Preparing for epidemics in South Africa

LESSONS ABOUT PANDEMICS

The public information on Covid-19 does not even begin to touch on the extensive amount of operational work, research and development that is happening in South Africa around the epidemic. The National Science and Technology Forum held a Discussion Forum on ‘Preparing for epidemics in South Africa – human and animal’ that provided much insight.

Previous public health emergencies

There have been numerous public health emergencies in South Africa and globally, each providing an opportunity to learn and build on previous experience. Dr Kerrigan McCarthy was one of the presenters who spoke on this. She is a Consultant Pathologist at Centre for Vaccines and Immunology, NICD. In ‘The Covid-19 Pandemic – what lessons have we learnt for the future?’, she uses three examples: Life Esidimeni, the listeriosis outbreak and the Covid-19 pandemic. The focus is on aligning operational breakthroughs with SET innovation, so important in South Africa where there is a lack when converting planning to action. Take the World Health Organisation’s Incident Management System Framework. This emerged from learnings around the Ebola Crisis of 2013-2014. The NICD adapted this to coordinate patient relocation back to Life Esidimeni. (In a failed attempt to de-institutionalise mental healthcare in Gauteng, patients were unsuccessfully moved to NGOs in 2016.)

McCarthy says without a good coordinating mechanism, resources are misused or poorly allocated. Other lessons included the importance of stakeholder communication (especially with the community and family) and rapidly creating data management systems that are accessible and user-friendly. In fact, flexibility and adaptability become core principles as new information often means decisions must be revisited.

The listeriosis outbreak (2017-2018) first led to the contamination of casings and meat and then other products on the shelves. The NICD coordinated a multisectoral response to the outbreak, similar to the Life Esidimeni plan. This emergency highlighted the importance of including the public. McCarthy says public cooperation is critical for health interventions. The surveillance of outbreak-prone diseases also came to the fore. It included further development of local and international networks for epidemiology and surveillance.

Covid-19 response

Reflecting on the Covid-19 response, McCarthy believes South Africa has done well, learning lessons from previous public health events. Once the virus reached South Africa, it was quickly followed by legislation to support lockdown (which started on 27 March 2020). From a dramatic increase, numbers of infections then levelled out post-lockdown.

Coordinating structures at national level

Further coordinating structures were created in response to requirements around the pandemic. These included a National Command Council to make key decisions, a Ministerial Advisory Committee involving academic specialists, the NICD’s incident management team and the National Department of Health (NDoH). McCarthy says that government created an environment conducive to multi-sectorial coordination at a high level. Covid-19 brought home the importance of working across sectors, from those dealing with animals, humans and health to the environment and legislation. This is of particular note since departments classically work in silos.

For a detailed explanation of the legislative framework and coordinating structures, see ‘Policies and Regulations for Dealing with Disease Outbreaks & Epidemics in South Africa’. This was presented by Dr Wayne Ramkrishna, Deputy Director: Communicable Disease Control, NDoH. More than a year into the pandemic, more lessons have been learned. McCarthy says it’s clear that coordinating structures need to be replicated at provincial and district level as these are service delivery points.


Risk communication and community engagement

Previous experience had already shown that risk communication and community engagement are key. They support public trust in authority structures and engender cooperation with public health interventions. McCarthy says that Covid-19 created communication difficulties due to uncertainties among scientists about the effectiveness of public health interventions. It created gaps for misinformation. There is now renewed emphasis and greater appreciation on the importance of clear communications.

McCarthy notes that good communication should state the facts, explain what is unknown and what is being done to address the uncertainties, and then what the public can do to protect itself. Prof Stephanie Burton added to this – see her presentation. She is in the Faculty of Natural and Agricultural Sciences and Professor at Future Africa, University of Pretoria (UP). Burton says we need to communicate that the Covid-19 virus is likely to become endemic, how to live safely, and how the virus works. It’s also important to understand the public’s specific questions to provide relevant factual answers.

Burton says that information needs to be understandable, accurate and evidence-based. There should be reasons to trust the information and the people providing it. Consequently, we need to increase educational and awareness programmes. This moves us towards a greater science culture, one where the public grasps scientific developments and takes part in debates.

It also means being able to separate fact from fiction by knowing how to access and assess information. People also need to understand why information changes ie that science changes as evidence changes.

McCarthy explains that an early challenge was the lack of data sharing between private labs and the NICD. A data interface has been progressively established between all the parties, allowing access to data. This is critical for surveillance. There was a need to track the epidemic ie cases, admissions, patient progress, reported deaths, excess deaths etc. Initially, there was no system in the public sector. DATCOV, a portal for logging hospital admissions of Covid-19 patients, was then set up by the NICD.

To further understand the causes of deaths, the NDoH mandated that post-mortems be conducted on all community deaths ie not just hospital deaths. Then the South African Medical Research Council (SAMRC) assisted with the interpretation of data on deaths. There were issues such as a lack of clarity on case definitions and delays in capturing the cause of death. This is partly due to each province having its own health systems and approach. McCarthy says one of the most important lessons is the importance of real-time quality data and good management systems. We need investment in data management infrastructure and the associated people skills.

Other sources of data – wastewater and earth observation

Complementary sources of data can add to the picture, says Mr Jay Bhagwan, Executive Manager: Water use and waste management, Water Research Commission (WRC). He spoke on ‘Monitoring of outbreaks – what can wastewater reveal?’ Wastewater-based epidemiology can reveal pharmaceuticals and other substance use, diet choices, and genetic markers, for example. A qualitative analysis of environmental samples can be used for determining general pathogen circulation within populations. Regarding Covid-19, the analysis detects RNA fragments (ie traces of the virus). Note that the live virus is not in the water.

Researchers can use wastewater-based epidemiology to track the number of infections and then map hot spots in communities. This is useful for determining risk levels and for supporting decisions around lifting or imposing mitigation interventions. Bhagwan says we’re just starting to see the range of possibilities. The WRC is working on a
Covid-19 National Surveillance Programme as part of early warning systems. It has already reached pilot phase.

More complementary information came from earth observation data via the South African National Space Agency (SANSA), says Ms Naledzani Mudau, Remote Sensing Scientist, SANSA. Various technologies and outputs, such as satellite imagery, can help monitor health services and available resources. It includes mapping and monitoring water quality, air quality, pollution, and heat extremes. Depending on the application, you can gain data from global to street view, as well as a historical view. SANSA can also create co-data sets, for example, vegetation monitoring over time can be integrated with data from the weather service. The most important lesson has been around increasing stakeholder engagement, says Mudau. Decision-makers need to be more aware of the type of data available and how to use it.

Data modelling

Another important area is data modelling, explains Prof Sheetal Silal, Director: Modelling and Simulation Hub Africa, University of Cape Town. She is part of the South African Covid-19 Modelling Consortium, which provides mathematical modelling support to national government during the Covid-19 epidemic. Mathematical models can be understood as tools that create synthetic populations in silico (on computer) that have features similar to the targeted real-world populations. Silal says mathematical modelling is so much more than path diagrams and mathematical equations.

In a real-world application, a lot of data is not available in a numerical format. In fact, some of the data isn’t even collected. The modellers need to meet with experts to understand the disease, the affected population and the public health system, among other factors. This information becomes part of the mathematical model. Silal explains it as using maths, combining it with computer programming and knowledge about the disease, to create a tool for better decision making by gaining insight on the behaviour and trajectory of the epidemic.

Mathematical modelling has been used in numerous ways in South Africa for Covid-19. One is to project future trends and the severity of infectious disease. It has also been used to predict the impact of interventions in the population, such as the impact of mask-wearing. It has also been used to estimate the cost and number of resources required. Silal emphasises that modelling predictions cannot be seen ‘as a crystal ball’. Mathematical modelling is about ‘what-if’ scenarios: “If we make certain assumptions based on available data, this is the likely outcome.”

Covid-19 had and still has a lot of unknowns. Mathematical modelling is used as a tool to understand complex relationships between features of infection. This can be seen when the second wave of Covid-19 came. The drivers
of the resurgence were unknown until the new virus variant emerged. The consortium developed a resurgence monitoring framework with outputs such as a dashboard, the SAMC Epidemic Explorer.

The focus is now on the third wave – variants and vaccines, looking at new lineage, reinfection, and vaccination – and developing a modelling framework around that.

Silal says that numerous lessons have been learned. These include further highlighting uncertainty in disease models and making public communication a full time effort. Furthermore, there is an urgent need for improved surveillance data infrastructure.

Research around Covid-19

A great deal of research has been generated around Covid-19. Topics range from surveillance (such as investigations of Covid-19 in people with HIV) to biobanks (where researchers can investigate possible genetic markers for predisposal to severe Covid-19). There is also research on which diagnostics to use, as well as developing our own. Besides being part of the Oxford AstroZeneca trials, there is research being done in South Africa around prevention and treatment. And this is to name but a few, explains Ms Glaudina Loots, Director: Health Innovation, Department of Science and Innovation (DSI) in her presentation. Of particular note, says Loots, is the establishment of the Network for Genomic Surveillance in South Africa.

Role of indigenous knowledge

Prof Nceba Gqaleni from the African Health Research Institute (AHRI) asks ‘if there is a role for indigenous knowledge in fighting epidemics or pandemics?’ He notes that Indigenous Knowledge Systems (IKS) play an essential role in empowering people, catalysing grassroots innovation, and enabling commercialisation and stable livelihoods. This is of particular importance when faced with a legacy of colonialism, economic dominance, and western systems hegemony. At the same time, one of the objectives of IKS is to build links between community-based knowledge systems and formal scientific institutions.

Investigating preparedness

Prof Jeffrey Mphahlele, Vice-President: SAMRC, notes that countries need to be prepared and to continue to strengthen their response to pandemics. Most countries were caught off guard. (He spoke on ‘Influenza pandemics – lessons for Covid-19 – human and animal’.) This comment was widely endorsed by the speakers, with Ramkrishna pointing to preparing for emergencies with an all-hazards approach. Think beyond communicable disease to the health
consequences of droughts and cyclones.

Research is critical during and after epidemic outbreaks, says Mphahlele. It includes identifying research gaps and priorities, as well as strengthening biosecurity, the research infrastructure, and the legislative framework. McCarthy notes that outbreaks are a signal that something underlying is wrong.

Covid-19 is more than a virus; it’s a conflation of social weaknesses with the virus that has exploited gaps in our society. This results in the weak and vulnerable and those with less access to resources suffering an unfair distribution of the disease.


READ: THE ESSENTIAL NON-ESSENTIALS, the thought leadership piece by Llewellyn van Wyk in the latest issue of Green Economy Journal. He writes:

“Covid-19 has starkly highlighted the central role of those whose daily jobs ensure our health and safety. Just the identification of this group as essential workers says it all although the opposite term raises difficult philosophical notions about the value of non-essentials. But the divisions go well beyond essential and non-essential. The pandemic has created a catastrophic health and economic crisis that has illuminated the fragile existence of low-wage and gig workers in general, and that of marginalised workers, in particular.”


Beyond policies and regulations, Ramkrishna spoke of the burden of zoonotic diseases in general. Already in 2018, a World Bank Report showed that zoonotic diseases accounted for just under one-billion cases and a million deaths annually. He notes that the occurrence and impact of known and novel disease outbreaks are likely to increase with changes in land use, agricultural practices, climate and weather, travel and trade, and urbanisation. Ramkrishna says we need to strengthen health systems to be resilient.

Alternative perspective

Dr Yogan Pillay, Country Director: Clinton Health Access Initiative, spoke on nonpharmaceutical interventions. Pillay stressed that work needs to be done across sectors and across all levels of government. This includes interventions at
all levels, especially community level. Involving the community and local government made a big difference, for example, putting experts at decentralised levels to analyse data at a local level. Action can then be taken in real time. At the same time, there is a need for more agile decision-making by management, as well as greater autonomy for front line workers. He says that all of government and all of society should be responding to Covid-19. We need to be co-creating health and wellness.

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Why preparedness matters

THOUGHT LEADERSHIP | Llewellyn van Wyk, B.Arch; MSc. (Applied), Urban Analyst

“Son, we live in a world that has walls and those walls have to be guarded by men with guns.”

A Few Good Men, 1992.
Surge, Lian Chan 2020

In a court scene in the 1992 movie, A Few Good Men Colonel Nathan Jessup (played by Jack Nicholson) is being cross-examined by Lieutenant Daniel Kaffee (played by Tom Cruise) about the death of a marine at the Guantanamo Bay Naval Base. Goaded on by Lieutenant Kaffee, Colonel Jessup finally loses his temper and retorts with the line quoted above.

While I am not a big supporter of war analogies, it is perhaps apt under the current circumstances as multiple political leaders have referred to the fight against the Covid-19 pandemic as a “war”. Covid-19 will not be stopped by wars, and hopefully, we will not resort to guns as a defense, but standing watch stresses the need for vigilance i.e. keeping careful watch for possible danger or difficulties. Two capabilities are required – anticipation, and response.

ANTICIPATION

David Quammen, writing for the New Yorker, questioned Ali Kahn, formerly of the Centers for Disease Control and Prevention (CDC), on what went so disastrously wrong. Where was the public-health preparedness that he had overseen at the CDC? Why were most countries – and especially the US – so unready? Was it a lack of scientific information, or a lack of money? Kahn’s response was, “This is about lack of imagination.” [i]

The best time to panic, i.e. overreact to a potential pandemic, says Nassim Nicholas Taleb, author of The Black Swan, is shortly after a novel pathogen has been detected.[ii] Unfortunately, at that point, few people have the virus and therefore it does not seem like a threat to the whole community. In hindsight, he concedes, it is perfectly obvious that the extraordinary efforts now being made by individuals and communities across the world to prevent the spread of Covid-19 should have been made in those areas where the virus was first discovered when it appeared.

However, it is natural that authorities do not wish to be criticised for “crying wolf” and, if they are elected officials, beaten at the next election for unnecessarily interfering with the life of the community. But it is precisely what would be called an “overreaction” that might have stopped Covid-19 in its tracks at the beginning. Taleb has previously written about those whose jobs are to make sure that small problems never become large and that some problems never even appear. 

Almost without fail commentators are emphasising how unprepared governments were for an event of this kind.

With a few exceptions, most notably South Korea, governments’ failure to act quickly and decisively contributed to the rapid spreading of the disease. In the US the disastrously tardy, inadequate, confused, and (for many citizens) confusing response of the federal government to Covid-19, both before and after the first case, derives from too many factors to list, but David Quammen mentions two: failure to appreciate the SARS and MERS warnings, both delivered by other coronaviruses; and loss of capacity at high government levels, within recent years, to understand the gravity and immediacy of pandemic threats.

The result of that loss is what Ali Khan means by lack of imagination. Almost paraphrasing Jack Nicholson in A Few Good Men, Beth Cameron, a former head of the Directorate for Global Health Security and Biodefense on the National Security Council staff, calls it the absence of “the smoke alarm.” Those in power, she says, who are charged with “keeping watch to get ahead of emergencies” need to smell the smoke and smother the fire while it’s small, As Cameron warns, “You’re not going to stop outbreaks from happening. But you can stop outbreaks from becoming epidemics or pandemics.”[iii]

Of greater concern is that several scientists expressed their alarm at an increasing emergence of the transmission of zoonotic diseases well before Covid-19 emerged. This was highlighted in, among other, a paper published in the Journal of Emerging Infections in 2010 where the authors noted that “current global disease control focuses almost exclusively on responding to pandemics after they have already spread globally.”[iv] Citing the response to the HIV pandemic as an example (it took over 25 years to develop a viable vaccine), the authors argue that this wait-and-see response is inadequate and what is urgently required is the development of systems to prevent pandemics especially given their rapid pace of spread and mutation.

As Jeffrey Sachs puts it, “There are many aspects of any major crisis that are similar in character, in that they require governments to assess the situation with sophistication, to identify options, to come up with strategies, and to implement them. Although crisis management has a lot of common points, the core issues are the capacity of political leaders and their inner team, and the capacity of the institutions of governance – agencies, departments, and ministries – to be able to process information in a timely way and to be able to harness expert advice and evidence in a timely way.”[v]

A similar situation applies to medical research funding: intermittent, stop-and-start funding that is provided only when there is a public health emergency undermines the ability to create capacity for rapid response as new pathogens emerge. Research must be ongoing before, during and after a disease outbreak. Several promising vaccines were in development during the SARS and MERS coronavirus outbreaks – but once infections waned, so did the research funding. Proto-vaccines that could have been useful in developing a rapid response to this novel virus were literally put on ice at the University of Texas and elsewhere – thus handicapping the current development process by many months.[vi]

Dennis Carroll, a former research virologist who led a pandemic-threats unit at the US Agency for International Development for almost fifteen years, believes the global community has a difficult time investing in what many think of as risky.

Spending big money is itself a form of risk, especially if it is public money, even if you are spending it to insure against a greater risk.

What if you spend a billion dollars, or ten billion – small change compared with what Covid-19 is now costing—and the pandemic does not occur during your term in office? “There’s very little appetite for that when the threat isn’t clear and present,”

Carroll said. When SARS happens, when a swine-flu pandemic happens, when an Ebola epidemic happens, political leaders and private donors react with fretful largesse, but when the crisis ends, he said, “we see a total collapse of those kinds of investments.” Homeowners buy fire insurance, governments buy vast armouries of weaponry hoping they will not be used, but there’s reluctance to invest seriously in preparedness against pandemics. “It’s attention-deficit disorder on a global scale,” Carroll said.

Sustained funding is necessary to support the full range of discovery – from elucidating the biology of the virus to developing drug candidates to creating improved systems of care delivery.

Still, some countries fared worse than other countries not because they lacked information or funding, but because they failed to learn the lessons of last outbreaks.

RESPONSE

Some governments have been keen to lay all the blame for the virus at Beijing’s door, but while initial coverups and lack of transparency undoubtedly delayed the international response, by February 2020 much of what is known about the virus – including its severity and ability to spread quickly – was common knowledge, and yet countries, at best, still failed, or, at worst, refused, to act.

Authorities and experts were certainly taken unawares by how quickly and widely the virus spread itself, however, multiple experts agree there was also a general sense of complacency among governments in the West that the outbreak was a China – or an Asian – problem, and would not necessarily behave the same way inside their borders. Some of this response is often a “feeling in countries that they might be affected in a different way because their community has a different structure … or that hot weather is going to keep it away, or their community is more spread out.”[vii]

Despite signs, the threat was making its way across the globe, there was a clear pattern of response in many parts of the world – denial, fumbling and, eventually, lockdown. It is especially puzzling that in our globalised world, so few lessons were learned in the early weeks of each country’s outbreak when the chances of containing and stopping the virus were highest. After all, this is one of the key arguments of globalisation protagonists.

There’s a lot to be said for the argument that any government would have been hard-pressed by a crisis of this nature and scale, but there were already clear indicators of what resilience looks like in the face of a global crisis such as this.

Although Asia has been able to start easing lockdown measures quite quickly, (Asia, after all, has been dealing with the coronavirus since late 2019, so governments have had longer to respond), the situation has grown increasingly dire in the West. While considerable attention has been paid to China’s initial response to the virus, anger is growing within countries over their government’s failure to respond when the alarms went off.

Rick Bright, who filed a whistle-blower complaint after being removed from his position as head of the agency in charge of the pandemic response, testified for just under four hours before the House Committee on Energy and Commerce’s health subcommittee. In his testimony he warned there is still no “master, coordinated plan” and noted that a “comprehensive strategy” was needed to combat the coronavirus pandemic that included widespread testing, tracing and ongoing efforts to “develop a cure,’’ as well as what to do with a vaccine once one is developed.[viii]

In the United States, a national shortage of diagnostic kits for the emerging coronavirus meant that only people who had recently visited China were eligible for testing. Even as beds began filling in Seattle with cases of flulike symptoms, doctors were unable to test them for the new disease, because none of the sufferers had been to China or been in contact with anyone who had. For nearly a month, as patients complained of aches, fevers, and breathing problems – and exhibited symptoms associated with Covid-19, such as “glassy” patches in X-rays of their lungs – none of them were evaluated for the disease. Calls to implement life-saving social distancing measures in the United States faced “a lot of pushback.”[ix]

Consequently, nationwide social distancing guidelines were not put in place until 16 March despite the country’s first case being recorded on 15 January, and the first signs of “community spread” detected in late February.

As noted by David Quammen, author of unsettling 2012 book, Spillover, which warned how (as we continue to disrupt the natural world) viruses are increasingly spreading from wild animal populations to humans, has not been surprised. He notes how the lack of preparedness is the only thing about this whole situation that has surprised him. “I didn’t have any illusions that the people who control the wheels of power and government were listening carefully to the scientists, but I thought they were listening at least enough to have some preparedness. And in this country, of course, I knew that [President] Trump was trying to defund the Centers for Disease Control as much as he could and had gotten rid of the key people on the National Security Council who were in charge of pandemic preparedness” he notes.[x] “Still, I am surprised at how unprepared we’ve been and how badly we, meaning this administration but also state governments, have managed this thing. It’s appalling” he concludes. Ultimately the lack of a timeous response cost the lives of at least 36 000 people.[xi]

The UK too dragged its feet on taking concerted action, only instituting lockdowns and a stay-at-home order in late March, two months after its first case was recorded. In the UK there is a growing scandal over, for example, the lack of protective gear for frontline medical workers. In the United States, some nurses had to resort to cutting makeshift protective clothing out of black rubbish bags. Both countries have also struggled to test enough people, with the US suffering delays due to the release of a flawed test that had to be corrected, while the UK lagged behind many of its European neighbours forcing people to order testing kits through the mails. The European Union’s chief scientist resigned over the bloc’s response to the virus.

In Asia, there is a growing sense of astonishment that the long lead time many countries elsewhere had was not better used. Unfortunately, responses to crises are equally shaped by experience, regardless of how much we try to look beyond them. From the outset, many saw the current pandemic as a rerun of SARS, from its emergence in China to that government’s apparent attempt at a coverup, to how it spread through Asia. The two viruses are related and have similar symptoms, but the novel coronavirus has long overtaken SARS in terms of death toll and spread. Nevertheless, an inability to look beyond SARS may have negatively shaped responses. Complacency, combined with calls to preserve the economy at all costs, appears to have caused governments to refuse to see what was staring them in the face, or being shouted in their ears, by increasingly desperate scientific advisers.

Still, while learning from mistakes is useful, learning from success stories is equally valuable.

Despite the pandemic hitting Europe hard, in Germany, with more than 100 000 people infected, the percentage of fatal cases has been remarkably low compared to those in many neighbouring countries. Much of this can be attributed to their response, which included the testing of far more people than most nations. That means it catches more people with few or no symptoms, increasing the number of known cases, but not the number of fatalities. The testing has included medical personnel: medical staff, at particular risk of contracting and spreading the virus, are regularly tested. To streamline the procedure, some hospitals have started doing block tests, using the swabs of 10 employees, and following up with individual tests only if there is a positive result. Health authorities also plan to roll out a large-scale antibody study, testing random samples of 100 000 people across Germany every week to gauge where immunity is building up.

An important key to the success of broad-based testing was that it did not cost the patients anything, a notable difference with the United States where individuals had to pay for the tests in the first several weeks of the outbreak. Regarding testing and tracking, Germany learnt quickly from the strategy that was successful in South Korea. Germany also learned from getting it wrong early on: it is now recognised that the strategy of contact tracing should have been used even more aggressively.

Germany benefitted from a robust public health care system: for example, hospitals have expanded their intensive care capacities across Germany for some time. And they started off a high base. Germany projected a need of about 12 000 beds at the peak of the outbreak according to projections from the Institute for Health Metrics and Evaluation. Crucially, it has over 147 000 beds, more than 10 times it needed.

Beyond mass testing and the preparedness of the health care system, many also see Chancellor Angela Merkel’s leadership as one reason the fatality rate has been kept low. As an academic stated in Germany, “Maybe our biggest strength in Germany is the rational decision-making at the highest level of government combined with the trust the government enjoys in the population.”[xii]All told there are significant factors that have kept the number of deaths relatively low, epidemiologists and virologists say, chief among them early and widespread testing and treatment, plenty of intensive care beds and a trusted government whose social distancing guidelines are widely observed.

Taiwan, with a population of around 24-million people, had, by 15 April, recorded just over 390 cases and six deaths, and on the same day reported no new cases at all. It managed to achieve that without implementing severe restrictions, like lockdowns, or school and nursery closures. In terms of its death toll, at least, Taiwan does not have much of a curve to flatten, more like a stepped line. Compare this to the United States which had reported over 60 000 deaths at the same time. Adjusted for population size, a level of Taiwan-like success could have meant just 83 deaths in the US. Among the early decisive measures taken was the decision to ban travel from many parts of China, stop cruise ships docking at the island’s ports, and introduce strict punishments for anyone found breaching home quarantine orders.

In addition, Taiwanese officials also moved to ramp up domestic face-mask production to ensure the local supply, rolled out island-wide testing for coronavirus – including retesting people who had previously unexplained pneumonia – and announced new punishments for spreading disinformation about the virus. Taiwan also went big on the use of big data and technology. It successfully merged national health insurance data with customs and immigration databases to create real-time alerts to help identify vulnerable populations. Having a good health data system helps with monitoring the spread of the disease and allows for its early detection. Critically again, although Taiwan has high-quality universal health care, its success lies in its preparedness, speed, central command, and rigorous contact tracing.

New Zealand, another government that has been praised for its handling of the pandemic, was also faster to introduce restrictions and widespread testing than the United States or Great Britain although not without several significant challenges. Not only was there an apparent shortage of personal protective equipment (PPE), the greater threat lay in a capacity shortage to test and contact trace.[xiii] While New Zealand had a stockpile of 24 886 kits, at the rate of testing that would have lasted only a fortnight. The shortage was due to a lack of specialised swabs used to collect mucus samples from the back of the nasal passages. However, the main global supplier of these swabs was a factory in Italy that was already struggling to meet local demand, creating a weak link in the supply chain that appeared at the time to potentially be the difference between New Zealand having a chance of containing Covid-19 or not. A further weakness in the supply chain became evident: disruptions to air freight undermined the ability to get aircraft to transport the swabs. Fortunately, the aircraft, and subsequent orders, were able to get through and make the crucial deliveries. However, reforms had to also be brought into a system that was found to be already overextended to enable the scale of testing and contact tracing required.[xiv]

In Cuba, its public health infrastructure supported community workers to identify vulnerable citizens and support their isolation early on, averting the overwhelming pressure on hospitals, staff and equipment that has characterised situations in either northern Italy or New York.

Iceland’s prolific approach to testing has enabled its government to keep the economy moving and keep the rate of infection down at the same time.

In all of these cases, the ability to respond has been supported by a long-standing commitment to investment in reliable broad public infrastructure — healthcare and the universal provision for basic human needs like housing, energy, sanitation, water and food. These are the structures that make a lockdown event viable in the first place. Where such structures have either been compromised by underinvestment or do not exist at all, a collective vulnerability has been glaringly exposed.

The lessons that become abundantly clear from the above are be prepared; be quick; test, trace and quarantine; use data and technology; be aggressive; get the private sector involved; act preventatively, respect privacy; learn from the past; increase testing as restrictions ease; build capacity in the health system; and funding for medical research must be sustained and predictable.

The clear message is: the precautionary principle applies whenever we are faced with problems that have the potential to cause systemic ruin. In future we will have to “overreact” and panic early to contain such potential pandemics. You may never know if you are overreacting, but you certainly will know if you have under-reacted. That could force us to do that right thing – even when the right thing seemsextraordinarily out of proportion to the risk – in order to prevent a massive problem that is many orders of magnitude worse that the inconvenience and economic loss associated with the early preventative steps taken.

With over a third of the world’s population at one time or another been shut away at home, the big question is what next. An opinion piece in the Economist makes a compelling case for dealing with this next phase. It argues that it is hard to think of any policy ever having been imposed so widely with such little preparation or debate. It argues that closing society was not a thought-out response, so much as a desperate measure for a desperate time. While it has slowed the pandemic, it has done so at a terrible price. Now as governments seek to put lockdowns behind them, governments are not thinking hard enough about the costs and benefits of what comes next the article argues.[xv]

Lifting lockdowns risked a second wave – and that is evident now. To limit the risk, it is suggested requires an epidemiological approach that focuses on the places and people most likely to spread the disease. An example is care homes, which in Canada have seen 80% of all the country’s deaths even though they house only 1% of the population. In Sweden refugees turn out to be high-risk, perhaps because several generations may be packed into a household. So are security guards, who are often elderly and are exposed to many people in their work.

For this approach to succeed at scale, you need data from tests to provide a fine-grained picture of how the disease spreads. Testing let Germany rapidly spot that it had a problem in its slaughterhouses, where the virus persists longer than expected on cold surfaces. Likewise, South Korea identified a super-spreader in Seoul’s gay bars. Without testing, a country is blind. Armed with data, governments can continuously refine their policies.

Some are universal. Masks were once thought ineffective, but in fact help stop the spread of the disease. Like handwashing, they are cheap and do not impose hidden costs. However, closing schools’ harms children and stops parents from working. In contrast with flu, it turns out, the benefits to health are not especially great. Schools should reopen, under conditions that lower the risk to teachers and vulnerable pupils.

Too many governments failed to spot what was coming, but then did what they could. In the much longer second phase they will have no such excuse. They must identify groups at risk; devise and enact policies for them; explain these so that vulnerable people change their behaviour without becoming scapegoats; provide vital infrastructure; and be ready to adapt as new data come in. This will sort countries where the government works from those where it does not. The stakes could not be higher the Economist concludes.

So, what happens after the virus has been contained (it will not be eradicated)? Complacency and apathy is what worries Brenda Ang from Tan Tock Seng most. Her concern,  mundane but crucial infection control measures, like the assiduous hand washing and wiping of doorknobs with alcohol – can lapse after a crisis as people become complacent and begin to believe that no new bugs exist. As for the larger lessons, beyond the outbreak locale, understand that there is no point in protecting your own turf. Infectious diseases are globalized, or, as Ali Kahn puts it, “a disease anywhere is a disease everywhere.”[xvi]

One of the implicit assumptions about western capitalism has always been that wealth was what would allow a democratic government to provide for the public during good times, and to protect it from harm during the crisis.

Sung notes that the pandemic has altered this view and points to the example of the U.S. and that of the Indian state of Kerala to show that wealth is not a sufficient condition for a good government response. He argues that it is not even a necessary one. Kerala, he argues, showed that three things matter: one, does the state actually have the ability to do something when a crisis like COVID-19 happens; two, even if the state can do something, does it actually do it when it needs to; and three, has the state been exposed to a crisis of this sort before?[xvii]

Lastly, ponder this: Taiwan, Germany and New Zealand have received accolades for their impressive handling of the coronavirus pandemic. They are scattered across the globe: one is in the heart of Europe; one is in Asia and the other is in the South Pacific. But they have one thing in common: they are all led by women. [xviii]

Read more in Green Economy Journal: Is Covid a salvo from Mother Nature?

References


Quammen, D. 2020. “Why weren’t we ready for the Coronavirus?” Available from: https://www.newyorker.com/magazine/2020/05/11/why-werent-we-ready-for-the-coronavirus?utm_source=nl&utm_brand=tny&utm_mailing=TNY_Daily_050420&utm_campaign=aud-dev&utm_medium=email&bxid=5be9f5bd2ddf9c72dc879e86&cndid=48809828&hasha=4c2641b64be4fbc96d3272bb1a96ae71&hashb=c9c1dba6c170b93151f4dd39d2d298d2cb950fd6&hashc=122c6030809ad6616af10d52091c32b56f95b8f727c69a827fdfdd7af1aa3c83&esrc=right_rail_magazine&utm_term=TNY_Daily. Downloaded: Tuesday, 05 May 2020

[ii] Cobb, K. 2020. “Overreacting to Coronavirus? The perverse logic of panic during a potential pandemic.” Available from: https://www.resilience.org/stories/2020-03-29/overreacting-to-coronavirus-the-perverse-logic-of-panic-during-a-potential-pandemic/. Downloaded: Wednesday, 15 April 2020

[iii] Quammen, D. 2020. “Why weren’t we ready for the Coronavirus?” Available from: https://www.newyorker.com/magazine/2020/05/11/why-werent-we-ready-for-the-coronavirus?utm_source=nl&utm_brand=tny&utm_mailing=TNY_Daily_050420&utm_campaign=aud-dev&utm_medium=email&bxid=5be9f5bd2ddf9c72dc879e86&cndid=48809828&hasha=4c2641b64be4fbc96d3272bb1a96ae71&hashb=c9c1dba6c170b93151f4dd39d2d298d2cb950fd6&hashc=122c6030809ad6616af10d52091c32b56f95b8f727c69a827fdfdd7af1aa3c83&esrc=right_rail_magazine&utm_term=TNY_Daily. Downloaded: Tuesday, 05 May 2020

[iv] Pike, B., Saylors, K., Fair, J., Le Breton, M., Tamoufe, U., Djoko, C., Rimoin, A. and Wolfe, N. 2010. “The Origin and Prevention of Pandemics.” In Journal of Emerging Infections, CID 2010:50 (15 June), p1636-1640.

[v] Chotiner, I. 2020. “Jeffrey Sachs on the catastrophic American response to the Coronavirus.” Available from: https://www.newyorker.com/news/q-and-a/jeffrey-sachs-on-the-catastrophic-american-response-to-the-coronavirus?utm_source=nl&utm_brand=tny&utm_mailing=TNY_Daily_042320&utm_campaign=aud-dev&utm_medium=email&bxid=5be9f5bd2ddf9c72dc879e86&cndid=48809828&hasha=4c2641b64be4fbc96d3272bb1a96ae71&hashb=c9c1dba6c170b93151f4dd39d2d298d2cb950fd6&hashc=122c6030809ad6616af10d52091c32b56f95b8f727c69a827fdfdd7af1aa3c83&esrc=right_rail_magazine&utm_term=TNY_Daily. Downloaded: Friday, 24 April 2020

[vi] Pomeroy, C. 2020. “if you think preparedness is expensive, the pandemic puts things in perspective.” Available from: https://blogs.scientificamerican.com/observations/if-you-think-preparedness-is-expensive-the-pandemic-puts-things-in-perspective/?utm_source=newsletter&utm_medium=email&utm_campaign=today-in-science&utm_content=link&utm_term=2020-04-30_top-stories. Downloaded: Friday, 01 May 2020

[vii] Griffiths, J. 2020. “As Coronavirus spread through Asia, the West has a head start to prepare. Why wasn’t is used?” Available from: https://edition.cnn.com/2020/04/16/asia/asia-europe-us-coronavirus-delay-intl-hnk/index.html. Downloaded: Friday, 17 April 2020.

[viii] Macaya, M. 2020. “5 takeways from Rick Bright’s House hearing.” Available from: https://edition.cnn.com/2020/05/14/politics/key-moments-bright-hearing/index.html. Downloaded: Saturday, 16 May 2020

[ix] Griffiths, J. 2020. “As Coronavirus spread through Asia, the West has a head start to prepare. Why wasn’t is used?” Available from: https://edition.cnn.com/2020/04/16/asia/asia-europe-us-coronavirus-delay-intl-hnk/index.html. Downloaded: Friday, 17 April 2020.

[x] Cohn, R. 2020. “Spillover warning: How we can prevent the next pandemic.” Available from: https://e360.yale.edu/features/spillover-warning-how-we-can-prevent-the-next-pandemic-david-quammen. Downloaded: Friday, 10 April 2020

[xi] Ebrahimii, A. 2020. “If the US had started social distancing a week earlier, about 36,000 fewer people would have died, study says.” Available from: https://edition.cnn.com/2020/05/21/us/us-social-distancing-study-trnd/index.html. Downloaded: Friday, 22 May 2020

[xii] Bennhold, K. 2020. “A German exception: Why the country’s Coronavirus death rate is low.” Available from: https://www.nytimes.com/2020/04/04/world/europe/germany-coronavirus-death-rate.html?utm_source=Nature+Briefing&utm_campaign=d04639c3df-briefing-dy-20200406&utm_medium=email&utm_term=0_c9dfd39373-d04639c3df-44601129. Downloaded: Tuesday, 07 April 2020

[xiii] Nippert, M. 2020. “How COVID was crushed.” The New Zealand Herald, May 23, 2020, pA6.

[xiv] Ibid.

[xv] Leaders, 2020. “Lifting lockdown: the when, why and how.” Available from: https://www.economist.com/leaders/2020/05/23/lifting-lockdowns-the-when-why-and-how?cid1=cust/ednew/n/bl/n/2020/05/21n/owned/n/n/nwl/n/n/A/478899/n. Downloaded: Friday, 22 May 2020

[xvi] Quammen, D. 2020. “Why weren’t we ready for the Coronavirus?” Available from: https://www.newyorker.com/magazine/2020/05/11/why-werent-we-ready-for-the-coronavirus?utm_source=nl&utm_brand=tny&utm_mailing=TNY_Daily_050420&utm_campaign=aud-dev&utm_medium=email&bxid=5be9f5bd2ddf9c72dc879e86&cndid=48809828&hasha=4c2641b64be4fbc96d3272bb1a96ae71&hashb=c9c1dba6c170b93151f4dd39d2d298d2cb950fd6&hashc=122c6030809ad6616af10d52091c32b56f95b8f727c69a827fdfdd7af1aa3c83&esrc=right_rail_magazine&utm_term=TNY_Daily. Downloaded: Tuesday, 05 May 2020

[xvii] Sung, E. 2020. “How a southern Indian state crushed its coronavirus outbreak.” Available from: https://mail.google.com/mail/u/0/?hl=en#inbox/FMfcgxwHNWBVghvgmHjNCnlGBBsgNxWL. Downloaded: Saturday, 23 May 2020

[xviii] Fincher, L. 2020. “Women leaders are doing a disproportionately great job at handling the pandemic. So why aren’t there more of them?” Available from: https://edition.cnn.com/2020/04/14/asia/women-government-leaders-coronavirus-hnk-intl/index.html. Downloaded: Friday, 17 April 2020

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