Lessons learned

Virus Wake-Up Call

Covid-19 has defied all expectations. Countries with more sophisticated healthcare systems have not fared the best, while countries that learned from past outbreaks have been the most resilient. What lessons are there for the rest of the world?

Public health workers wear protective gear while disinfecting a cinema in Seoul, South Korea, during the MERS outbreak of 2015. Chung Sung-Jung/ Getty Images

In Sep­tem­ber 2019 the Glob­al Pre­pared­ness Mon­i­tor­ing Board pub­lished its first annu­al report, look­ing at how pre­pared we were for a glob­al health emer­gency. Just a few months after pub­li­ca­tion, the worst-case sce­nario in the report was start­ing to unfold in Wuhan, a major com­mer­cial and trans­port hub of 11 mil­lion in cen­tral Chi­na. Con­vened in 2018 by the World Bank Group and the World Health Orga­ni­za­tion (WHO), the Board was tasked with iden­ti­fy­ing gaps in glob­al pre­pared­ness for a future pan­dem­ic. Its co-chair, for­mer WHO head Dr. Gro Harlem Brundt­land, warned that the world was unpre­pared for the “very real threat of a rapid­ly mov­ing high­ly lethal pan­dem­ic of a res­pi­ra­to­ry pathogen killing 50 to 80 mil­lion peo­ple.” Her prophet­ic warn­ing went most­ly unno­ticed by the world’s media. She had good rea­son to be wor­ried.

Between 2010 and 2019, the WHO had been track­ing almost 1,500 epi­demics world­wide. Dis­eases such as Severe Acute Res­pi­ra­to­ry Syn­drome (SARS), Asian Influen­za, Mid­dle East Res­pi­ra­to­ry Syn­drome (MERS), Ebo­la and Zika had already revealed them­selves to be for­mi­da­ble adver­saries, some with the poten­tial to kill hun­dreds of thou­sands of peo­ple if they were to spread at speed through our glob­al­ized economies. Each time an out­break occurs, key lessons are learned. But to the clear frus­tra­tion of Dr. Brundt­land they are not being act­ed upon. “For too long we have allowed a cycle of pan­ic and neglect when it comes to pan­demics: we ramp up efforts when there is a seri­ous threat, then quick­ly for­get about them when the threat sub­sides. It is well past time to act,” she warned.

The SARS outbreak taught us the importance of disease surveillance, international cooperation, transparency and the need for national and international public health authorities to take rapid and decisive steps towards containment.

SARS SHOWS THE WAY

In Jan­u­ary 2020, as events unfold­ed in Wuhan, there were uncom­fort­able echoes of the SARS out­break in 2003 that ulti­mate­ly claimed around 800 lives and impact­ed 29 coun­tries. Sim­i­lar to Covid-19, SARS-Cov is thought to have begun as an ani­mal virus. Lat­er analy­sis revealed that the first infec­tion of humans in Guang­dong province of south­ern Chi­na began in Novem­ber 2002. It was not until Feb­ru­ary 2003 that the WHO was alert­ed to unusu­al num­bers of pneu­mo­nia cas­es. The WHO issued its first glob­al alert on March 12 2003. Cas­es out­side Chi­na start­ed to appear from March 3 in Viet­nam, Hong Kong, Cana­da, Sin­ga­pore and Tai­wan. The SARS out­break taught us the impor­tance of dis­ease sur­veil­lance, inter­na­tion­al coop­er­a­tion, trans­paren­cy and the need for nation­al and inter­na­tion­al pub­lic health author­i­ties to take rapid and deci­sive steps towards con­tain­ment. It is no coin­ci­dence that those areas worst impact­ed by SARS in 2003 — Tai­wan, Sin­ga­pore, Viet­nam and Hong Kong – were the fastest and most effec­tive at tack­ling the first wave of Covid-19 in 2020. SARS was the first coro­n­avirus to reveal its poten­tial to trav­el around the world while fail­ing to respond to the clas­sic antivi­ral ther­a­pies. Affect­ed coun­tries were forced to fall back on tra­di­tion­al pub­lic health inter­ven­tions: ear­ly case detec­tion, case iso­la­tion, trac­ing and quar­an­tine of con­tacts, strict infec­tion con­trol, social dis­tanc­ing and the dis­sem­i­na­tion of accu­rate pub­lic infor­ma­tion.


Introduction

Coun­tries are dif­fer­ing in their approach to one of the great­est threats to human health. What can we learn from these dif­fer­ent approach­es as we come togeth­er in glob­al coop­er­a­tion to build resilience against the hid­den ene­my of dis­ease?

Testing: The countries with the most successful records on disease containment have applied the three Ts – test, track and trace – at the earliest opportunity. Learning to do this at speed will bolster global defences against future disease.Rui Oliveira
Measuring: The more we know, the better we are able to combat disease. With big data and AI, we have the power to predict and prepare as never before, providing we learn how to turn the mass of data into actionable insights.Bay Ismoyo/Getty Images
Disinfection: Disinfection has always been an important tool in preventing the spread of infectious disease. If robots could take on this job, particularly in clinical settings, it would reduce the risk of exposing human workers to infection and safeguard lives.Ethan Miller/Getty Images
Distancing: With Covid-19, we became used to the streets of many major cities being emptied of people as countries applied differing degrees of societal lockdown. In the absence of a vaccine, social distancing is one of the key weapons in our defensive armoury against infectious disease. Alex Hay/Trunkarchive

SETTING THE STANDARD

Tai­wan is just 80 miles off the coast of Chi­na, with more than one mil­lion of its 23 mil­lion cit­i­zens either resid­ing or work­ing on the main­land. With 2.71  mil­lion Chi­nese vis­it­ing Tai­wan in 2019, Tai­wan had the poten­tial to be one of the world’s worst impact­ed regions. How­ev­er, thanks to its state of con­stant alert to the spread of epi­demics, Tai­wan has man­aged to keep the num­ber of peo­ple infect­ed to about 400 with only six deaths. Its actions, born out of its expe­ri­ence with SARS, are seen as a tem­plate for the rest of the world. A year after the SARS out­break Tai­wan set up a health com­mand cen­ter to act as the oper­a­tional com­mand point in the case of a large out­break. On Decem­ber 31 2019, the day the WHO was noti­fied of a pneu­mo­nia of unknown cause in Wuhan, offi­cials began board­ing planes arriv­ing from Wuhan to test tem­per­a­tures. With response struc­tures in place, offi­cials were able to quick­ly assess and man­age capac­i­ty while iden­ti­fy­ing cas­es, imple­ment­ing quar­an­tine, and reas­sur­ing and edu­cat­ing the pub­lic.

...unless you have a better understanding of people’s political and economic context and their cultural beliefs it becomes very difficult to enforce a particular set of measures.

Hayley MacGregor
Research fellow at the Institute of Development Studies

It took just one day to lever­age big data by inte­grat­ing nation­al health insur­ance records with immi­gra­tion his­to­ries so that staff in clin­ics, phar­ma­cies and hos­pi­tals were able to iden­ti­fy high-risk indi­vid­u­als. Under the Com­mu­ni­ca­ble Dis­ease Con­trol Act, a plat­form was set up to ensure epi­dem­ic infor­ma­tion was quick­ly released to the pop­u­la­tion. Dai­ly press con­fer­ences began on Jan­u­ary 23. Peo­ple placed under quar­an­tine were mon­i­tored using their mobile phones. Those unable to self-iso­late at home were giv­en hotel rooms. The mil­i­tary was brought in to increase mask pro­duc­tion and, by Jan­u­ary 20, the gov­ern­ment had under its con­trol 44 mil­lion sur­gi­cal masks, 1.9 mil­lion N95 masks and 1,100 neg­a­tive-pres­sure iso­la­tion rooms. Con­scious of the risk of pan­ic buy­ing, the author­i­ties set up “epi­dem­ic pre­ven­tion maps” to inform the pub­lic about the loca­tion and stock lev­els of epi­dem­ic pre­ven­tion sup­plies in 6,000 phar­ma­cies. Pub­lic health mes­sag­ing was designed to address dis­ease stig­ma, while those in quar­an­tine were pro­vid­ed with an income, food, fre­quent health checks and encour­age­ment.


Mapping Disease Outbreaks

Progress of an epidemic

Although Covid-19 is in many ways unprecedented, previous epidemics have given plenty of indication of the risks we face. The timeline shows the course of major disease outbreaks this century from the first to the latest known case. Work is constantly being carried out to develop diagnostics, vaccines and medicines for these and other dangerous pathogens. The WHO tracks development from discovery to market launch. Click for more information on how many products are in the pipeline for each of these diseases.

In the cases of MERS and Covid-19, as these outbreaks are ongoing, the data is correct as of June 16, 2020. Data on product development is correct as of May 19, 2020.


Like Tai­wan, South Korea will also be stud­ied for its ear­ly mod­el response to Covid-19, born of its expe­ri­ence with MERS in 2015. South Korea’s deci­sion to over­haul its test­ing sys­tem after the MERS out­break is cred­it­ed with pro­vid­ing the capac­i­ty to effec­tive­ly respond to Covid-19 when the first cas­es pre­sent­ed them­selves in late Jan­u­ary 2020. By the end of March, South Korea had test­ed a quar­ter of a mil­lion peo­ple through a nation­al net­work of 600 test­ing sites. Results were avail­able with­in six hours via SMS. This com­pre­hen­sive test­ing regime allowed for an infect­ed person’s his­to­ry to be tracked so that all those who had come into con­tact could be traced. South Korea’s pol­i­cy of test­ing, trac­ing and treat­ing suc­cess­ful­ly stemmed the spread of the virus while avoid­ing a dam­ag­ing eco­nom­ic lock­down.


Impacting the economy

US$ 0.0 billion

is the estimated cost of Covid-19 (as of May 19, 2020).

BEYOND MEDICAL EPIDEMIOLOGY

The 2014 Ebo­la out­break in West Africa, which claimed over 11,000 lives, proved the impor­tance of social sci­ence input when tack­ling an epi­dem­ic. As the dis­ease unfold­ed, field work­ers wit­nessed resis­tance to cer­tain WHO mea­sures. Top-down approach­es to epi­dem­ic con­trol were not work­ing. The break­through moment came with the dis­cov­ery that 20 per­cent of Ebo­la infec­tions were hap­pen­ing as a result of reli­gious rit­u­als dur­ing the bur­ial of vic­tims. By work­ing with local com­mu­ni­ties and faith groups it was pos­si­ble to help the bereaved find safe alter­na­tives to deeply cher­ished bur­ial prac­tices.

Mapping Disease Outbreaks
SARS (2002-2004)
Infected countries: 37

SARS (2002-2004)

Total infected: 9,106
Fatality rate: 10.1%
Total deaths: 922

SWINE FLU (2009-2010)
Infected countries: 169

SWINE FLU (2009-2010)

Total infected: 741,371
Fatality rate: 2.5%
Total deaths: 18,449

MERS (since 2012)
Infected countries: 28

As of April 28, 2020

MERS (since 2012)

Total infected: 2,557
Fatality rate: 34%
Total deaths: 871

EBOLA (2013-2016)
Infected countries: 10

EBOLA (2013-2016)

Total infected: 28,628
Fatality rate: 39.5%
Total deaths: 11,312

ZIKA (2015-2016)
Infected countries: 55

ZIKA (2015-2016)

Total infected: 749,694
Fatality rate: <0.1%
Total deaths: 45

COVID-19 (since 2019)
Infected countries: 213

As of June 19, 2020

COVID-19 (since 2019)

Total infected: 8,550,458
Fatality rate: 5.4%
Total deaths: 456,726

“It became rapid­ly evi­dent that unless you have a bet­ter under­stand­ing of people’s polit­i­cal and eco­nom­ic con­text and their cul­tur­al beliefs it becomes very dif­fi­cult to enforce a p artic­u­lar set of mea­sures all the way from quar­an­tine through to bur­ial,” explains Hay­ley Mac­Gre­gor, research fel­low at the Insti­tute of Devel­op­ment Stud­ies, who sits on the WHO social sci­ence expert group on Covid-19.

Most European countries responded too late. There were one or two champions, like Denmark, which acted early and closed borders.

Professor Ilona KickbuschProfessor Ilona Kickbusch
Member of WHO Global Preparedness Monitoring Board

Social sci­en­tists argue that the sophis­ti­ca­tion of health­care sys­tems does not nec­es­sar­i­ly make a nation well­pre­pared for an epi­dem­ic. It is only when gov­ern­ments are informed by a broad base of sci­en­tif­ic dis­ci­plines that they will be able to address some of the wider ques­tions aris­ing from the cur­rent pan­dem­ic. One fac­tor that has been under­es­ti­mat­ed in all coun­tries dur­ing Covid-19 is how we deal with death and dying. Psy­chol­o­gists fear long-term men­tal health prob­lems as fam­i­ly mem­bers have been unable to say good­bye or grieve for their loved ones.

Oth­er soci­etal fault lines include how the virus is impact­ing low income fam­i­lies, the strain placed on chil­dren in lock­down, sup­port for those suf­fer­ing men­tal health prob­lems, the pro­tec­tion of fam­i­ly mem­bers from domes­tic vio­lence, the impact on the home­less and, one of the most con­tentious issues to emerge out of Covid-19, the pro­tec­tion of the elder­ly in care homes. “It is only when you ask who are the most mar­gin­al groups and try to pre­empt ∏ unin­tend­ed con­se­quences for them through your pre­pared­ness plan­ning that you will avoid the care home sce­nario unfold­ing the way it has or the impact on the home­less and the men­tal­ly unwell,” says Mac­Gre­gor.

Wearing a mask on public transport in Taipei, Taiwan, during the height of the SARS epidemic in 2003 – now a common feature throughout the world. Chien- Chi Chang/ Magnum Photos

DIFFERENT RESPONSES

As Europe and the Unit­ed States went into lock­down through March, two strate­gies emerged. The first was mit­i­ga­tion by slow­ing the epi­dem­ic spread to reduce the peak of health­care demand and pro­tect the most vul­ner­a­ble. The sec­ond was sup­pres­sion, the rever­sal of epi­dem­ic growth by cut­ting infec­tion rates to the low­est lev­els pos­si­ble. Most coun­tries, with the excep­tion of Swe­den, adopt­ed the lat­ter with vary­ing degrees of sever­i­ty. As the Covid-19 sto­ry unfolds, glob­al health spe­cial­ists will have the oppor­tu­ni­ty to see how dif­fer­ent coun­tries of broad­ly sim­i­lar demo­graph­ics respond­ed, and what can be tak­en for­ward for future pre­pared­ness.

Pro­fes­sor Ilona Kick­busch, mem­ber of the WHO Glob­al Pre­pared­ness Mon­i­tor­ing Board and Direc­tor of the Swiss Glob­al Health Cen­tre, says the first les­son learned is that most were just too slow in their respons­es. “Most Euro­pean coun­tries respond­ed too late. There were one or two cham­pi­ons like, for exam­ple, Den­mark, which act­ed ear­ly and closed bor­ders with a tough lock­down.” Por­tu­gal was also fast off the mark, going into full lock­down after record­ing only 448 cas­es, com­pared to its neigh­bor Spain, which delayed imple­ment­ing extreme mea­sures until case num­bers had reached 6,000. Ger­many has had few­er deaths than oth­er coun­tries in part because of its abil­i­ty to test its p opu­la­tion on a large scale through an exist­ing net­work of pub­lic and pri­vate lab­o­ra­to­ries. Mean­while, in the Mid­dle East, hav­ing pre­vi­ous­ly fall­en vic­tim to MERS, the Unit­ed Arab Emi­rates and Sau­di Ara­bia took ear­ly action, imple­ment­ing harsh lock­downs with cur­fews and heavy fines.

We need to know how to communicate issues around a situation like this... cities are important actors. It is not enough to do this with national governments.

Ilona Kickbusch
Member of WHO Global Preparedness Monitoring Board

PREPAREDNESS PAYS OFF

The expe­ri­ence of Covid-19 so far sug­gests that coun­tries that have learned from expe­ri­ence have come off light­est in this glob­al pan­dem­ic. Accord­ing to Kick­busch, anoth­er key mes­sage is the need to improve the health lit­er­a­cy of pop­u­la­tions and the con­ver­sa­tions lead­ers have with cit­i­zens pri­or to a cri­sis. “We need to know how to com­mu­ni­cate issues around a sit­u­a­tion like this. One answer would be to sim­u­late togeth­er as com­mu­ni­ties. We are also learn­ing that cities are impor­tant actors. It is not enough to do this with nation­al gov­ern­ments — just look at New York, Berlin and Lon­don.” Kick­busch believes there is now an oppor­tu­ni­ty for gov­ern­ments to learn from com­mu­ni­ty expe­ri­ences of Covid-19 and include these in future pan­dem­ic plans. As the Covid-19 sto­ry unfolds across the globe, health experts are now hop­ing that their long-stand­ing warn­ings about the need for greater pre­pared­ness will final­ly be heard.

Call To Impact
1 Despite facing the continuous threat of a global pandemic, we were unprepared for the Covid-19 crisis. Unless something changes, we will be unprepared for the next major disease outbreak as well. 2 Those nations hit hardest by past crises were able to tackle the outbreak more effectively. Public health officials need to do more to learn from the healthcare crises of other nations, even if not directly impacted. 3 It is not enough to focus on one area of preparation. Governments must ensure that transport, homeland security, social services and finance ministries are ready to swing into action.
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