By OB Sisay
As the coronavirus spreads policymakers are facing the challenge of structuring effective responses to manage the risks to public health, critical services and the economy. It will get worse before it gets better as many find that previously-held assumptions about their capabilities to absorb and manage the shock are misplaced.
There will be a parallel economic contagion to match the ongoing viral one that will wipe billions off asset values globally – the virus will use globalisation to replicate, spread fear and financial loss whilst at the same time freezing its trade arteries. There will be pressure to take drastic steps. Many mistakes will be made. And in disaster response this means losing people, property and profits that could otherwise have been saved.
Policy responses must be based on evidence and the best expert advice. Those in charge must ignore the noise which inevitably will flow from the pressure around them. The most obvious and populist measures are not always the best so they will have to hold their nerve and be calm and deliberate with their interventions.
The first and most important element they will have to get on top of is information. What to collect and how to use it to guide their decisions. How to share it with people involved in the response and what to tell the public. Governments are programmed to avoid alarm, which can unfortunately lead to deliberate efforts to hide the truth or mislead. This is bad in governance generally but in dealing with an epidemic it can be a fatal mistake.
Trust in what authorities are saying is vital because it affects what behavioural changes people make – a key element in ending transmission during an outbreak. Information determines whether people panic or are complacent; go to hospital or not; stay in quarantine or touch loved ones who are sick. Will they modify their behaviour enough to reduce the risks of getting infected or infecting others?
Social media is already awash with corona conspiracy theories that will complicate the efforts of response managers and public officials to win that vital public trust – just like Ebola.
The message – and the messengers – governments use will require credibility if they are to be effective. During the initial stages of the West Africa Ebola outbreak the World Health Organisation and governments in the affected countries (Guinea, Liberia and Sierra Leone) were posting conflicting figures about infections and deaths. Many people initially didn’t believe Ebola even existed or they doubted positive test results – often because authorities refused to admit when their labs got it wrong. Some governments lied about how many cases they had. One factor for this is that the moment you are declared an international health risk the world locks you down – insurance and other costs of trading with your country rocket, travel restrictions are slammed, business starts to suffer. Initial public messaging in West Africa emphasised the lack of a cure for Ebola, instead of the chances of survival with early diagnosis – so some people went to traditional healers instead of hospital. Each time creating new infection hotspots as those healers, their patients and families who cared for them, got sick and worse, travelled home to spread it further. This is not because they were illiterate Africans. We saw highly trained clinicians and other experts dealing with Ebola take paracetamol to fool temperature checks at the airport as they flew back home. People are not always rational when they think they might die. Public information has to be as accessible, accurate and timely as possible.
The quality of the operational response is the next key factor. Do not assume that your systems will work. Stress-test them! Do your hospitals and other response elements have what they need, and can this supply be efficiently maintained? Will they spot that first patient and isolate ALL their contacts? Health facilities can tragically become infection centres if infection prevention measures to protect staff and patients are not clearly understood and implemented.
Viral epidemics often attack medical staff in the second assault – as the first wave of infected patients meets staff and hospitals unprepared for the unknown. When patients and staff fear going to hospital during an outbreak death rates for other diseases will rise.
This operational efficiency applies to every element of the response – from minute performance indicators in clinical services like sample testing turn-around times and the flow of patients through hospitals to wider interventions like quarantining people and large populations. Fighting an epidemic is like fetching water with a basket. It doesn’t matter how well equipped your hospital is, if a single bed or ambulance is poorly disinfected there will be trouble. If you miss just one out of ten contacts of an infected person, you still have a potential epidemic. It will require attention to detail and a willingness to run towards problems instead of hiding or ignoring them.
As governments introduce mass population movement restrictions to contain corona, I wonder whether they all fully understand when and how to use this tool and the challenges it poses. Confining people en mass or in individual homes is about keeping the virus from spreading, but if not done right it can cause infection – something I suspect happened on the Diamond Princess cruise ship in Japan. Is it the best option in each case or are politicians just trying to show they are “taking serious action”? Is there a proper system for keeping them supplied with essentials or will they all rush to the stores causing unnecessary shortages as they hoard and even worse, infect each other in the scramble? In cases of individual confinement is it better to keep people at home or should you bring them to health facilities where they can be more closely monitored for symptoms? The answer is different in different scenarios.
As the world rises to the new reality of global pandemics policy makers must understand that they need totally different and more nimble processes and structures to respond. In many cases cures or vaccines will have to be developed during the outbreak. Economic and other public policy responses also have to be more dynamic than the machinery of governments and international institutions are used to.
How do we pay for these unpredictable responses – before, during and after? Do the normal peacetime rules around allocating, disbursing and accounting for funds work in an emergency response? The financial systems we had to work with during the Ebola epidemic led to delayed hazard payments to frontline Ebola workers, leading to strikes. These rules were there to contain corruption. But when disease surveillance officers, blood and saliva sample collectors, lab staff or burial teams that collect highly infectious corpses from homes go on a pay strike during a viral outbreak, people die needlessly. This happened on our watch in West Africa. Can we really say we will do better next time?
On the wider financing question, is there a role for insurance, as we have for terrorism and natural catastrophes? Can countries and companies buy insurance cover to mitigate shocks to their budgets and balance sheets? Globally, richer countries must understand that they have to support weaker countries to strengthen their own systems to minimise the risk to everyone. Not just to people but to supply chains for all sorts of inputs and crucial commodities. Companies have to rethink their entire supply model to ensure resilience.
Municipal administrators also have to contend with what this means in the face of rapid urbanization. Companies, schools, the police, public offices, prisons etc all have to review their first aid and isolation capabilities and training.
National healthcare systems need to evolve like their security counterparts did to face a post-911 world. For example, currently most healthcare systems around the world – including the most advanced and well-resourced ones - have perhaps a handful of specialist facilities and people able to deal with the sorts of pathogens that cause epidemics. Early detection is key, but regular frontline staff, especially those in advanced countries, will often have never seen them before. It is one thing to train people to look for corona symptoms now that we know there’s an outbreak, but what about the day the very first patient carrying the next new virus walks in? Will that first hospital and nurse be ready? Global resilience has to be addressed too. Does the UN – especially its specialized agency the WHO – for example, now need a dedicated epidemic response agency with the financing to match? How will the current model of flying in the handful of global experts on these things to affected countries cope with serious outbreaks in several countries at the same time?
Viruses have been around for longer than humans. And paradoxically it is our advancement – local and international public transport and supply chains, mass urbanization, freely available and overused antibiotics etc – that is amplifying the risk they pose to humanity’s health and wealth. Like climate shocks they are here to stay. One thing for sure is that it would be a mistake to treat this pandemic as a one-off and simply move to the next big topic. Something politicians and the press are notorious for.
OB Sisay was Director of The Situation Room at the National Ebola Response Centre of Sierra Leone during the West Africa Ebola outbreak of 2014 -2016. He was awarded a Gold Medal by the President of Sierra Leone and awarded an OBE by HM The Queen for his role in ending the outbreak.
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