We Need an Urgent and Inclusive Response

COVID-19 Narrative by Dr David Nabarro, published 26 February 2020.

SUMMARY

Outbreaks of Coronavirus Infectious Disease (COVID-19) are serious threats for all peoples in our world. Responses require the urgent and inclusive involvement of everyone – their families and their communities – as well as the contribution of all sciences, the engagement of civil society and professional organizations and the collective capacities of businesses (as well as employees and customers). Consistent, enlightened leadership from local and national Governments is key to making this happen. This means leadership from the Head of State: it goes beyond, but is crucially dependent on, national Ministries of Health.

As we see the number of outbreaks increasing in different locations around the world, we recognize that any one of us global citizens may be at risk at some time and all of us are likely to be involved in responding – in some way or other. Preparing and responding well, as a determined community, can only happen if we all make a point of getting ready and staying ready for it.

Getting ready requires full collaboration among all involved in local and national governments, and in all other parts of society, in ways that are generous (in terms of what we offer each other) and reinforcing (in terms of acknowledging what we each have to offer).

Readiness means connecting with all people and recognizing that there will be heightened anxiety in multiple settings as a result of the way this outbreak evolves. That anxiety is a reality and we must do all we can to meet people where they really are, engaging with (and never dismissing) their feelings. We must be joined up and work together seamlessly in the face of a global challenge – everything possible must be done to avoid political positioning and point scoring from undermining our ability to work together on readiness, response and recovery.

China's Effort

The world has known the new coronavirus (the COVID-19 virus) for 7 weeks: the focus so far has been on the way it is affecting people, societies and the economy in China. Heroic health professionals raised the alarm: once the nature and severity of the threat was appreciated across different levels of government, people and officials pulled together in mounting a large-scale, well-coordinated and whole-of-society effort in order to reduce the intensity of the initial outbreak. This process is referred to as containment: it has had considerable success.

China’s people and health services, local and national governments, and numerous other groups within Chinese society, have pulled together and succeeded in reducing the numbers of new cases and limiting the number of casualties. In China the levels of human suffering and death rates have fallen thanks to skilful repurposing of health systems, the exemplary engagement of the people in the response and effective coordination among all engaged in the response.

The world is getting to know the new Coronavirus (nCOV) and what is involved in responding to the outbreaks it causes in ways that minimise people’s suffering and contribute to the resilience of communities. We have learnt much from colleagues, mainly in China but also elsewhere, on what steps need to be taken in containing an outbreak and how best to treat and prevent those who are affected. However there are many questions to be answered and we have much more to learn. Most estimates suggest that it will be at least a year before there is a vaccine against COVID-19 so getting ready and making use of proven techniques is the best way to proceed at this time.

On Readiness

Outbreaks of COVID-19 can be expected to happen in every community and country anytime. No-one should behave as if the spread of the outbreak will pass over their communities or the virus will not affect them, if they are exposed. All local and national authorities should take advantage of the present to get ready and to maintain a state of readiness for weeks to come. They should be developing plans across the whole of Government, involving all who are providing services to people, checking their plans through simulations and seeing whether they make sense, and engaging with the public openly, honestly and clearly in getting ready for outbreaks.

The core message is that the impact of an outbreak on people and on nations can be diminished if we get our mindsets right; make a point of working well together; share information and adapt in response to what we see; organize public health action well; give high value to effective case-finding, contact tracing and social distancing; and repurpose clinical facilities to reduce suffering and death while protecting health workers.

Most nations now have a window of opportunity in which to learn from the experience to date and get as ready as they can: this means having a readiness mindset and turning it into meaningful action – right across government and society. You can never be fully ready for multi-centred evolving outbreaks like COVID-19 but those who are now doing all they can to contain the threat recognize that getting ready in advance makes a huge difference to the response. No time should be lost: you do not know when cases will appear.

Public Health Functions

The starting principle is that prompt detection isolation and treatment (as needed) of people with COVID-19 is key to reducing outbreak intensity and associated suffering. This means enabling people to have easy access to rapid COVID-19 testing so that those with the disease can quickly be diagnosed, isolated comfortably and cared for. Their recent contacts must be traced and the close contacts must be isolated or quarantined too: this painstaking work helps break the chain of transmission, reduces the intensity of an outbreak and benefits society. We must remember that the COVID-19 virus is easily transmitted, spreads quickly and makes people ill: 20% have severe or critical disease and 2% die.

Every community should be expecting a COVID-19 outbreak to start at any time: all communities are at risk even if there are strong screening facilities at ports. Experience to date suggests that travel restrictions can make the situation worse. Everyone who is thought to have COVID-19 must be treated with the fullest respect and no stigmatization: we may well count on those who recover to provide care in future outbreaks as they are expected to be immune from reinfection.

Once an outbreak starts it can double in scale every 3 to 5 days: most people will be scared, some will be ill, a proportion will be found to have COVID-19 and a few will die. Hospitals will quickly get overloaded. Hence the need to focus on reducing the intensity of transmission, suffering and hardship, especially at the start of an outbreak, and to diminish the chance that one outbreak leads to others. That is why bans on public assemblies, accompanied, sometimes, by movement restrictions, can be helpful too. They are best applied in ways that take account of people’s needs, making every possible effort to avoid exacerbating other illnesses or making people’s lives even more difficult.

As is so often the case, the interests and concerns of poorer people should be heeded with a view to no-one being left behind. Why do we encourage isolation of people with COVID-19 and quarantine of their closest contacts? Any one individual can quickly infect many others and the likelihood can be reduced if an infected person is more than 2 metres away from others. Isolation and keeping a distance from each other can reduce the number of people an affected individual infects. And there should be sustained readiness even as an outbreak in a specific location diminishes as it can easily restart and affect people who were fortunate the last time.

There should be no reduction in vigilance until there is confirmation from WHO that the threat has subsided. Readiness planning is urgently and immediately needed. It helps leaders to ensure that when outbreaks start, those concerned know what they need to do, can act and adapt quickly and seamlessly, and are ready to do this at scale. This calls for organizing, scaling up and promptly rehearsing public health functions (eg finding people affected by the virus and transporting them safely; tracing and quarantining close contacts) planning major adjustments to hospital capacities and services, and getting the required materials in place. The materials are important – protective equipment to create safe working environments especially in hospitals and clinics, reagents for lab tests, and all that is needed to enable best quality intensive patient care (including oxygen and ventilators) so as to maximise the likelihood of recovery.

Making sure that the essentials are ready involves a huge effort across government. It requires temporary changes in roles of officials, repurposing government so that focuses on the multiple dimensions that need attention – people’s well-being, societal cohesion, and economic stability – when a COVID-19 outbreak takes root. This can only be done through involving people to the full at all levels – individual, household, community and nation.

Working Together Seamlessly

Those of us who have been responsible for outbreak responses have learned that we have to make a point of working together in ways that recognize our interdependence and reflect our respect for each other. This applies regardless of who we are, the nation we come from and our affiliations. We have learned that we do best if we are willing to share what we know (and do not know) openly with each other and do all we can to ensure that no person, no community and no nation is left behind.

Efficient communications, intersectoral working and abandonment of political point-scoring are all key to helping societies weather what will be tough times. We need to prepare for this series of COVID-19 outbreaks to last for several months. Respectful and inclusive working that brings diverse actors together calls for effective systems leadership. This approach recognizes that different people will have differing perspectives on any complex situation, and that these are all valid: in encouraging joint working it makes space for dialogue, co-learning and collective action.

A massive synchronized multi-actor readiness effort is now urgently needed in all communities and nations: this requires trust between all who are involved, and systems leadership establishes the conditions needed for this kind of deep trust to emerge. It is a joint undertaking by all involved in the response to contribute to the well-being of everyone everywhere.

This is the only way…

Dr David Nabarro is a Special Envoy of World Health Organization Director-General on COVID-19, Co-Director of the Imperial College Institute of Global Health Innovation at the Imperial College London and Strategic Director of 4SD. The COVID-19 Narrative series amplifies and interprets the available information and progress related to the pandemic response. They identify questions that leaders can consider when making decisions about measures to contain and suppress outbreaks. And, whilst many factors continue to evolve, the systems perspective that underpins the narratives can continue to be useful in making sense of this and other crises and their multiple consequences. Details, individual views and understanding of the pandemic are relevant to the authors at the time of publishing and are not adjusted to reflect changes in order to maintain the integrity of what is known at the time. They are published at 4sd.info/covid-19-narratives and complement weekly Open Online Briefings that provide further context and updates as the situation unfolds. Short video clips are also being produced to encourage all leaders - global, national and local - to act in solidarity as the world learns how to live with and mitigate the impact of COVID-19 outbreaks.