countries reach their limits, plus an immediate waiver on all interest payments on debt for African countries.

However, as the economy is at the center of attention other aspects of the response now need urgent attention – These include supporting and caring for people. COVID-19 will impact on the poorest and the most vulnerable including women and children, daily wage workers, single heads of households, refugees and migrants, homeless people and residents of large slums in lower resource settings. Governments will seek creative solutions to reach the most marginalized, considering all options including approaches such as cash transfer programs and financial targeting of the most vulnerable.

ELEMENT THREE – Community resilience response

How best to ensure that measures to suppress COVID-19 outbreaks will protect the most vulnerable? The engagement of people within communities (including neighborhoods in urban areas) is a vital component of the response. The many small outbreaks that characterize early COVID-19 presence can be stopped by strengthening and building the capacities and resilience of diverse communities. Everyone is part of the response.

With global value chains and international systems being disrupted, proven methods of community-based outbreak response can and will work. Collective local action based on the solidarity that exists within many communities and drawing on community structures and organizations can drive local community-based actions and solutions. This includes communities themselves deciding how to implement and enforce physical distancing to reduce opportunities for transmission of the virus. This is not new to public health in low resource settings. We saw widespread behavior change mounted within communities when they battled Ebola in West Africa in 2014 -15. The key is that communities are fully aware and fully engaged, working out with each other how to support their members as they manage the difficulties that must come with physical distancing, even among close family.

While containment of COVID-19 requires that people the world over physically distance themselves from each other, social cohesion and connectedness are more important than ever to ensure that we come together to be part of the response.

At the local level, organizations, networks and structures already exist: they are at the heart of community resilience, solidarity and cohesion. While containment of COVID-19 requires that people the world over physically distance themselves from each other, social cohesion and connectedness are more important than ever to ensure that we come together to be part of the response.

Education and community support have a vital role to play in enabling communities to follow advice of physical distancing and other measures requiring behavioral change. Community trust in the health system to deliver their health needs safely and not put them at risk is vital. This must be built on the basis of what is known to work in other settings and tailored to local realities in ways that recognize and integrate with each community’s sense of self and cultural identity.

The COVID-19 response must recognize women’s leadership roles as well as their care work which is often unpaid. Efforts to mobilize communities that amplify the voices of women have been effective in outbreak responses before: they will help women feel both safe and empowered.

The continued functioning of essential public services is essential with a focus on effective sanitation, clean water, access to food and social wellbeing. This requires the appropriate prioritization of front-line services and the people who run them (health and non-health sectors). They are at the heart of our communities and are loved family members. 

Women face multiple demands as they care for their families: they also are at risk of losing their livelihoods, gender-based violence, and perhaps other challenges beyond the risk of coronavirus infection. They are the majority of front-line health care responders, caregivers and household and community managers. The COVID-19 response must recognize women’s leadership roles as well as their care work which is often unpaid. Efforts to mobilize communities that amplify the voices of women have been effective in outbreak responses before: they will help women feel both safe and empowered.

As more people are asked to stay in their homes and be distanced from each other, the Internet offers a vital means for connecting individuals and families, those who are vulnerable and without homes of their own, government officials and citizens, health workers and patients, schools and students, companies and suppliers, people who live alone and migrants, and more. However, for it to make the most difference to the most people, innovative solutions are needed to ensure that that even the least developed environments have access. Those developing applications are focusing on how they can function even when internet access is limited and bandwidth is tight, and to make it affordable by ‘zero-rating’ certain key applications. In practice this means not charging for the underlying data used for those applications and adapting regulations and contracts so that communities can develop their own Wi-Fi networks to increase availability.

Underlying all these efforts is the need for a coordinated global strategy so that governments can protect their citizens.

From individuals, communities, neighborhoods, countries and global action, every one of us has a role to play to stop the virus now.