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?
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.
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.
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?
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.
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.
Progress of an epidemic
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.
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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.
Infected countries: 37
Fatality rate: 10.1%
Total deaths: 922
Infected countries: 169
Fatality rate: 2.5%
Total deaths: 18,449
Infected countries: 28
As of April 28, 2020
Fatality rate: 34%
Total deaths: 871
Infected countries: 10
Fatality rate: 39.5%
Total deaths: 11,312
Infected countries: 55
Fatality rate: <0.1%
Total deaths: 45
Infected countries: 213
As of June 19, 2020
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.
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.
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.
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.