Emma Ross
Good morning and thank you for joining us today on the Living with COVID webinar series with Chatham House Distinguished Fellow, David Heymann. Today, we’re exploring a country case study on one of the European countries that’s widely considered to have been among the more successful in managing the pandemic, despite having terrible numbers in the beginning, Iceland. With us today to discuss how Iceland has approached this crisis is its Chief Epidemiologist, Þórólfur Guðnason, or I will be calling him Thor from now on, who’s been responsible for organising the response. He’s also one of the three leaders who’ve been the public face of the response, as a member of what some in Iceland have dubbed the tripod or even the holy trinity, which includes besides the country’s top Epidemiologist, its top Doctor, the Director of Health, and top Policeman, the Chief Superintendent. And Iceland is certainly one of those countries considered to have had a particularly science-led response. So, welcome, Thor. We’re really looking forward to exploring with you how Iceland has faced the pandemic, and what we can all learn from the experience there.
First, I’ll go through a reminder of the housekeeping stuff. This briefing is on the record, and questions can be submitted using the ‘Q&A’ function on Zoom. Upvoted, as usual, upvoted questions are more likely to be selected. So if you have a question that’s similar to one already in the ‘Q&A’, please upvote it. So, welcome, Thor, and thank you for joining us today. Do you want to – oh, you can unmute if you’d like.
Dr Þórólfur Guðnason
Yeah, okay, thank you very much for having me.
Emma Ross
That’s great. So I was hoping you could start by giving us an overview of Iceland’s experience with the virus, and its response setup and strategy. What have been the hallmarks of your response, and what’s been most key in leading the country through the crisis?
Dr Þórólfur Guðnason
Well, I think I have to go back really to the preparedness work that we have been working on for many years. We started our preparedness plans on – in 2005, so – and we have been working extensively on our preparedness plans, along with the Civil Protection, since then. Updated our plans, and we have focused on that – our plans as general and all hazard plans, and we have used the same plans for every single type of hazards that we are using in Ice – we are facing in Iceland. Whether it’s a natural hazard or whatever it is, we use the same plans, same setup.
So I think we were quite prepared when this thing happened. Of course, we have learned a lot, and we have to update and change our plans. But we were planned. We started in January already to just to, sort of, look at our plans again, and all our stakeholders identified in the plans that they should be ready. And what the plans – plan, preparedness plan basically says is that it identifies the stakeholders, and what their responsibilities, individual companies, and official offices and so forth, and we asked everybody in January to be ready for this new crisis if it might hit Iceland.
So, when it first – we started also looking for the virus early in February, and it was only on the 28th that we diagnosed our first case. So we were quite prepared, and decided from the beginning that we would use as much testing as possible, and we would isolate cases, and we would quarantine. We would do contact tracing and do quarantine of all exposed individuals. So, we – and right from day one, actually, we decided that both my office, healthcare officials, and the police would join forces, and they would actually be responsible for the contact tracing. So that we started off right from the beginning, and we haven’t really changed course since then. We have used the same approach, and we have tried to learn from our experience as much as possible. We have tried to identify our weaknesses. We tried to identify whether we should do extensive screening, or how we should do things at our borders. So we have tried to use our scientific approach to guide us further. I think that has been, sort of, our trademark and probably success also, in many ways.
Emma Ross
Okay, I just want to talk about something you haven’t measured – mentioned in that, and that’s about your power and – just for a little bit. I came across this quote from Kári Stefánsson, the CEO of deCODE Genetics, which is the famed Icelandic, now American-owned, genetic-sequencing firm. And he had said, “The remarkable thing is – in this whole affair is that in Iceland, it has been run entirely by the public health authorities. They came up with the plan, and they just instituted it and we are fortunate that are Politicians managed to control themselves.” I understand that as Chief Epi, you have a lot of statutory power that doesn’t compare to the authority that your counterparts in other countries have, in terms of putting out directives or taking – instituting measures, without needing the permission of Politicians. Tell me about that and how that played out in this response.
Dr Þórólfur Guðnason
Yeah, I think that was probably one of the strengths, in my opinion, is that the law and how the law states the responsibility of the Chief Epidemiologist in Iceland, and what the responsibility and power of the Chief Epidemiologist is, actually. And as it is stated in the law, usually the Chief Epidemiologist can do a lot of things about, you know, containing infectious diseases, and he is allowed to work with the police and ask for the help of the police to either isolate, get people even, you know, have them contained without their consent for some time. So, we have been using this for some diseases for some time, so this setup, the partnership with the police has – we have worked on that and quite extensively.
Also, what it says in the law is that the Chief Epidemiologist, he can do a lot of thing. He can even close the country, and without asking permission from the Politicians or the Minister. But, as it says in the law, he has to inform the Minister as soon as possible, whatever that means. But usually how this works out is that I make suggestions, written suggestions to the Minister directly, and then the Minister decides whether he’s going to put the suggestions into regulation. And we were fortunate, I think, to work with the – with these Politicians right now. They kept themselves, sort of, in the back row, and – but I have the extensive communication with my Minister several times a day, throughout the whole crisis, and so we have exchanged opinions. The Minister knows exactly what I’m thinking about, and I know what she’s thinking about.
So when I make my suggestions, I’m not making any, sort of, surprises for the Minister. I have, sort of, worked on and undermined what’s going to happen, and this has worked out pretty well, I think. It’s more complicated now, with the past few weeks, I think, because there are more political issues involved, and so forth. But I think this setup has worked well for us.
Emma Ross
And what, specifically, have – how – when have you used it in this pandemic, a concrete example of when you’ve used that power?
Dr Þórólfur Guðnason
Well, I have not really used my power without making suggestions to the Minister. It usually takes quite a short time to get the regulation into effect, maybe one or two days actually. So, I have not had to use my power, without informing or talking to the Minister, or having regulations about it. I think that’s very important to have regulations about it because then we, you know, who’s going to be liable? Am I going to be liable for those regulations, and so forth? So, unfortunately, I have not had to use my power in that sense.
Emma Ross
David, that level of power seems pretty unusual among Chief Epis, or am I imagining that? I mean, what impact do you think that would have, and have you seen this, kind of, relationship between Scientists and governments in other responses?
Professor David Heymann CBE
Not really. I think this is a unique situation. You know, I myself come from the Center for Disease Control in the US, and we’re a part of the government. We’re not outside the government, able to make our own policies or – thei9r policies are made by Washington, not by the Center for Disease Control or the Director. But I think the UK actually attempted to do something like that when they set up the Health Protection Agency, which was a statutory body outside of the government, and which, just as Thor has described, worked very closely with the government, and never surprised the government with any new recommendations. They always worked with the government to make sure that everyone was working together. But it was an attempt here for a period of time that then, for some reason, was not the way that the government wished to continue to proceed forward, and it came back into the Department of Health. So, yes, the UK did try to set up this statutory body. Maybe Thor remembers those days. I don’t know if you do or not. Do you remember those days, Thor?
Dr Þórólfur Guðnason
Yeah, I do, yeah, yeah, yeah, yeah.
Professor David Heymann CBE
Yeah, and I think it was an imitation of what you were doing because you were quite admired back then in Iceland for what you were doing. I just wanted to make an observation though. I think that it was very interesting that you said your preparedness plans were multi-hazard, and were based on other hazards, including infections. And I just wondered, if the volcano episode in 2009/2010, was one of the reasons that stimulated you to do that plan, and to follow it afterwards? Because that’s what happened in Asia with SARS and with MERS. They had those outbreaks right in their countries, and they were ready when this occurred and I just wondered if that volcano had had any impact on that, Emma and Thor, as I was thinking of what you were saying.
Dr Þórólfur Guðnason
Most definitely because that’s one – also my responsibility. Volcanoes are also my responsibility because, as it’s stated in the law, the state – the Chief Epidemiologist is not only responsible for responses from infectious illnesses. He is also responsible for public health actions due to chemicals, radio-nuclear accidents, and unknown events, actually, unidentified events. And we thought that was pretty important that if you can’t identify something that’s happening in the society, and whether it’s due to infections or whether it’s intoxication or chemical events, who is responsible then? And it’s the responsibility of the Chief Epidemiologist. So, we have wide experience from the volcanoes, actually. When we have a volcano, we have an ash fall, and we have toxic chemicals coming from that volcano, and it’s a big hazard for the inhabitants in particular areas.
Then we use the same structure everywhere. We have the same close co-operation with the Civil Protection, and we have the same responses. So, we have also identified a network within Iceland, within the healthcare centres and primary healthcare, actually, where we have identified key persons. We have, sort of, reinforced that network with us for many years. We have regular meetings on Skype on – and so forth and so forth. So we didn’t have to prepare the healthcare also this time. So we have – so that’s why, I mean, all hazard general response plan for every single type. Of course, we have different focus on – depending on the type of threat we are dealing with. But that was one of the strengths that we didn’t have to spend time on reinforcing our network, communication, whom should I talk to? Who’s responsible for what? So, definitely, the natural hazards in Iceland have, sort of, practised us throughout the years, when it came to this pandemic, sure.
Emma Ross
I wanted to move into the detail of some of the key aspects of the response now, starting with testing. So you’d said, and it’s quite widely known, that you started testing early, very early, screening maybe a month before you had any cases. How have you been using tests in Iceland, I mean, in what context? And, also, I was hoping you could go into how you integrated deCODE Genetics into your pandemic response? And just for the audience, by way of context, deCODE is a global leader in analysing and understanding the human genome, and has done a lot of work studying the connection between disease and genetic variation. So, what’s been the story with testing in Iceland, and how have you used deCODE? Why were they so useful, and what’s the work shown us about the pandemic?
Dr Þórólfur Guðnason
Yeah, it’s a – this is an interesting story, and it’s only by itself, really. I mean, we have one virology laboratory in Iceland. And as soon as we started on our preparedness in January, actually, we asked or talked to the laboratory, virology laboratory, on their capacity for how many tests they could do, and it was quite clear, from the beginning, that the capacity of the laboratory was quite limited, actually. So that was really worrisome in the beginning, and how we could extend and increase the capacity was a big challenge.
But, at that time, the deCODE Genetics approached us, and asked or offered their help really that they could – what they could do, they could help us to identify, because they had extensive experience in working on genetic materials and sequencing and analysing, so they had much more capacity in testing than the virology lab. So what they did from the beginning was, first of all, they did genomic sequencing of the virus, and I will come back to that later. Then they also did some extensive screening, and what they also did, you know, when – because the virology laboratory at one point crumbled. Their equipment, sort of, didn’t work and, at that time, deCODE Genetics, they came in and also did analysis of the patient samples.
So, they came in with a big bang, I would say, and, additionally, they approached this whole assignment as a research project that they would do some – had research questions on various issues of this epidemic. And so that’s why deCODE Genetics, in co-operation with us and many other in the healthcare system, we were able to produce, sort of, scientific articles in New England Journal, for example, about the epidemiology, about the genomic sequencing. We could analyse well, who was infecting whom. We could analyse by the help of deCODE Genetics, whether children were as infectious as adults, for example. So, this whole approach to this epidemic, as a research was very, very helpful, and also, helpful for me in our responses.
So they have turned out to be very helpful, and now they’re, sort of, pulling back because now the virology laboratory is increasing the capacity a bit. But they have been very helpful. But it caused a lot of controversy in Iceland, I can tell you, because this company has – is controversial, in many ways, and it’s caused the controversies about the privacy issues. But the legislation of the Chief Epidemiologist really proved to be helpful because it allows him or me to almost do whatever I want to when I’m dealing with a pandemic like this. So, we could – therefore, deCODE Genetics was able to work extensively with us.
Emma Ross
And on your testing, I don’t know if this correct, but I’d read that, at one point, you were aggressively testing for the virus, and, on a per capita basis, you had the highest rate of testing in the world. Is that right, and how did that happen?
Dr Þórólfur Guðnason
Yeah, that’s true. I mean, initially, we started on the patient samples, you know, people with specific symptoms, they were tested. But, at the same time, we did this method also do some screening and both in groups of people around the cases and also, sort of, random sampling within the society. We did a whole city – whole towns throughout Iceland with testing, and that was mostly deCODE Genetics that did that. And so it was quite clear early on what the extent of the virus was within Iceland. We saw initially that the, you know, it was not more than maybe 1% or less than 1% that was infected. But what deCODE Genetics did also, they decided to test on all the different antibody tests. They tested out, I don’t remember exactly, maybe nine or ten different types of antibody tests, and they helped us to do random screening within the society within the population. So, we tested more than 30,000 people for the antibodies, and so that was very helpful in, sort of, alienating the outline and the extent of the epidemic during the first wave.
Emma Ross
And I understand they sequenced the virus of every Icelander that tested positive. Is that still true? Was that early on?
Dr Þórólfur Guðnason
Yeah, that’s true. That’s one another thing that’s been very helpful. We have done or deCODE Genetics, they have done genetic analysis on all Icelanders in Iceland, both at the borders and within Iceland. So, by doing that, for example, at the borders, we were able to track down where are the infections coming from? What is this epidemic or, for example, the cluster we’re dealing with now, or the epidemic or the wave we’re dealing with now, where’s it coming from? I mean, where did it come from and when throughout the – from the border? So we’re able to then identify now with our setup at the borders where we have identified more than 300 people at the border since the 15th of June, and by this genomic – genetic analysis of the virus, we have seen that only one clone of the virus is responsible for the – for this outbreak that we are dealing with now. So we know when and how this virus came into Iceland.
Emma Ross
And you were also the first to identify the link with the ski resorts in the Italian Alps, weren’t you?
Dr Þórólfur Guðnason
Yeah, we were able to identify the risk from the Italian Alps and – but it was quite clear that most of – from the sequencing the data, that most of the virus was coming from the Alps initially, but was also coming from other countries, actually. We also saw, during the first wave, other clones from – coming from Scandinavia, coming from England, coming from the United States. So, we cannot blame only the first wave on the Alps and the Italians and from Austria, really.
Emma Ross
Yeah, and David, this sounds like quite a comprehensive testing that’s yielding a lot of information. Could other countries, if they had started earlier, have been as on top of testing as Iceland, or do you think there are special circumstances there that mean there isn’t really a lesson in this for the rest of us?
Professor David Heymann CBE
And one of the major problems in testing has been not linking the testing to any epidemiological response as they did do in Iceland. So, what countries did was set up testing, and the Politicians were focused on how many tests they were doing, not really having any specific strategy moving forward. But now that’s changing quite a bit, and it’s changing because there’s not only the PCR that Thor was talking about in the genetic tests, there are also the antigen-detection tests, which detect the protein associated with these viruses, and those tests are being rapidly studied. There are two that have been shown to be very specific and very sensitive. They’re being studied in areas such as increasing the possibility of international travel, and used to determine when people can come out of quarantine, various issues like that.
So we’re just at the point where countries will have a much larger selection of tests to use, and hopefully they will, as they did in Iceland, be able to use them in an effective testing strategy that will help them with international travel, that will help them understand where disease is being transmitted, and a whole series of other things. It’s very strange to me that some countries are proud when they can get PCR test results in 24 hours. You need those results immediately, as Thor will know, in order to stop the outbreaks that are occurring. Because if you stop those outbreaks, you also decrease transmission into the community.
Dr Þórólfur Guðnason
Yeah, and if I can add to that, I think it was quite clear in the beginning that we would have to have the results of the tests as rapidly as possible and I can say that we get the results now within two or four hours, actually. When we had the biggest tourism last summer in Iceland, then it took maybe up to 24 hour to get the results. And as you were talking about the use of the antigen tests or the rapid tests, it’s a challenge, I think. It’s more of a juggle than in how you’re going to use those tests widely and in a structured way, and how are you going to deal with the results of those tests? And that’s going to be a big challenge, and we’re, sort of, dealing with that now.
At the moment, we don’t have limitations in our testing capacity, so the PCR testing capacity is quite good, and we get the results pretty early. But that is going to be a big challenge, I think, and I think everybody is struggling with that, and also the international communities and agencies like ECDC and WHO and we haven’t got any good, reliable guidelines in how to use those tests yet. Hopefully, they will appear soon.
Professor David Heymann CBE
Yeah, yeah, and they need to be used in the proper way, and certainly there’s been some modelling, I think, in Asian countries, in Singapore, that shows that if you could do an antigen screening 72 hours beforehand, you could decrease some, but not all of the people who are infected who travel. So, they’re willing to compromise their travel safety by having an antigen test requirement, and then being able to respond to the other disease when it does come in, understanding that some may come in. So there are many different strategies that need to be developed, I think, and you’re right, Thor, it’s a mixed bag, what’s going on right now.
Dr Þórólfur Guðnason
Yeah, it is a mixed bag, and I can tell you also, our experience at the borders, for example, of these more than two or more than 300 people that we have identified at the borders with the virus, about 80% of them were identified at the screening at the borders when they came in. And now we have two screenings, actually, on each individual. They have to be screened at the time when they get into the country, and then they have to go into five days of quarantine, and then they have to have a second screen. And 20% of those we have identified have been identified at the second testing, and they were negative at the first test.
So, in my opinion, it’s that, you know, it’s with a vulnerable society like Iceland, and our hospital system, for example, now is – has reached its capacity, I would say, we have to keep that in mind when we’re discussing about, you know, how freely should we allow people to get into the country, and so forth and so forth? We have the data to identify and say what the risk is.
Emma Ross
Can I just move on to contact tracing quickly? It seems you’ve had a very vigorous contact tracing operation. What’s the setup? Who gets involved? How quickly do you find them? What proportion do you reach? Have you had any struggles with it? It sounded like you involved the police in tracking down contacts. So how does your contact tracing operation work?
Dr Þórólfur Guðnason
Well, I would say it’s a little complicated but, at the same time, a simple system that we use. So, how do we do this? I mean, as soon as a person or individual is identified positive on our PCR testing, then we have our walk-in clinic at the hospital called COVID Clinic. They call this person up right away. They get the results immediately. They call them up or contact them immediately to tell them that they’re positive, and inform them that a Contact Tracing Team will get into contact with them very soon. And the Contact Tracing Team will contact them within minutes or maybe hours, depending on, you know, what the load is, and ask them extensively about, you know, where they’ve been and who they’ve been in contact with. We have also been using this contact tracing app that 50% of the population has downloaded in Iceland. And the app works in the way to help people find out exactly where they have been located for the past 24 hours, and they have to be willing to release those information from their phones.
So, by then, this individual with the Contact Tracing Team – and the Contract Tracing Team consists of healthcare personnel and Police Officers, so it’s very easy to – the police can find – they can find everybody, exactly the name and the personal number that identifies their telephone numbers, and so forth. The police is the best – they are the best in finding people, so they do that. So with this co-operation, it takes not a long time, maybe it takes up to 24 hours to get everybody involved around the cases. Sometimes it takes a little longer and also, it depends on when the positive results appear from the laboratory. Sometimes they come late that night, so we don’t do this contact tracing during the night. We then start all over the next day. And it’s been quite effective, I would say, and it’s well-known, and people don’t seem to mind that this is the police that contact them and I think this has probably been one of the key issues in our handling of this crisis, I would say.
Emma Ross
What, the use of the police? So it sounds like you actually find most of the contacts. I mean, are you trying to call them, and do they pick up the phone, or are they knocking on doors or – because a lot of – in some countries, they’re having trouble actually getting in contact with the contacts. Either they don’t pick up their phone or they give a wrong phone number or…
Dr Þórólfur Guðnason
Yeah.
Emma Ross
So, I guess involving the police would overcome some of those. So how successful is it at actually finding them, and getting them, you know, to engage?
Dr Þórólfur Guðnason
Well, most people are – we find most people by the phone, actually. But we have also had to send Police Officers to their homes, and find them, knock on the doors, and just let them know that the Contact Tracing Team is trying to locate them. We also try to – we also use some other methods of contacting people, for example, people who have been clearly infected at bars, for example. It’s not easy to – how do we get them? How do we get the message to them? And we have used credit card information to identify which person were at a particular bar during a particular night. We’re not looking for what they bought, and how many beers they bought, and how much they drank, really. But who were – who was at the bar? And so we’re using several different methods to find people that’s been very successful. I would say that we have been able to probably track down, well, I can’t say exactly the percentage, but I would think that’s maybe 80/90 – 80 or 90% of the people. That’s my guess, educated guess.
Emma Ross
Wow, wow, and once you contact them, the quarantine, how’s the compliance with the quarantine? And they do – being asked to do it at home? Are they taken off to a quarantine unit?
Dr Þórólfur Guðnason
Well…
Emma Ross
How’s that gone?
Dr Þórólfur Guðnason
Yeah, there are different – several different ways and most people stay in quarantine at home, and we have some thorough guidelines for them, what they can do and what they cannot do and we have a telephone – the answering system that they can ask for information. And we have also a specific housing here in Iceland where people who don’t have a house – housing to stay in quarantine, they can go there and, right now, all – most of the hotels also in Iceland are empty, so we have been using those also. So it’s – it has worked out and – but mostly people work it out themselves.
Regarding the compliance, we don’t know exactly what the compliance is. The police checks, sort of, there’s a random check on people, both in isolation and in quarantine, and we – and also, neighbours and other people, everybody knows about everybody in Iceland. So, if the neighbours know that somebody, John, next door, is in quarantine, and if they see him outdoors, they call us and say, “Well, I’m not sure if he is following the rules, but, on the quarantine.” So we check on them. But we don’t know exactly what the compliance is, and it’s a little bit worrisome that in Norway, for example, they reported that the compliance was only, like, 30%. But we believe and hope that the compliance is – in Iceland is more than that.
Emma Ross
David, how does that contact tracing setup sound to you, quarantine?
Professor David Heymann CBE
So, that’s the ideal, isn’t it, to be able to really use what powers you have to find people, and do it in a transparent way, which is apparently what’s happening. And it also, I guess, depends on the trust of the people in their government, and if they trust the government and understand that the government is using this for public health purposes, then they’ll be willing to really collaborate.
I think many countries have not had the courage to try that approach. Certain countries in Asia have. But I don’t think European countries, other than Iceland, have really had the courage to attempt that approach because, you know, the – it’s a – it’s what Mike Ryan calls a contract between the government and the people, and the government has to be trusted by the people in order to do that. And many times, governments aren’t trusted by all the people, and they can’t do it. So I think, you know, Politicians in many countries are afraid to try anything like that because there isn’t the trust that people need to really do it in a way that won’t cause some type of civil disturbance within the country.
Emma Ross
Yeah, I’m going to go to audience questions in a bit, but I just wanted to come back in, since you mentioned it about trusting the government, and the way you’re communicating with the people. I understand the holy trinity does the press conference, and you have the Politicians sitting in the audience with the Journalists, and you have a dedicated website with a ‘Chat’ function. It seems like you put a lot of focus on transparent communication with the population.
There’s also something I wanted to ask you about your messaging. So, I had a look at your website, and I saw, from your COVID website, that echoed across a lot of your public health messaging is this concept of civil defence, and there’s some other interesting framing. But here’s one I particularly like. It says, “A smile for a while. Leave the hugs and kisses for a better time. Civil defence is in our hands.” And here’s another one for the hand-washing message, “Civil defence is in our hands, or rather washed hands.” Why the framing on civil defence? That’s an interesting appeal. Was that a conscious decision, or how did you end up there, or has that got to do with the police being involved? It’s something I haven’t seen before as a framing.
Dr Þórólfur Guðnason
Well, it’s based on the – what I last told you before about this long-time collaboration between the Civil Protection and the Chief Epidemiologist and the official responses for health crisis, because we know that the public in Iceland trusts the Civil Protection because the Civil Protection is appearing – is the key player in responses to all kinds of natural hazards. Whether it’s storm, or snow, avalanches, earthquakes, or volcanoes, the Civil Protection is number one actually.
So we know that the public trust in the Civil Protection is very good in Iceland, actually. So, that’s why decided that we would use Civil Protection for our promotion of our responses, and sort of, cheering up and encouraging people to continue. So we decided also, and that’s also what we use in other kinds of natural disasters to do a, sort of, daily press conferences, together with the Director of Health, me, and the Civil Protection to just inform about everything that’s going on, all the latest information, so we had nothing to hide in how we interpret the information, and our recommendations. So we did that from day one, actually, on daily press conferences, and I think the conferences now are daily conferences, direct conferences are probably up to, I would say, maybe 140 or 50 from the start of this year. So…
Emma Ross
And you’re still doing daily? Are you still doing daily?
Dr Þórólfur Guðnason
Oh, we’re – now we’re doing it now twice a week, actually, and we are doing it – have some additional conferences if something is happening. So we think that that is very important just to keep the trust, keep the focus on the right information and what’s going on. And I think the public really has liked that and, of course, some people are getting really tired of those conferences, and I can understand that. But that’s why we used – thought that this was the way to get the public working with us. And we admitted the mistakes we did. If we had to change our policy, we did that without hesitation, with new information coming in, and then – and so we have done that throughout, and I think that has enabled us to keep the trust, and hopefully, we can continue on this path, throughout this whole epidemic, whatever, how long it’s going to take.
Emma Ross
Okay, I’m going to go to the first question from the audience, and this is from Brodie Owen from The National, and it’s a question for you, Thor. “Iceland has – is a sparsely populated island. How helpful was that factor in your response? And what is your advice to other European leaders struggling to contain a second wave?”
Dr Þórólfur Guðnason
Well, it’s – I have always avoided to give my opinion on what other countries are doing. It’s really not fair to do that. I think every country, they have their own infrastructure, they have their own setup, they have their own things to deal with, and it’s – so I think one method does not really apply to all countries. But I think that in dealing with this, I think one of the advantages for us was that we tried to deal with the first cases as soon as possible. And in my opinion, if you do it in the way that we do it, you have to do it very early. You have to catch the epidemic in the beginning phase, really. If the epidemic has spread out, and then it’s too late to do it several weeks or months later. It’s going to be very difficult to do. You might, sort of, keep it contained a little bit, but I really doubt the results and we can see that from our experience now with the current wave we’re dealing with. It’s much more difficult now, even in Iceland, with a scarcely populated country like Iceland.
I mean, we have an advantage in Iceland. We have – we are an island, isolated island, and we are scarcely populated, so it’s – we have all the things going for us to take these measures that we have taken. I’m not sure if it’s going to be as easy in other countries to do, unfortunately. But I might be wrong, but I think if you start doing it now, it’s too late, and I’m not sure if it’s going – how effective it’s going to be. Then you probably have to – other countries have to rely more on the general restrictions of lockdowns, and so forth and so forth and, fortunately, we have not had to do that. We have never had a lockdown in Iceland. We have had some restrictions. We haven’t never closed the schools. So, I think we have been able to do that because we responded soon, and we did it focusedly and we did it in a way with the – that’s why we were able to keep things open and going for us.
Emma Ross
And, David, do you see – what do you see of what Iceland has done that could be exported, adopted by other countries, given where other countries are? They’re not, you know, as Thor said, for the countries that didn’t act early or, you know, don’t – aren’t up and running, how much of what’s been described, do you think, could be used in other countries, at this point?
Professor David Heymann CBE
What Thor has been describing is really transparency, and not only transparency, but an agreement between the Political Leaders and the Public Health Leaders as to who is leading the response. And I think that’s been a problem in many countries, and, as a result, those countries that have the difficult discourse between Politicians and Public Health Leaders have had the most difficulty in making a unified approach going forward. I’m thinking of a country like Germany, which has been very transparent. Their Public Health Leader has clearly been the leader in that country, and the Prime Minister many times defers to that Public Health Leader and endorses what the Leader says, and moves ahead with that Leader together and I think that’s a good example of how it can be done.
In other countries, it’s more difficult sometimes. Political Leaders have made some promises, such as there will be a vaccine or there will be something that’s coming in the future, and we don’t need to worry today. Whereas those countries that have really said, “Here’s where we are today. This virus is coming into our country. It will likely remain with us for quite a while, whether we have a vaccine or not. We just have to learn better to live with the virus, as it is coming in now, protecting those people who are at risk, making sure that are deaths are low, and saving lives along the way, while at the same time making sure that life can get back to – as much to normal as it can, while controlling the entry of the virus.”
Emma Ross
And if that isn’t being done up to this point, can other countries adopt that stance at any time now, if they haven’t?
Professor David Heymann CBE
My view would be that they could, yes, but I’ll ask Thor what he thinks because Thor has experience with this as well.
Dr Þórólfur Guðnason
Well, I think it’s going to be difficult. I think that you have to prepare pretty extensively before you do it. I mean, if you’re going to have – be – if you’re going to be successful with it, you have to have a – the public – the people have to know exactly what the game plan is. And just like a football game, I use my quote in football games, I mean, everybody knows exactly what the – what they – and how many players you have, and who’s in the defence, and who’s the striker, and so forth. And then you might change your game plan throughout the game, but people know who is running, who’s playing, and so forth. So you have to prepare, and have to get the public used to this structure and this arrangement. And then, I think, it’s critically important to start as early in possible, and I think, for countries who are not prepared for this, and have not prepared the public for this game, and do it in that way, I think it may be difficult. And if you have a widespread infection in the society already, I think it’s going to be very hard to do, and it’s going to be difficult to show the results of your contact tracing and your quarantine, and so forth and so forth.
Now, we can say that. I mean, we – what we have been doing with our – whenever we put some new measures into play, a new regulation, we always say, “Well, it takes one or two weeks to see the results.” And it has been very accurate. It has taken one or two weeks, whenever we have put a new restriction or new measures. It’s been taking one or two weeks, and we have seen the results from – after one or two weeks. So, I think that has also increased the trust from people that we can say, sort of, beforehand what we are expecting, and then most of the time it’s turned out to be true and not always, of course. But I think this is a type of play that you have to prepare in advance. It’s difficult to do in the middle of the war, actually, but you might try it, and maybe you might be successful with it.
Professor David Heymann CBE
Emma, I might just add that, yes, I think a long-term vision is really what’s important, as you say, Thor, to – for the population to understand after the lockdown, here’s what we plan on doing, or before the lockdown, here’s what we need to be doing. I think complete transparency has been successful in the countries that have used it and having an exit strategy when they lock down, not just letting the population understand that it’s a month or two months, and then what – then not knowing what happens afterwards, even though it’s difficult to say.
Dr Þórólfur Guðnason
Yeah, I agree with that, and I think, for example, now, I mean, we constantly have a new game plan or something new to focus on. I think now what we’re going to do in Iceland, I think, we are trying to express to the people we have three options really for the next few months. It’s either we have to have very strict restrictions in Iceland. That would, sort of, affect the daily life of everybody. We can open up and have everything open, and we know what the results are, so we can point to our results and our studies and what’s going to happen then, and then we can go in between. We can have, sort of, moderate restrictions, and try to keep down the epidemic curve, as much as possible, until we get the vaccine, or if we don’t get the vaccine, then we have to just stick with it longer than that. So, I think that’s the new vision that we have to focus on now because everybody is getting very tired, and everybody’s waiting for some final solution to this whole problem, so we can get our old life back, so to speak.
Emma Ross
Yeah, there’s a question from Hillary Briffa here about “How has Iceland’s engagement at the international level played out? I mean, for example, have you been affected by supply chain competition? Did Iceland co-ordinate with other Nordic leaders in sharing best practices? Has it applied for funding, from international institutions, etc., or have you just, kind of, gone it alone?”
Dr Þórólfur Guðnason
Well, the easiest answer to this is just, no, we have not done that. But, on the other hand, we have, of course, we have extensive co-operation with, for example, within the ECDC, for example. We have extensive co-operation with the other Nordic countries, and I communicate weekly almost with my Chief Epidemiologist in the other countries about what they are doing, and what we are doing. But the strange thing is, throughout this whole pandemic, is that all countries do it their own way, basically. I mean, I don’t know of any country, any two countries that do this or respond to this crisis in the same way. And that’s really interesting, and it’s interesting to me because we have spent a lot of time preparing for things like this. We have been preparing for this within WHO, we have been preparing for this within the ECDC, and we have been preparing for this within the Nordic countries. We have a lot of meetings. We have exchanged information. We have discussed things. We talk about mutual co-operation, and how to help each other out. But when it comes down to the problem, we – everybody stays on their own, basically. That’s my opinion, and that’s my experience right now.
Emma Ross
Okay, and next question upvoted, but I’m going to alter it slightly because I don’t think you have military involvement, do you? Just…?
Dr Þórólfur Guðnason
No, we don’t. We don’t have any military involvement.
Emma Ross
Yes, I’m going to switch the question to ‘law enforcement’ ‘cause I think the same principle applies, and it’s from Afifah Rahman-Shepherd. “Law enforcement involvement in public health response in many contexts does not always work, and can have long-term damage on public health leadership and infrastructure.” So I’ve switched out ‘military’, since this doesn’t apply, but I guess the question is about the acceptability of law enforcement involvement, and the question is, “What is the key to the successful partnership in Iceland between law enforcement and public health that other countries or contexts might be able to learn from?”
Dr Þórólfur Guðnason
Well, I think I partially answered that, I think, earlier. I think the – I mean, the public in Iceland is used to this co-operation between the public health authorities and the Civil Protection for various health hazards. So, we use it all the time, and so, we have not had to have the law enforcement, the extensive law enforcement now. Of course, we have used strong penalties for people not applying to restrictions or isolations and so forth. But that has not been a big issue. So, I think that just reflects the public trust in this, how we deal with it, and how we deal with all the health hazards. So, I think if you are going to have the police involved or the military, I can’t think about the trust in the military. But that’s maybe why I’m not used to the military. But I think you have to prepare for it. I think you have to have the public used to this appearance, used to these people in the frontline dealing with these issues, and have to monitor the trust in those people. That’s how you’re going to be able to do it, and have people comply with your measures.
Emma Ross
Okay, I’m going to circle back to, kind of, move towards wrap-up now and this seems to me, like, a success story of preparation, readiness, I guess, agility in your system, and early action, and a committed following of the science. Pretty much what WHO has been advocating for everybody, all the cornerstones aggressively pursued, and early, without a wholesale lockdown, and without an elderly care home crisis, schools and restaurants open throughout, high level public trust in the authorities. Seems like your people get to socialise with each other. They can travel, go to parties, okay, small ones, but still. You must have faced some challenges. Can you tell me what’s gone not quite so well as you would’ve liked, and what are going to be your main challenges going forward?
Dr Þórólfur Guðnason
Yeah, this is something – this is a good question, actually, and I think if we look back to our preparedness plan, and say, “How well did our preparedness plan work out?” I mean, when we are – were preparing for a crisis like this, we always thought this would not take such a long time. We would just deal with it, and then – and in a short time. But now we’re dealing with it for much longer, so that’s something we did not, sort of, anticipate. We did not prepare for how to ease on this – on your measures. How are you going to do your exit strategies from restrictions? How are you going to do that? And we did not, I would say, and nobody was prepared for that, and there was really not any good guidelines from the – neither the WHO, or ECDC, in my opinion, for that. So we had to, sort of, do it on our own, and every country did it on their own.
And also, what was surprising to me was how much guidelines the public needed. I mean, you put some restrictions, some general measures on, and everybody had to have their own guideline. So left-handed people asked, “Does this apply to me?” Or this company asked, “Does this apply to me? How can I avoid being – how can I be exempt from these restrictions, and so forth?” And it’s – that’s been the biggest strain on our capacity and our resources, I would say, and still is. Every time you put new restrictions on, or if you relieve restrictions, you have the same whole circle up and running again. That’s something we did not anticipate, and we need to look into.
Then we also need to – how are we going to discuss or have a discussion with the Politicians? It’s easy to – when you have the, like, during the first wave, everybody was just focused on the illness. Now, people are much more focused on the consequences, on the restrictions and what you’re doing more than on the consequences from the disease. So, this has taken a lot of time and it’s a big strain on whatever we’re doing. So, keeping the trust of people, keeping the discussion going, is much more time-consuming and difficult, in my opinion, than I anticipated at the beginning, so – and it’s going to be a huge strain, you know, for the next few months. Especially if we don’t get the perfect and ideal vaccine, then we’re going to deal with this much more extensively than we have been doing.
Emma Ross
Yeah, so before I wrap up finally, David, what do you think the take-homes are from all of this, from what we’ve heard about Iceland’s experience and approaches? So much in there, juicy, but what’s your take-home for us?
Professor David Heymann CBE
There are a few things, Emma, that I’d take home. First is that preparedness is really necessary, and to learn from previous experiences, and to apply that, and make sure that when you’re doing exercises to see where the weaknesses are, you plug up the gaps, and make sure those weaknesses are rectified. I think also, transparency is extremely important, as was shown in Iceland, and making rational decisions on what to do with what’s available, including testing or other things going forward. I think the other thing is that one Leader and one trusted face is what’s important. In this case, there were three trusted faces, one in particular, the Medical Epidemiologist, and I think that’s extremely important moving forward. Who do I turn to? Who’s going to give me the right information? Who can I trust? And I think Thor has shown that he’s been trusted in his country, and that’s what’s been very important to leading forward. Persistence on contact tracing, persistence on outbreak investigation, and just basic good epidemiology and good public health have led Iceland to a very important and very exemplary response.
Emma Ross
Yeah, it does seem a little bit of a poster child for all the cornerstones of WHO’s guidance.
Professor David Heymann CBE
Yes.
Emma Ross
So, that’s a good segue actually for the wrap-up. So I’m afraid we’ve – that’s all we had time for today, and I’m sorry, as usual, we couldn’t get to everybody’s questions again. But, Thor, thank you so much for joining us today…
Professor David Heymann CBE
Thank you, Thor.
Emma Ross
…and the really amazing insight into what you’ve been doing in Iceland.
Dr Þórólfur Guðnason
Thank you very much for this.
Emma Ross
So, that’s it, everyone, and thank you all for tuning in, and segueing on from what David said about trusted voice, we will be back next week at the slightly unusual time for us of next Thursday at 2pm, and that is because we’ll be In Conversation with Tony Fauci, which I’m sure will be a slightly different case study to what we’ve heard today, but equally interesting. And so, I guess that’s it, and hopefully see you all next week, and thank you again, Thor, for the time…
Professor David Heymann CBE
Thank you, Thor.
Emma Ross
…and the amazing insight.
Dr Þórólfur Guðnason
My pleasure. Thank you very much.
Emma Ross
Thank you.
