Emma Ross
Good afternoon and thank you for joining us again for the Chatham House COVID-19 webinar series, with our Distinguished Fellow, Professor Heymann, David Heymann. Today, we’re going to be joined by David Nabarro, one of the WHO Director-General Special Envoys on COVID-19. He’s a Doctor who’s worked in more than 50 countries, with broad experience from communities, hospitals and NGOs, to universities, government and the UN system. He is currently Co-Director of the Institute of Global Health Innovation at Imperial College, London, but he seems to be the go-to person for the Special Envoy role in outbreaks and crises for quite a few years now.
We’re going to be talking about where we’re going with the pandemic, what the main issues are at the moment from the global perspective, and what conversations are going on at the highest levels internationally, and what the likely scenario is for how we will be living with this virus for the next few years. So – but before we launch in, I just need to remind everyone of the housekeeping stuff. The briefing is on the record, and you can ask questions throughout the session by writing them into the ‘Q&A’ function on Zoom. Please upvote other people’s questions that you’re keen on as those tend to get more of a chance. So, welcome David and it’s great to have you on with us today and share your pretty unique insights.
David Heymann, I was hoping we could start with you, and let’s start with a bit of an orientation ‘cause it’s been a while since we convened and vaccine rollout is more underway than it was, with a lot of hope out there that we are almost through this, at least in some places in the world, apart from the spectre of the new variants ruining everything. So, from your perspective, David Heymann, where are we with this right now?
Professor David Heymann CBE
Well, Emma, thanks for the question, and, David, thanks for joining us today as well. In the short-term, I think we have to learn to live with this virus. This virus will not go away any time soon and many, many Epidemiologists feel that it will become like influenza, a disease which periodically causes outbreaks and is with populations in somewhere in the world at all times. So, we’re not sure exactly what the final destiny will be, but certainly, at present, it’s a disease that we have to learn to live with.
Now, we’re fortunate, Emma, because we have all of these tools that we’ve talked about in past sessions. We have excellent vaccines now. We have diagnostic tests, which can be used very rapidly and show whether or not there’s infection or not, and we also have some therapeutics coming along, including some exciting work with antibody preparations, which may in fact be useful in people who have been exposed to the infection to prevent them from becoming sick. So, technology has really ramped up rapidly and I expect that, as populations that are more susceptible to serious illness are vaccinated, governments will begin to change their policies to adapt to that situation as well. But the big problem of course, and the most important urgent issue, is getting vaccines to all countries, and I know David will have a lot to say about that as we move forward.
We need to make sure that there is a more equitable distribution of vaccines, so that we can prevent serious illness and death in countries where it’s causing a major problem. At the same time, as I said, I believe governments will change policies and relax their policies a bit after they feel that their populations at risk have been vaccinated, but then there’s the question of long COVID, what does this mean? Can we just let anybody go out and get infected and expect that they’ll be well, even if they’re young? Or in fact, will they need to be wary because of infections that somehow result in some people in long COVID? And long COVID is still not completely understood, whether or not it’s a phenomenon that’s only associated with this virus, we know, for example, with other viral infections, like mononucleosis, like influenza, that after infection, there’s a period when people are extremely fatigued and that can go up to months. So, we don’t know yet, with this virus, how long long COVID will last, the fatigue, and we also know that there’s damage to some organisms – or some organs, rather, by infection that will be long-term.
So, to summarise, Emma, and to go over to David, I think we have to learn to live with this infection, it will be with us a long-term, at least in the immediate future, and at the same time, it will probably remain longer and be periodically causing outbreaks. We can use the tools we have and companies, for example, the private sector are using diagnostic tests, rapid tests to see whether or not they can make their work environments safer and at the same time, other tools can be used to live with this virus in the long-term.
Emma Ross
Thanks, David. Over to you, David, but I was hoping, could you give a little bit more meat to what does it mean to learn to live with it? We are living with it, what does that mean, as far as what we’re not doing now, as well as your take on where you think we are with this and what you’re hearing out there with your connections, ‘cause you’re very much, in your position as one of six, or is it seven, Regional Special Envoys, you have that very specific role to play in strategic advice and high level political engagement, and part of that, I guess, involves getting close to decision-makers as they weight up the decisions they’re facing and advising them? So, I’m really interested to hear what are you hearing? What’s going on out there at the level you’re engaged in? Do you get the sense that decision-makers are thinking they’re on their way out of this, and what’s your take on where we actually are with it?
Dr David Nabarro CBE
Thank you, Emma. Actually, I wanted to say, right at the beginning, what a delight it is to be hosted by you and David Heymann and Chatham House for this event. Do you know, I started work in the World Health Organization in 1999. Before that, I was working with the British Government in the health part of the aid elements in British Government. It used to be called the Department for International Development until quite recently, and I was in at the beginning of that wonderful creation. and David and I met and spent a lot of time talking about communicable diseases. He taught me about re-emerging infections, and I was involved in working with David on the Emerging and Re-emerging Infections Programme at WHO, which was the precursor of the Health Emergencies Programme that’s there now. So, it’s super satisfying to be here. And within that now, let’s focus on this extraordinary thing happening at the moment of a new virus coming into the human race.
It’s a difficult virus because it’s dangerous, yet, at the same time, it’s not easy to take it super-seriously, and let me just start with that because I think it’s necessary to put this in. I mean, this virus is dangerous, because it does kill between one and 10% of the people that it infects. It also causes a long debilitating illness in about one in 20 of the people who get the disease and survive. And containing the virus is particularly difficult because it is highly transmissible, as a droplet-borne respiratory infection, and so the containment effort requires some quite substantial dislocation to human wellbeing. So, there you go, you’ve got a virus that kills some. You’ve got a virus that causes long-term morbidity in quite a lot. But you’ve got a virus that is droplet-borne, highly transmissible, so dealing with it requires behaviour shifts by a very large number of people. And as soon as you’ve got that kind of dynamic in an illness and you are working for public health, inevitably, you are faced with numerous really difficult ethical choices. And I mean, the most important of these is will it be possible to actually persuade large numbers of people to adapt the way they behave, in order to reduce the suffering and risk of death for a relatively small number of people? Oh, and by the way, they happen to be people in my sort of age bracket, over 70, especially if they’ve got other illnesses like diabetes or cardiovascular disease. And often, when I’m thinking about this, Emma, particularly when I’m feeling a bit down and wondering what’s going on, I think you couldn’t have made a much more difficult ethical challenge for humanity than the one we’ve got with this virus right now. And I think that’s why an awful lot of governments are finding the navigation of the pandemic, in its current state, to be really difficult.
Now, my role, I thought maybe I should be clear on that, Emma, it’s to work with Tedros, the Director-General of WHO, and to do about four things. The first is to amplify the guidance that WHO Secretariat, with all its wonderful support systems, is actually offering the world, because we have to remember, WHO has a budget of one third of the United States Centres for Disease Control. WHO has a budget that is about the same as a moderate-sized district hospital in the UK. I mean, this is not a big organisation and yet, at the same time, it’s expected to handle just about any health issue that the members of the United Nations want to give it to do, and it has to be able to deal with an acute situation like COVID, and has to do it really well, because it’s under the spotlight all the time. And so, I think Tedros’s thinking was, I just need some more people who I can trust to give us a little bit of extra amplitude on our guidance.
Part two is, because this is a new virus, and Tedros also asked us to try to interpret the guidance into different settings. The third thing he asked us to do was to accompany decision-makers as they were making really tough ethical decisions about how to deal with this virus. And then the fourth thing was feedback. So, every week, we meet with the senior team from the WHO Secretariat, sometimes with Tedros there, and us six Special Envoys are asked to feedback on what we’re seeing and hearing, and there’s a lot of interest. So, that’s our role, and sometimes I think actually, the WHO needs more people like us because it really does not have the foot soldiers that are necessary to deal with a problem on this scale, nowhere near enough, and I think that we’ve, sort of, added a bit of extra energy.
Now, just a couple of other things. The way in which I believe this particular virus will, sort of, bed down in human society is exactly as David Heymann has suggested and, you know, this will become part of the viral cocktail in which humanity lives. But learning to live with and all that stuff, it’s quite a lot that needs to be unpacked. First of all, we need to think, well, what does living with this virus mean in practice? And, number two, we need to think what risks we might face if we don’t get the relationship right. So, first of all, I mean, I think it’s really, really important to remember this is an infectious disease and how do you deal with infectious diseases? Answer, you find people with the disease, you make certain that they isolate from the moment that they might be infectious, and you keep them isolated until they stop being infectious. You provide treatment, but, again, in an isolated setting, and you find the people with whom your cases have been in contact and, very importantly, you find the contacts and you isolate them as well. And that is the basis of it.
I mean, I was involved in this with the Ebola outbreak in West Africa in 2014/15, and it gets really important to do this case identification and isolation together with the contact tracing and isolation, especially as your numbers get low. And the time that’s so risky in outbreaks, as those of us who worked in outbreaks know, is when the curve showing numbers of cases over time is dropping down nicely, you’ve crossed your plateau and you’re on the descending arm of the curve, you’re nearly at zero, and then the cases start to build up again and it’s that keeping the numbers down that is key to living with the virus, and that means having really well-developed, community level, public health services.
So, for me, living with the virus means having super good public health, picking up the spikes of disease as they occur, and being able to manage them, to suppress them nice and smoothly, and it means engaging with people everywhere because people are the solution to a virus, they’re not the problem, and so if people are the solution, then in a really engaged partnering way, people will get on top of it. So, in the end, rather longwinded, you said, “What does living with this virus mean?” Answer, holding it at bay with good quality public health and keeping it at bay through the excellent and well-organised behaviour of people who know how you stop a virus like this from spreading. On the other hand, if it’s all done through force, through restrictions, and through instructions, and through fines, it’s much harder and that will be the dilemma for societies in the coming weeks and months. Can we do this without creating restrictions and having people chafe against what they feel are restraints on their individual liberty?
Emma Ross
Yes, thank you, David, that last bit really is great to pull us into the next thing I wanted to discuss, which is, so if it’s here to stay for a while, we’re going to have to live with this, when do we move out of crisis mode and, you know, lurching from lockdown, you know struggling with our test and trace, when do we move from being in crisis mentality to it shift – surely, it’s then got to shift into being just a regular disease control programme? Are we – do either of you feel we’re at that point now, or we’re nowhere near that point, and how does that happen? Are we talking about it just becomes another department at WHO, or are we starting up a whole new agency? How do we transition out of this crisis thing back into – okay, I don’t even want to say normal or new normal, or – but shift out of crisis, we can’t stay in crisis forever, especially as you’re both accepting that this is here for the long haul, when do we make this shift and how?
Professor David Heymann CBE
Emma, maybe I’ll start. First of all, to just endorse what David has said, and especially about WHO and its importance. David’s at the very top level, at the political level, I’m at the technical level, at the advisory level in WHO, and I can say that the same is true at the advisory level. WHO has collected the evidence incredibly well and used that evidence to formulate the guidelines and the strategies that David can then promote, as he goes about his work, with the political leaders in countries. So, WHO is not the only act in town, but it’s certainly the act that is doing the most, in the current COVID-19 outbreak, as far as helping countries understand how to deal with the virus.
The advisory group that I Chair actually has made recently a recommendation, and we meet twice-weekly, or once-weekly, depending on what’s necessary, and usually with Mike Ryan and his team. And more recently, we undertook some discussions to really begin to talk about shifting the WHO programme from an emergency programme to an actual programme of control, as David was saying, and there are many tools, as we said, to do that. But, above all, before that can be done, people need to learn how to do their own risk assessment, as they’ve learned for HIV, as they’ve learned for TB, for other infections that have emerged from the animal kingdom into humans, and we’ve learned to live with them, and we’ll learn to live with this one.
What that means is, that governments need to stop this strongarm of trying to keep people locked down, in order to protect hospitals, by getting people vaccinated, by making sure that they have decent programmes, and by doing the contact tracing in the outbreak investigation and containment that’s necessary, moving forward. And at the same time, we have some models, we have Sweden, which attempted to let its people – to give its people the information they felt they needed to do their own risk assessments, and those people – I just looked at the statistics again today for Sweden, and they’ve been able, recently, to keep deaths downs and to keep people doing their own risk assessments. They had some failures at the start, but we can learn from these failures, as well as from the successes of countries, and we see countries in Asia, where risk assessment has been a part of daily life for many people and they’ve learned how to live with this virus quite well, as well.
So, as David said, the population must be at the base of any response, they must understand how to do their own risk assessment, how to protect others and how to protect themselves. And if they know that, when they go to the pubs, outdoors, they’ll stay at a metre’s distance, or they’ll wear a mask when they’re moving between populations in that area. So, these are the things we have to count on, moving forward, in learning to live with this virus, and it may be that in countries that haven’t had the habit of wearing masks when people have infections, they may start to do that, as a courtesy to others, to protect them from their infection. But I know David will have another take on this and I suggest we go over to David now.
Dr David Nabarro CBE
Well, actually, Emma, we’re quite – we’re cut from the same cloth, David Heymann and me, and as well as having the same first name, and I want to do – I want to go further on what David was saying, and I want to tell a bit of a story. I’ve been watching what is happening, particularly in Western Europe, and the narrative is often presented in the following way, your numbers of cases start to spike and then to surge and then you get a big outbreak, and you try to stop it, using case finding and contact tracing and well supervised isolation. But your figures cross the magic threshold of about 150 per 100,000, for instance, ratio, and then you just can’t handle the workload. You haven’t got enough people to do your testing, you can’t bring your testing close to the population, and then, you haven’t got enough facilities to isolate people and make sure that they stay isolated for the requisite time. And so, your surge builds up into one of these explosive outbreaks and people start dying in big numbers, hospitals get full, and so, the natural and correct, in a way, reaction of government is to say, we will stop movement, and, in fact, the stopping movement has been so often presented as ‘lockdown’.
Do you know the origin of the term ‘lockdown’? It was used to describe what you do when you get a jailbreak or something really horrible happening, you just stop people from moving and you usually have quite strong firepower to help you do so. It’s a very, very extreme measure. And yet, when we look at what’s happened in Western Europe, over the last year we have had several instances where numbers came up, they became excessive, lockdown was imposed, numbers came down, as the numbers came down, lockdown is released, numbers go up again, it’s a seesaw.
And the story I wanted to tell you was, I was asked about this and I was asked about whether I believed that the UK should be applying lockdown earlier, this is by a guy called Andrew Neil on Spectator Television, and I said to him something I thought that was totally, totally harmless. I said, “The World Health Organization does not believe that lockdown should be used as the primary means to keep this virus at bay.” Gosh, I got into trouble. Not from WHO, and people like Mike Ryan, who David just mentioned, was really very positive, but I got into trouble from a lot of public health people who said, “You just can’t talk like that, you know, you’ve got to be able to support governments because they’ve got to use lockdown as a major means of controlling this virus.” And I said, “Surely, there’s a middle path.” Surely, what we could have done in Western Europe, over the last few months, while the virus was causing all the trouble last year, was to build up community level capacity to find people with the disease, build up local level capacity to isolate people, build up integrated local organisations, so that we could respond quickly to outbreaks when they occur, and so keep the numbers down below the 100, 150 per 100,000, so that life goes on, despite the threat of this virus.
But I’m really troubled, Emma, because I actually think that some of the basics of public health, community-based public health, that David Heymann has taught for years as a Professor and as a practitioner, just did not enter into the calculations of many government responses in Western Europe, particularly last year. Because I believe that if they had, that it would have been much easier to stop this virus from developing to explosive outbreaks, and it would have been much easier to avoid these incredibly damaging lockdowns that have such a nasty impact on so many aspects of human existence, and that I believe contribute to greater poverty. And I think with half the world in lockdown for several months last year, I’m absolutely certain that many of the gains that we had on the Sustainable Development Goals have been lost. So, that leads me to make the point that keeping the virus at bay does mean having capacity in societies to deal with infection as a base capacity.
It’s the base six of public health, and I kind of don’t understand why it’s proved so hard for European nations to re-establish a basic public health capacity that could have kept this thing at bay. After all, many developing nations, especially the East Asian nations, have used that and continued to use that as the basis for their maintaining society and the economy, despite COVID, but it’s just not yet entered into the fabric of the planning and implementation in many Western European countries.
Now, I want to know from David, is my analysis completely off, in which case I must rethink it, but if it’s correct, then what has gone wrong, in terms of the narrative and its implementation in Western Europe on this issue, and why? Because, in my view, the failure to find the right narrative has had an economic impact of billions of dollars’ worth and countries are going to be paying the price for many years to come.
Professor David Heymann CBE
Thanks, David, yeah, I – you know, it’s a real difficult discussion about Europe and about my own country, the US, as well, because the dialogue has been so difficult between the public health leaders and the political leaders, and I know you and I and many others have spoken behind the scenes with the public health leaders and said, “Why are you responding in the way you do?” And they say, “Because we have to protect our hospitals and we have to decrease mortality,” which they’re good objectives. But the dialogue should have begun, “We need to first stop this transmission that’s going on in communities by getting communities more involved.”
Some countries have set up centralised contact tracing, and this never worked anywhere in the world, and you can ask anyone, how you do contact tracing? You do it by having trust and by having trust between the contact tracer and the person who’s infected, or the persons who need to isolate. When that trust exists, it’s much easier to do the job and it’s much more effective. It can’t be done, as much as we would like to do it, by telephone or by lack of face-to-face contact. It has to be done from the community upwards, not from the centre downwards. And public health leaders in all countries understand that, but the dialogue has been so difficult that they haven’t been able to convince their political leaders that this is the way to move forward. Why? I don’t know.
Some countries have listened very well to their public health leaders, especially, as you said David, in East Asia, where countries have used an outbreak approach from the very beginning. It was Japan that first told us, this does not transmit like influenza, despite what the modellers are saying. It stops off in clusters, before it goes into communities, and you can contain those clusters. But because the modellers didn’t use that approach, they were able to show that this would spread very rapidly, and many countries then just abandoned contact tracing and decided that they would let the outbreak enter into communities because that was the only way it could occur.
At the same time, as you said, when countries unlocked back in June, they unlocked everything at once. The Japanese would never have done that, neither would the Singaporeans or the Hongkongers, or the South Koreans. They only locked down where transmission was occurring and then they unlocked those areas, after they had rectified the situation and if they needed to, they locked them down again, but they didn’t lock down their entire societies. Why European countries and some other countries in the world decided to do that is very difficult for many public health leaders to understand and it was clearly to support a health system that wasn’t robust enough to take care of patients. Asia had learned to strengthen their health systems, they had robust health systems, they had hospitals with appropriate isolation facilities and they were able to deal with the patients and continue with a public health approach.
So, you know, there are many issues that will be shown in the long-term, David, as you know and as I know, but certainly, we’ve seen a remarkable and sometimes question – response to be questioned in many countries that we know very well. Back to you, Emma. Back to you, David.
Dr David Nabarro CBE
Oh sorry, I was going to ask Emma if you would mind if we tried to develop this a bit further with your help.
Emma Ross
No, no, no, absolutely. You mean right now, during this conversation?
Dr David Nabarro CBE
Yeah, I mean, here it goes.
Emma Ross
Yeah, no, and I – well, I was thinking, you know, to what extent is it due, and this is something that David Heymann has said and it’s not, you know, anything drastically new, of the chronic lack of investment in public health, as opposed to medical services. And this whole, you know, poor stepchild business going on, and I don’t know about other countries in Western Europe, but David’s nodding, and I thought maybe you guys could talk about that, is a chronic lack of investment in that or respect for it or there seems to be something there in the poor stepchild being public health as medicine, and I don’t know if there’s something to pick at there.
Dr David Nabarro CBE
Okay, I mean, I’m going to give it a try. You see, the cost associated with getting the narrative wrong is just astronomical, in terms of damage to business, damage to society and damage to people’s livelihoods. It’s almost impossible to work it out, and yet the narrative has been got wrong and the narrative is still wrong, in my view. I mean, it’s a bit difficult being a WHO Envoy when you come to the conclusion that a lot of people, particularly those working in decision-making, haven’t got the narrative right and therefore, they’re likely to make decisions that I don’t agree with.
Number one, we have public health systems in Western Europe. They have been chopped to pieces, of course, and people working in public health, in many countries, from what I pick up, do feel like they are somewhat undervalued and, not surprisingly after all, Western nations have quite steadily shifted the pattern of spending of public money for health, away from keeping populations healthy, which is public health, to treating people when they’re sick, which is curative medicine. And everybody knows that there’s a constant suction of cash away from the healthy money to the sick money, and the only way you stop that is by having governance that says, come on, we’ve got to preserve what’s needed to maintain health, because of the natural pressure to keep spending more on the sick, and that’s fine. But if you, over a period of years, do not actually continue to preserve the public health, then gradually, the health money gets taken away and it goes into the sick pot. But the sick pot is huge, so these bits of money from public health have to get bigger and bigger, because the needs of the sick pot just grow and grow and grow.
So, yeah, public health investment has dropped. But also, last sentence, the recognition of the importance of the healthy side of the public health part has just not been there, and that’s what I cannot understand. Because to me, if I was a Politician, I would see huge political advantage in managing to get a decent amount of money into health preservation, into health maintenance, into health promotion, and I just cannot, for the life of me, understand why the narrative, which is linked to the political economy, has somehow managed to go on shifting cash from public health into curative medicine.
For me, that is really the big challenge. Then, out of that, I go to the next part, which I’ll do after I go back to you, Emma, which is how on earth do we deal with this from now on, because this thing is not finished by any manner of means, over?
Emma Ross
Yeah, and that’s really where I want to go with this, but I want to take a few questions, ‘cause timing-wise, I don’t want to hog everything. But I do want to follow that up with, you know, given the situation we’re in now, what’s the vision or how do we shift again this question of, we can’t stay in crisis mode and you can’t build up – well, I don’t know, can you build up public health capacity, all the stuff you’re saying is necessary, to bring us back into sanity, can that be built overnight, and if it can’t, how do we shift out of crisis and when? That’s – I really want to get back to that and – but I don’t want to leave little time for questions, so I’m going to squeeze in, if I may just interrupt this, but let’s hang onto that, how we get out of crisis mode, because that’s the similar vein of what you’re talking about, with where we are with public health and the narrative, of how do we shift that and we have to do something, otherwise we can’t go round and round in circles with this? Unless we’re going to have a conversation about whether the vaccine really is going to save us, and these vaccines…
Dr David Nabarro CBE
Well, why don’t we park that one.
Emma Ross
Park that one for now.
Dr David Nabarro CBE
Just for now, honestly, that’s…
Emma Ross
I’ll go to audience questions, so – and this is about getting back to normal and it’s – well, there are three that are the most upvoted, but I’ll pick the top one here on my list, and Neil McCloud, “How long before we can travel internationally with the same freedom, we had pre-pandemic?” So…
Professor David Heymann CBE
Maybe I’ll take a try at that. You know, there are many things that are going on right now to see if travel can begin and can begin in a safe way, and there’s talk of immunity passports, of vaccine passports, this is all talk. There are some pilot studies that will begin, when people with a vaccination certificate may be able to get on an aeroplane easier than those with not – without, but that will be an inequitable and unethical solution to the problem.
What needs to be done is that countries have to understand when they feel they have an equal risk with another country and therefore, are willing to open up their travel between those two countries, but in place, they must have a response mechanism, which can detect and respond when a disease or an infection comes in. This was tried, it’s not easy, it was tried in December between Hong Kong and Singapore, and they were all set to open up free travel between the two, and all of a sudden there was an outbreak in one of the two countries, and they stopped their planning.
They’re beginning to do that again. They’re beginning to do discussion in Asia between Australia and New Zealand and others, but then, there’s the issue of forced quarantine afterwards or voluntary quarantine afterwards, and that’s a detriment to travel as well. So, there are many things being tried, and I think that travel will only get back to normal when countries have confidence in each other that they have a lower – an equal level of transmission, a less severe risk of variants coming from one place to another, and a whole series of things that have to be in place.
That’s not a good answer, but I just wanted to say that there are some other things, which will be helping us, as we go along, because, as the population begins to develop immunity, either from infection or from vaccine, there may be a shift in the virulence of this virus in those populations. We don’t know that for sure, but remember, this virus came into a population, which had no experience, no response immunogenetically to the virus. So, we don’t know what will happen, as more and more people become infected, but there may be a change in the way that this virus acts in human populations, moving forward, which will help us in travel and a whole series of other things.
So, for now, nobody can answer when travel will get back to normal, unless David has that answer, which he may have, but I know that IATA is working with 33 different countries, to see what may be useful in making sure that safe travel can occur. But that’s only travel being safe, it’s not what happens when a passenger arrives in a country, which is sovereign and makes its own decisions about what people can do when they land. So, I turn it over to David to give a better answer and maybe the full answer.
Dr David Nabarro CBE
Well, of course, we’re both having to cope with the fact that there are masses of unknowns on this issue. There are unknowns that we know we don’t know, like how long your protection will last for after infection, and there are unknowns that we don’t know about, which is…
Emma Ross
Oh, you’re doing a Dick Cheney here.
Dr David Nabarro CBE
What?
Emma Ross
A Dick Cheney, the known unknowns and the unknown unknowns.
Dr David Nabarro CBE
Okay, I mean, I’ve always found the unknown unknowns one of the best of all because it’s what makes life so interesting, but it’s on this thing it’s a real nuisance, Emma, because you just don’t know when a horrible variant is going to come along that’s capable of evading the protection that’s offered by the five or so vaccines that are being widely used at the moment. We just don’t know. It could suddenly appear tomorrow, or it might not appear for two years, and that’s what biology – makes biology so interesting, that we’re dealing with risk, but we’re also dealing with chance. So, my own view is that we probably will never be able to travel in exactly the way that we used to travel, certainly ten years ago, five years ago.
I think that there will be, as David has said, a lot more thinking about the risk we face through different travel mechanisms, and the risk we face when we arrive at our destination. But what I think might change is the extent to which responsibility for helping us handle risk rests with authorities and to what extent the responsibility is going to be transferred to ourselves. And it’s a bit the theme of this discussion and where I feel that David and I have been talking, but we both are of the opinion that looking ahead it is going to be absolutely essential that humanity will be able to work out how to deal with the risks associated with this virus in exactly or the same way or similar ways as, over time, we’ve been able to work out how we deal with the risks associated with HIV, or with other viruses that have entered into the human race.
Emma Ross
Okay, but that took a long time, I mean, the whole HIV story took quite a few years.
Dr David Nabarro CBE
Yes, and I think it will take – it’ll be quicker on this one, but, I mean, honestly, I don’t think it’s going to happen tomorrow, and, you know, it’s really interesting because on the one hand, you’ve got huge pressure from the tourism industry, which has completely collapsed, which is having massive economic consequences all over the world. Big. I don’t think we realise how bad it is, so you’ve got huge pressure from them and from the airlines and from the ships and from everybody else, the hotel industry, to open up, for heaven’s sake, come on governments, open up, don’t you see what damage is being done to our economies? But then, on the other hand, you’ve got a real recognition that this is one of the most potent ways in which it will be possible not just for the virus to move around, but for the variants to move around. And, I mean, this is something that we’ve just got to learn as humanity to deal with, and I suppose my view, and I’d like to suggest that it may be David’s as well, is that the timing of return to some degree of freedom to move around between communities and nations, will depend on the extent to which the risk calculus is handed more to individuals and communities and is less handled on our behalf by governments. And that is going to be a very tricky thing to get to because governments have not yet worked out in the, sort of, ethical calculus, to what degree they can afford to let health services become a bit overwhelmed. To what degree they can afford to run with lots and lots of long COVID, and if the position of governments is going to be, we want to try to keep the numbers right down, we want to try to keep COVID surges from blocking our hospitals, then there will be a move towards trying to go towards zero COVID, and that will work against any kind of opening up of transport. The opening up of transport requires governments to be able to deal with some degree of threat of surges and spike – of spikes and surges, and I’m not quite sure when we will stabilise on that, but I suspect it’ll be not before the end of this year.
Professor David Heymann CBE
Emma, let me just insert one more unknown, and, you know, it’s – these viruses are very unstable, they mutate, they can also mutate in another way and that spike protein could mutate in such a way that it wouldn’t be able to enter, hook onto a human cell and enter. We don’t know that, but mutations aren’t always for the worst. They’re sometimes for the better, and sometimes – and a mutation could occur that could make this infection less virulent or more virulent in humans, or, as we’ve seen now, more transmissible, or even less transmissible in the future. So, these mutations are random, they occur from selective pressure, from pressure on the virus, and it could be that those mutations, at some point in time, might become – make a less virulent virus.
We have four endemic human coronaviruses. Those viruses entered human populations from the animal kingdom at some time in the past and there’s a hypothesis that at least one of them may emerge – may have emerged with a major global pandemic that was very serious and then the virus became endemic after a time. We just don’t know what this virus will do in the future. So, we can’t be all pessimistic, we have to also talk about reality and maybe, in some instances, we may see a virus which could change and become a different virus that’s more easy to live with. But, as David says, that’s – right now, the future is very difficult and it will depend on how well we, as individuals, are able to do our own risk assessment and protect ourselves and protect others. We have to get governments back into their rightful position of facilitating that by good policies, but not forcing it by lockdowns.
Emma Ross
Okay, I’m going to tack on another audience question before I go back ‘cause I don’t want to end without talking about how do we get out of crisis mode and whether that needs to be directed, co-ordinated on an international level, or will it just happen organically, or whatever? But before we get to that, this is related, another question about, you know, the persistence of some of these measures, as we go on, from T D Button, it’s an upvoted question, “It sounds as though it would be very difficult to return to the way society functioned before the pandemic. Will we need to maintain social distancing indefinitely, or do you foresee a threshold below which social distancing can be dropped?” You know, and I guess that we could tack on any of these mask-wearing, you know, social distancing, bubbles or whatever, do – yeah, so do we see this as indefinite, or patchy, or where do we see this going? What have we got to look forward to on this?
Dr David Nabarro CBE
David, are you going to go, or me?
Professor David Heymann CBE
Go ahead.
Dr David Nabarro CBE
Thank you. Emma, if there’s a lot of virus around, you’ve got to maintain physical distancing, you’ve got to do masking, unless you’re absolutely convinced that you have no capacity to carry the virus, because otherwise, if you don’t take these precautions, you’re a liability. So, a lot of this depends on just how much virus is there in your community. If there’s not much virus in your community, then it’s going to be possible to be less worried about physical distancing and less worried about masking. It’s very dependent on the context. And I want to add one other feature, it’s also dependant on the individual. If I am immunocompromised or if I’ve got bad diabetes, I don’t want to get this virus and unless I’m absolutely certain that my immune status is going to prevent me from getting this virus, I’m going to be super cautious. So, I view it as two things. One, what’s your own risk? If you’re high risk, you probably will be more likely to physical distance and mask wear and shielding.
Emma Ross
And not travel.
Dr David Nabarro CBE
Yeah, yeah, whereas if you are fitter and younger, it’ll be less of a problem. So, that means you’ve got to think about the individual, you’ve got to think about the context, how much virus there is, and if the individual is basically strong and not at risk and also is not worried about being a vector for the virus, then obviously, they could be less needing to do these practices. And if the virus incidence in the community is very low, then my own view is that there will be a reduction in the need for people to do these practices, but they will need to be ready to reintroduce the practices if the context shifts. And I think we’re going to be much more dynamic than perhaps it has been in the past.
I’ve got one last comment, which is, I wanted to express to you, Emma, I’ve been really impressed by the ability of humanity to actually tolerate the wearing of face masks and to put into practice physical distancing in different settings. The only problem for me is that to people who are really poor often don’t have the luxury of being able either to mask up or to physical distance in their work or in their domestic settings, and that’s what really concerns me. It’s not so much whether or not there will be a continuing need for A, B or C, but it’s whether or not all of the different strata of society will be in a position where they can practice A, B or C, ‘cause my constant worry is that actually, this disease is one of those that really hits poor people so much harder than it hits people who are privileged, and that’s the part that continues to nag away in my head, as we’re looking forward.
Emma Ross
Again, I’d love to go more into that, but unfortunately, I’ve been given my five-minute warning, that I’ve got to ramp down, and I’m not going to let you guys go before we do a little bit of this, how do we get out of crisis mode and does this need to be internationally co-ordinated, we all go as a world out of crisis, or it just happens piecemeal, organically, are we not ready, are we ready? I mean, how much longer do we go in crisis mode, who decides when we’re not, and where do you see that going?
Professor David Heymann CBE
Maybe I’ll start, Emma. I just want to come back to this last point that David raised, which is very important, the question that was asked was, have things changed? The question really should be, have I changed? Because I think we all have changed and we all understand that infections transmit very easily through the nose, through the mouth, and we need to pay attention in the future to make sure that we decrease our own risk to anything that might occur, not just to SARS, coronavirus too. So, I think the question should be transformed into, have I changed in any way? And I think most of us have changed and most of us in the future will be more careful in where we – how we travel, and where we go, enclosed spaces, a whole series of things moving forward.
But to come back to the question of how to get out of the current situation, I think there’s no question that we have to get out of emergency mode and into control mode, and that means using the tools that we have to the best advantage that we can, and it means equitable distribution of these tools throughout the world, and, as I said earlier, and as I continue to say, once governments feel that they’ve protected their people by decreasing mortality and the burden on their hospital systems, they will begin to use these other tools in a more rational way and will in fact be able to lead the country out of crisis. Will this be a global effort? Clearly, it won’t be, the world hasn’t been willing to work together at present and I doubt that they will be willing to work together on this in the future, although David may want to say a word about the new treaty that’s been proposed by the political leaders in 29 different countries, because that’s a start to making sure that the next time there will be better solidarity. So, that’s my two cents, moving forward, and over to David to finalise.
Emma Ross
Thanks, David. David, over to you.
Dr David Nabarro CBE
Thanks, Emma, thanks, David H. Why do we have a discipline called public health? Answer, in my view, because there’s abundant evidence that people who have wealth and privilege are able to ensure that they are free of disease much more easily than people who have very limited means and very limited agency over their lives. And so, because of that huge gap that we see expressed in – when we analyse social determinants of health, because of that, the discipline of public health has emerged in order to try to equalise some of the risk and reduce that rather pernicious influence of wealth and privilege over whether or not you are staying healthy. So, of course, there’s a constant political choice about how to navigate out of COVID.
Route A: route A is what I call the bubble of privileged protection. Your country is one of the wealthiest countries in the world. You have enough resources to be able to place not only orders for enough vaccine to protect your population, you believe, but also, you can be investing in new generation vaccines that will deal with possible mutants and you will also have a significant investment in high efficacy, care regimes, that use the kind of monoclonals and so on, that we were talking about earlier. And, yeah, those who can afford it will be fine.
But what happens to the rest? Do they just simply say we will only travel to places which have a similar bubble of privileged protection? We will only travel in conveyances that guarantee that the others in there are worthy of being in our bubble of privileged protection? And so, then, do we move to a world, which is fundamentally in two classes: the privileged protection bubble people and the rest, with really quite a lot of hassling for people to get into the bubble of privileged protection, so they demand access to the best possible vaccines that they can find. They demand to be protected from others who they feel might be carrying the disease, and so you move from the bubble of privileged protection to a wall, to restrictions, and that then means that you end up with really strong border controls that are linked to your risk of having this particular disease.
It’s not the first time that humanity has been faced with a challenge of do you want to deal with a potential disease threat by walling yourself off or do you want to deal with a potential disease threat by going down the other path, which is saying we’ve got enough wealth and skills and tools in our world to be able to enable everybody to come towards the state of protection? And it would just require a fairly high level of organisation between nations to make that work, but that was the whole sentiment behind the World Health Organization, that was the whole sentiment behind smallpox eradication, the whole sentiment behind the efforts to deal with other communicable diseases. You are trying all the time to say it’s not right to go on with a world where there’s just a few people who do really well and the rest have to cope with the crumbs, and that is what is really strange to me, that there hasn’t been an absolute clamour, from all the world leaders saying, why don’t we move towards a global programme on COVID, where we do close tracking of the virus and the variants and how those variants are emerging?
We continue to do synchronised research into rapid diagnostics, with a particular focus on those that don’t need electricity, and on treatments that are not very expensive, that can actually save the lives of people in poor countries. And why not have a global system of trying to understand where the vaccines are going and move away from the notion that it’s okay for countries to go and bid higher to get the vaccines off the companies, so that that means there’s less and less and less to go through this wonderful thing called COVAX. Where is the political will to do, after all, what, over the last 45 years, certainly since I started being a professional, was the style, the benchmark of public health, which is equity. And I know David agrees with me, but he may not say it in these words, but that is why some kind of global initiative is necessary, Emma, if the world is going to come out of this, it requires a concerted effort. But if you don’t care that perhaps 80% of the world continues with high COVID risk, and all sorts of threats for the next two years and that 20% of the world is protected in the bubble of privileged protection, if you don’t care about that, then of course you don’t worry about whether there’s a global programme. All you do is focus on those who are closest to you and perhaps those who elected you, into your position of power.
Emma Ross
Wow, okay. Well, that paints a picture of two very different options that we have. We seem to be on the threshold, still chance to make that choice, and I guess we’ll be watching closely at Chatham House what happens with this whole idea of pandemic treaty and we’re following this very carefully. David Heymann, before I sign off and thank David Nabarro for joining us, do you want a quick parting shot? I feel, kind of, like, blown over by what David Nabarro’s last bit, very powerful stuff, I think.
Professor David Heymann CBE
No, I think David’s said it much more elegantly than I can say it. But what I would say is that in the past we’ve looked at health security as being stopped disease at borders. Now it really has three components that we have to get our political leaders to understand. We need healthy populations, and they need access to good health. They need to be, because we’ve seen that this virus and future viruses may in fact select out for those who have poor health, who have comorbidities who could have been prevented. We have to also make sure that we have robust health systems, which can take care of people when they become sick, and we need good public health, as David has constantly talked about. We need to make sure that these three things are working together, not independently, if we want to have the security in the future that will prevent infections such as this from doing such damage. And, finally, we need to work together globally, we need to find that way of working together globally, whether it’s through a new treaty or something else, and that we will see as time goes on. So, I’d like to thank David for his elegant presentations and discussions. Only David can say things so well, so thank you very much, David, and thanks, Emma.
Emma Ross
Yes, so, thank you both and thank you, David Nabarro, we’ve been very naughty to run over by six minutes, so thank you everyone for sticking with us, and thank you David Nabarro for hanging in there and I will wrap up now. And we’ll be seeing you, David Heymann and I will be seeing you in two weeks with Helen Rees and Ilona Kickbusch, talking about soft power, vaccine diplomacy, access. Have a great rest of the day.
