Emma Ross
Good morning and thank you for joining us for the kick-off session of the Autumn run of our COVID-19 series, with Chatham House Distinguished Fellow, Professor David Heymann. For those of you who are coming back after following our Spring-Summer run, you’ll notice a slight reframing for the Autumn-Winter. Far from disappearing in the warmer months, this virus has ben very much with us throughout the Northern Hemisphere’s summer. We just passed the grim milestone of one million deaths now, and we’re still learning morning about it and how best to respond to it all the time, and we feel very fortunate to be returning with Dr Mike Ryan.
Back in February, when David and I first started doing these sessions, I said that nobody on the planet knows more about how to contain a Coronavirus outbreak than David. If there is anybody who can challenge that now, it’s Mike. He has huge experience as a firefighter in the field, with a variety of outbreaks all over the world. Before he moved into management, he was the one you called, if you needed to bring in the big guns to deal with a particularly nasty or tricky epidemic. And as Executive Director of the Health Emergencies Programme at the World Health Organization, he’s running the nerve centre of the international public health response to this pandemic, where he and his team keep tabs on what’s happening everywhere and corral the world’s leading experts from institutions across the globe to generate, share, and evaluate the evidence on all the key aspects of the pandemic, and give the rest of us guidance. So, a big welcome to Mike. It’s great to have him here, and I’m not sure whether he is here yet, he’s got back-to-back meetings.
Dr Mike Ryan
I’m here.
Emma Ross
Ah, here’s here, welcome, Mike. I know you’ve got a lot on at the moment, so we’re really thankful. I’m sure you ran down the corridor to get here, so…
Dr Mike Ryan
Yeah.
Emma Ross
…our appreciation for that. Before we start, actually, I’d like to just cover the housekeeping stuff. This briefing is on the record and questions can be submitted using the ‘Q&A’ function on Zoom. Upvoted questions are more likely to be selected, so if you have a question that’s similar to one that’s already in the Q&A, please upvote it, your chances will be better. Okay, we’re going to start now, Mike, if you’re ready. I thought to start off with, I wanted to ask you how you would characterise where we are with the pandemic right now, and maybe catch us up on what’s been happening, with the course of the pandemic over the summer, and what we’re facing going forward.
Dr Mike Ryan
Great, thanks, Emma, and hi again, David. It’s less than 12 hours since we last spoke. The – it’s great to be with you all and great to see you again, Emma, and thank you for preparing this and all the work you’ve done on these seminars to keep people up-to-date and generate these kinds of dialogues and discussions, they’re really, really important that we have these opportunities to speak across different professions, in order to look at where we are in this pandemic.
I won’t bore you with a big, long presentation. I think everyone’s seen the numbers evolve over the last number of months. The pandemic obviously continues to evolve, and if you look at it at a global level, it almost looks like a flattening, you know, that the amount of time it takes us to generate the next million has flattened, over the last number of months, but that belies a lot of underlying trends. If you see the number of cases reported from Africa or reported from the Western Pacific have dropped off, whereas now we’re seeing this rather worrying rise of cases being reported in the European region. So, what you’re seeing within what looks like a stable number, I mean, the, the pandemic was growing very substantially every week until maybe two months ago and, as I said, has flattened off. But that, in a sense, represents a kind of a transition, I think. We’re in a phase of transitioning into those Northern Hemisphere winter. Over the summer we saw the numbers drop in the Northern Hemisphere significantly.
You can argue whether that was the impact of lockdowns, the impact of surveillance, or the impact of people being further away from each other and the, just the impact of people not mixing as much. But now we’re heading into a winter season, in which people are going back indoors, in which the numbers are rising significantly in some countries, and where the ability of public health systems to test, to track, to trace, and to use epidemiologic methods to track and suppress this pandemic, are questionable. And at the same time, the spectre of countries reverting to lockdowns, as a more general tool, are really on the horizon. And I suppose, something myself and David have discussed in-depth, you know, how do we avoid, at this stage, sort of lurching back to a very, very blunt instrument of widespread lockdowns, and can that be avoided, and what do we need to do, from a public health and a social and behavioural point of view, to avoid that reality? And do we need to do it now, rather than investing all of our hopes in a vaccine that may or may not come or may or may not have the necessary effectiveness?
So, I’m giving you a very general sense, Emma, ‘cause I’d really like your participants to have this discussion because this is a discussion we’re actively happening and, as I’ve said many times, there are no correct answers to these questions. There are choices, and there are trade-offs, and there’s risk-benefits to each and every one of these choices we need to make in the coming months. Over to you.
Emma Ross
Thanks, Mike. David, what’s your sense of where we are now, and what we’re facing at the moment?
Professor David Heymann CBE
Thanks, Emma, and thanks, Mike, and before I start, I just need to correct you, Emma. Mike is the undisputable leader in coronavirus, and has more knowledge than any of us, as to how to deal with this outbreak. So, Mike is very modest, but in fact, it’s a truism that he is the world’s expert.
Dr Mike Ryan
Yes, Obi-Wan.
Professor David Heymann CBE
So, anyway, what Mike has said is right. People, in many countries, are living with the hope that the virus can be suppressed until there is a vaccine that will prevent infection, or a therapeutic that will cure infection or modify its outcome. So, people are waiting for this, and while they’re waiting, there are many things that we can do now with the tools we have available. We have an excellent array of diagnostic tests, that can help us in our contact tracing and understanding where transmission is occurring, so that that can be altered and stopped. And we have many diagnostic tests that can be used to look at what’s going on in communities, in families of schoolchildren, and a whole array of areas, where we need to understand how we can decrease transmission. Because, at present, we need to live with the pandemic with what we have available. And we can do a good job in doing, in living with this pandemic, as has been shown in Asian countries where they’ve relentlessly continued to do contact tracing forward, to isolate patients and keep them from spreading infection into the community, decreasing community transmission, and a trace backwards, understanding where outbreaks are seeded and what needs to be shut down and revised before it can be reopened. So, as Mike said, no more blunt shutdowns are necessary, what’s necessary is an epidemiological sound – epidemiologically sound approach, understanding where transmission’s occurring and how to stop it.
Emma Ross
Okay, thank you for that, but I wanted to pick up on, regarding that, something Mike said, which is the ability to test, isolate, contact trace, etc., those proven public health measures, is questionable at the moment. And that leads me to ask about lockdowns, and Mike, why are we in so many places back at this last resort option of lockdowns at this point? I mean, when Hubei province locked down, we were told that bought us time to get ready. Then we had the lockdowns in several countries. And, by the way, correct me if I’m wrong, but I don’t remember that WHO ever had lockdowns as one of its recommendations for how to respond to this. Anyway, the promise was that it took the pressure off the health system and bought more time to get systems in place, but in a lot of places here we are again, already back in lockdown or staring down the prospect of a lockdown and it seems a bit, tad chaotic, I mean, what’s going on here?
Dr Mike Ryan
And good question, Emma. I think we need to look at lockdowns as the most extreme form of physical and social distancing that you can implement, ‘cause essentially, the lockdowns aren’t there to lock down. The purpose of the lockdowns, as were implemented, was to take – when you have many countries were faced with widespread community transmission, they didn’t know who had the infection and who hadn’t, so they only option, in effect, that people felt was put people at home, right? You do take the risk of transmission in the family setting, but what you would do is take the heat out of the pandemic by reducing that mixing of the population that was driving high levels of transmission. So, in that sense, a really blunt instrument, and one without a whole lot of precision. And if you look at what was done in China, the big lockdown happened in Wuhan, and then, a lot of the measures that were in place outside that in other provinces and other countries like South Korea and others, was to go for an epidemiologically-based approach, and really try and understand the chains of transmission, in other words, not to have to revert.
I mean, the idea of – if we go back to first principles, what you want to do, in any situation, and we all know this going back to the days of tuberculosis and others, the principle was to isolate or quarantine the infected individual away from the rest of the population, and that had dire consequences. Many people on this call will have parents or grandparents, or others certainly coming from the Irish experience, where people were, in a sense, taken away and put in sanatoria, because we wanted to remove tuberculosis-infected individuals from the rest of the population. We didn’t lockdown. We identified the people with TB by mass x-ray screening. We did diagnosis and then we isolated those individuals, we treated those individuals, and we were able to contain TB, not just by treating individuals, and the main control of tuberculosis came from the capacity to take infected individuals from the population and treat them properly, but also, so they were in a situation where they wouldn’t infect others. That was the principle.
If we take this situation, we’ve seen the same with SARS, Ebola, and other diseases. The difficulty in this situation, and certainly at the beginning, was the disease had energy, there was a high force of infection and a lot of community transmission. And countries, to an extent, lost the capacity to see where the virus was, and in a sense, in a logical way, decided we need to extremely distance everyone. We can’t separate people with the virus from the population ‘cause we don’t know who has the virus, so the only thing we can do is separate everyone from everyone else, and that gives you time, the breathing space. But what you need to do when you’re doing that is say, okay, can’t keep this up forever.
Now how are we going to move on, what’s the next phase? And the next phase from that should be, how do we identify those who are infected, and how do we ensure that they will not continue the chains of transmission? And that requires a very deep partnership between a strong public health authority that can do the surveillance, and a very, very empowered and participatory community effort to comply with and participate in that process. And some countries have got that very right, some countries have not got that so right. And I think rather than look back and say who got it right, who got it wrong, I think we need to look at what are the positive lessons, because I think David said it, a number of countries have demonstrated doing slightly different things, not all at the same time, that you can contain and suppress transmission of this virus effectively, to a point where you can continue with normal societal activities.
The question is, have we distilled enough knowledge from the last nine months to know exactly what those things are, and I would say, going back to your initial question on test and trace, the central pillar of that remains, your capacity to identify cases, test suspect cases, isolate those positive cases, identify their contacts, and ensure that those quaran – those contacts are quarantined or tested as necessary. It is still the central pillar, and I do believe that not all countries have reached the point where they can do that effectively, and now we’re getting back to the situation where we’re starting to see wider-spread community transmission, and losing sight of the virus again. And it’s not the promotion of public health surveillance, my biggest fear is that we’re losing sight of the enemy, in that sense, by not having the surveillance systems in place, and where you cannot see where your enemy is, your responses can only be blind. And I think that’s the issue, we do not have the eyes to see exactly where this virus is, in some countries, and without that, these blunt type of measures are – and I do agree, WHO has never advised lockdowns.
What we’ve advised is a comprehensive strategy, the surveillance, the treatments and protection of highly-vulnerable people and severe cases, and appropriate mitigation, using social distancing as a measure to reduce chains of transmission. What countries ended up doing was taking a very extreme view of that, and in many cases, totally justified, given the situations that we’re in, in having to lockdown all of society, in order to stop transmission. And it did, to a great extent, but it’s not a sustainable solution on this planet, and I don’t believe anyone thinks that lockdowns are a sustainable way of dealing with this infectious threat.
Sorry, I’m rabbiting on as usual, Emma, but just wanted to focus in on your point.
Emma Ross
Okay, I wanted to dig a little deeper on isolating, identifying who’s infected and isolating. Going forward, we’re not going to discuss what was done up ‘til now, but going forward for a sustainable, is there an argument for plucking cases out of the community, instead of saying stay at home and isolate, or stay at home and quarantine? Why can we not go back to basics, and remove them from the community? Because I have, even in my personal connections, I have people who know in families where there’s a suspected case and – but they’re not willing to even do the separation within the home. So, why not pluck out the cases from the community, put them in isolation [audio cuts out – 18:46] facilities?
Dr Mike Ryan
Maybe David can take some of – I think this is very, very culturally specific. It’s very specific to what is the social contract between any government and its community, and therefore, there are situations in which that type of measure will be seen as entirely coercive and entirely unacceptable, from a population and a social perspective, right? So, I think what we need to look at, and what we’re trying to achieve, is that infected individuals do not infect another person. So, if the policy is to have people isolated at home, then how are we supporting that isolation at home? How is that individual able to be at home and not infect somebody else? If they live in a one-roomed apartment, that’s impossible. So, how – what is the supports that are in place, if you’re going to have the policy then you need to have the supports in place.
In places like China, they tried the home isolation thing in the beginning. They even tried having contacts at home, and after a number of days or weeks, they actually shifted to the policy of providing separate accommodation, not only for cases, but for contacts, ‘cause they were struggling to contain transmission, even with these home-based isolation measures. And that’s happened in other countries. In other countries it’s worked, and in other countries they’ve managed to do home isolation quite successfully with the proper supports in place. So, I think any of these systems is workable, number one, if it is culturally acceptable and well-explained, and if the community are supportive. Secondly, even if that is the case, it has to be very heavily supported, in terms of resources, and in terms of the social and economic and life support that’s needed to do that, and if those two things are in place, you can do it that way.
So, I think, Emma, yes, we need to be very careful here that we don’t end up being misrepresented as wanting to drag people out of their homes and throw them in an effective prison, in order to protect the rest of the community. You know, the principle here is to prevent an infected individual transmitting to another individual, and there are multiple ways to achieve that. And it is a matter of policy, and it is a matter of the social contract, and it is a matter of the resources and the agility and the capacity of a given government, to both design, explain, and sustainably implement a policy and a strategy for a prolonged period of time, with the buy-in of the community. And I think that’s been the problem that many communities have, they feel they’re being confused, they’re getting different information every day, it’s changing every minute, what are we supposed to do? So, I think we’re in a problem now, in that communities are getting frustrated, I see it.
I was on an interview last night on Irish radio, and you could feel the frustration coming around the perception of people just getting tired, just – I don’t know what the word is, David or Emma, not confused, but just genuine, and there is a word I could use, but then it wouldn’t be broadcastable, right? But people are getting peed off with this idea of what’s happening to them, what’s happening to their lives, what’s happening to their communities. And we need absolute clarity from governments on what their plan is, over the next six months, and we at WHO, cannot pre-specify the plan because we recognise that every country is different, even within a country, at a subnational level, things are different and, therefore, you cannot pre-specify exactly what each country should do. Each country elects its government, its government is there to support its citizens, and it’s important that governments, with the mandate of their citizens, design strategies aimed at supporting and protecting the lives of their citizens. That is their job, and that is their mandate and the question is, who’s going to step up and make that happen?
Emma Ross
David, I wanted to ask you, can you give us some examples of how you might support people to isolate at home, or to do this from a home-based situation, in countries where it’s not socially acceptable to remove them from the population, what does that mean supporting them, what?
Professor David Heymann CBE
Yeah, well, let me pick up on what Mike said. It’s clear, in all outbreaks, that people must be engaged from the start and understand how to protect themselves and protect others, if there’s going to be a successful response. We’ve seen that in countries where populations are getting clear communication from one public health – trusted public health leader, the outbreak has been easier to deal with than in countries where there are changing messages from different people on a continued basis. And Mike is absolutely right that there needs to be clear communication, and populations must be engaged at the very bottom of the response to this outbreak. And when populations understand they do perform, you know, communities are where actions begin, and community engagement is of utmost importance.
Having said that, what are some of the support mechanisms that can be used? Well, clearly, what can be used is neighbours helping neighbours, and that’s always been a way, in past history and in present history, where things can work out for the best. When neighbours understand that they need to help people who are being isolated, they may even need to put up – or other family members put people who are being exposed because they’re in the situation where they can’t self-isolate from patient – people who are infected or possibly infected. There are many ways that can be done, and to prescribe them from the top would be wrong. They have to develop within the community, from the community leaders who know what their community can accept and can do best. And so, if there were one lesson from this outbreak, it is that central control is not the way to control this outbreak. It has to come from the bottom up and I think Mike would agree with that, that he’s already said it, that communities and populations must be at the base of this response. Mike?
Dr Mike Ryan
No, I think that’s right, I think you need a plan, you need national planning ‘cause the government has to support the response. So, you need a national plan, but you need local implementation and adaptation. So, the issue is, you know, plan at that national or local level, but implement as close as possible to communities as you can and support those communities. It’s a partnership. Because if a government doesn’t have a plan, there won’t be the tests available. If a government doesn’t have a plan, there won’t be the Intensive Care beds. Communities can’t magic up testing and they can’t magic up Intensive Care beds. But communities can do a lot of magic, in terms of the way they support each other through a crisis, and we haven’t, and maybe in the wealthy North and West we’ve forgotten how to leverage the power of community, and we see the community as an obstacle to implementation, the community as the resistant ones, not the community as the central success, as the actual main pillar of your success. And I think we’ve learnt that, you and I, David, in the field, in Ebola and other outbreaks, until that moment where you recognise that the path between your situation and successfully containing an epidemic is ultimately and primarily dependent on the communities’ acceptance and participation in that process. And we saw the same, too, with HIV, in empowering people living with HIV, and empowering people to know their HIV status, in giving people who are victims of the disease control over their destiny and not just become beneficiaries of someone else’s largesse. But actually, put responsibility and resources into the communities who are experiencing the problem, and trust that they can find solutions, and I think this is something maybe that we’ve – that the North and the West and, sort of, in those euphemistic terms, have lost.
We’ve also quite frankly lost our muscle memory when it comes to basic public health intervention. The old adage of Field Epidemiologists and well-trained public health practitioners and others out in communities being able to do surveillance, and do contact tracing, and supervise and expand the workforce quickly, you know, we’ve done that, David, in the field in many diseases, where you’ve had to go to the field and effectively build a workforce while you respond to the outbreak. And being able to do that quickly and being able to have really experienced people who can make that happen, and I do think we’ve, in a sense, and I say that, I’m sure I’ll be challenged, but I think over the last ten or 20 years, public health practice has become more policy-oriented and the practical application of public health practice at community level, and it’s difficult for systems to adapt. And I do think that we have lessens to learn, both in terms of how we set up and how we resource public health, and how we empower communities to deal with these threats that are just coming over and over and over again. And I think that aside from what we need to do in the next six months, we have some long-term lessons to learn here, about how we plan and implement health security for our communities.
Emma Ross
Have there been any countries that have managed to magic up and respond and react quickly, even if they weren’t prepared before this came along? Can you give me some examples of any countries that got on it and got this organised after the pandemic came, and were able to get the systems in place? Has anyone been able to do it?
Dr Mike Ryan
There are lots of very good examples all over the world. I think the difficulty in comparing countries is, everyone got the disease at a different time. Some countries were, you know, had fully established transmission before they knew what was happening. So, the issue is not to look at perfection, but look at reaction, when the problem was apparent. So, you know, Italy got caught behind the curve, had a very difficult time. But then, when you see how it engaged its community to participate in the response, and the levels of compliance with social and public health measures, was amazing, given the way most of my Italian friends see self – the idea of self-determination and the right to be yourself, I was amazed at how well Italy managed to leverage a community-wide response to that awful situation they were facing. So, in each and every country you’ll see examples like that.
I think Germany is – and again, I’m not giving examples to say anyone was perfect, nobody has been perfect, including ourselves, that’s for sure. I mean, Germany, as a federal state, faced many of the same issues faced by other big federal nations, in that public health law in the country is administered at the local, sort of, state or province level. Integrating that into a national response, with different implementation, was a struggle, but what Germany did as well, was went out and trained and hired a lot of contact tracers. It really focused on its capacity to track and trace and test and that’s given it a kind of an advantage right the way through the response. And even though numbers may rise and fall, and are rising again in Germany, they have a system that’s very capable of knowing where the virus is at any one time, and have a good strong system in place for surveillance.
But if you go further afield, you look at somewhere like Thailand and other countries, Vietnam and others, where they’ve invested quite a bit over the years in community-based surveillance, and community-based response to epidemics, they have, sort of, taken this whole thing in their stride, and it’s kind of, nothing to see here, and let’s move on, this is just another thing we’ve had to deal with. I think you’ll see South Korea, when it had its problem in the religious community way back a number of months ago, I remember looking at that situation and saying, I wonder if, you know, in a sense, South Korea can hold the curve here? ‘Cause they were really embattled, they had a lot of transmission at community level, but it was focused on one area, and they could have stood back and put their hands up in the air and said, “Look, it’s community transmission, we’ve got to lock down everything.” They didn’t, they stuck with the task of continuing to stick with that public health principle and community dialogue and they managed to get it under control. They didn’t flinch, when it came to sticking with a comprehensive strategy.
Equally in Japan, Japan has done things and, again, no country is perfect in this. But the one thing I would admire about Japan’s approach is they really went after the clusters. They really tried to understand what was happening dynamically, within the clusters that were occurring, as a way of learning lessons. And, you know, the three ‘C’s that have come out, the way in which they’ve talked about these clo – a lot of what we’ve learned about these closed situations around the world, Japanese were very much the first to document many of those, sort of, superspreading events, those particular contexts in which transmission was being amplified. And that came from really good shoe leather epidemiology, I think that they were calling their teams ‘the cluster-busters’, you know? I thought it was a great name. But, again, that came back to that, sort of, really forensic investigation of clusters, so as to understand, from the perspective of Japan, what was driving transmission, and understanding the specific risk behaviours and risk environments in which their epidemic was being amplified. And in understanding that, then being able to take targeted measures to address that. So that’s a good example of reacting.
I think Singapore did extremely well at the beginning, but basically had a problem because it didn’t recognise the threat to its migrant communities, especially young migrant men, living in these huge dormitories, ‘cause they were seen as young, and fit, and healthy. And I think then realised, well, hang on, if this disease is going to spread in this community, this is going to be a constant threat to the health of everyone in Singapore. And they had to, kind of, take three steps back and really focus on surveillance in those dormitory situations, even though none of these individuals were dying or even very few of them going to hospital. But recognising that that form of unstopped transmission was going to be a threat to everybody, regardless of the impact on that population. And they’ve invested huge resources in surveillance and containment activities and decompressing those migrant and worker dormitories.
So, think there are really good examples, Emma, all over the world, and I can go on and on and on, but I what I won’t say is that one country has done better than another. Because I think this is the wrong discussion, because if we get this into, this country did better than this country, we’re not going to get anywhere. We really aren’t going to get anywhere and I think that’s where we need to step forward now and say, in each of the pillars of the response, in community engagement and empowerment, in surveillance, in clinical care, what are the positive lessons we’ve learnt anywhere in the world, and can we package them together in a more effective way over the next six to nine months?
Emma Ross
Okay. David, I want to turn to you now on what does it really mean to live with the virus? Can you give me three top things that you think we need to be doing, as a global community, and I appreciate what Mike said, that it’ll be tailored by country, as to what they’re facing and what their resources are, and their capacities are. But there’s a lot of talk about, we’ve got to learn to live with this virus, and it’s got to be sustainable. What, in your view, does that really mean? What does that look like? Can you give me three things?
Professor David Heymann CBE
Yeah, well, to start with, I think it’s very important when you talk about living with the virus, to say we’re living with the virus today because we still don’t know the destiny of this virus. Will this virus, in one scenario, it could, for example, become endemic in human populations like other coronaviruses, four others have done in the past. Or it could stay with us for a while and then disappear or be cornered by the outbreak response activities that we’re doing today. We just don’t know its destiny. But we can live better with the pandemic today, by strategically using the tools we have.
We can do epidemiological investigation to find out where transmission is occurring, shut that transmission down. We can make sure that those populations that are extremely vulnerable to sick – sickness, following infection, are protected, and that includes people in care situations, it includes people who are obese, and people who have comorbidities. At the same time, we can also make sure that communities understand their role and how important they are in contact tracing to decrease transmission into their own communities. So, those are three things that we could do, and we can do many, many more. But using the tools we have today, including using the diagnostic tests in a strategic way, not just saying we’re doing two million tests this week, but saying where we’re doing those tests and why we’re doing them, so that everybody understands what the importance of diagnostic testing really is. These are the tools that are advancing the most rapidly today, and they’re tools that we should be using even more strategically than we are at present.
Emma Ross
Mike, your top three, what does it mean to live with the virus, sustainable way forward?
Dr Mike Ryan
Yeah, and living with the virus I think could be interpreted in two ways, Emma. You know, living with the virus it means – it does not mean giving into the virus and just accepting that the virus is in control, or does living with the virus mean actively reaching a point where we can protect the most vulnerable, reduce and control transmission to the absolute minimum, so our societies can reignite our education, social, and economic systems? So, if that’s the interp – if that’s what you mean, living with the virus, then I’m all for it. That’s what we should be aiming for. And I think living with the virus where we’re in control, as opposed to living with the virus where the virus is in control, and they’re two very different outcomes and if we’re going to achieve that, I just second everything that David has said. There are no – I mean, the problem right now is, there are no easy answers. There’s just what we know works, and it’s just putting that together, and it’s almost like a game plan for any game you might like to play, you need to have a range of interventions that you’re prepared to implement and sustain over a prolonged period of time, and you’ve just got to stick with the plan and get it done.
And I know that sounds not what anyone wants to hear, but there are no, as I keep saying it, there are no unicorns in this land, and too many people are looking for them, right? I think, and not to be too humorous about it, I remember Rowan Atkinson once saying, rather like a blindman in a dark room looking for a black cat that isn’t there and that’s what we don’t want to be. We need to be open eyed. We need to know what we’re doing, and that needs to be resourced. It’s one thing to announce and say, we’re going to do X, Y and Z. That’s great, and there’s been lots of announcements, over the last nine months. It’s another thing to plan, and resource, and implement, and monitor that, and get it done. And I think that’s where – and again, there are terrible dilemmas here and maybe, before we move on to the more general Q&A, this isn’t easy for governments, and it’s really easy, I mean, to make governments the whipping boys and girls of this process, right? There are real dilemmas here. There are huge trade-offs here. There are really difficult choices here and inasmuch as we need to support governments in being able to achieve that. And we’ve seen the impact of division and we’ve seen the impact of not taking all of government approaches, and we’ve seen the impact of division, and I think we really do – we’re at that point where the levels of frustration and the levels of disappointment and exhaustion are such that the danger is we turn on each other, not on the virus. And if that begins to happen politically, maybe someone’s going to score some points, but it’s not going to do a single thing about this virus. So, I think we have to – it’s really tough, because everyone’s frustrated. But I think the answers are there, there are things we can do, but we have to maintain cohesion on that.
That doesn’t mean there shouldn’t be constructive criticism. That shouldn’t mean that people should not point out when they believe things aren’t being done correctly. But I can detect, going through the narratives right now, quite a negative and destructive narrative emerging around how we engage with each other on implementing what we need to do. And I just hope we can find a more positive way to express our views, express our differences, but find a common way forward, or else this is going to get really, really nasty, and that is not going to help the response to this pandemic.
Emma Ross
Okay, on that note, I’m going to move to the audience questions, and the most upvoted question is from Louise Hart, and this is about Africa, “What are your thoughts on why the numbers in Africa have dropped off, and what do think they are likely – and do you think they are likely to rise in the future, in line with other regions of the world?
Dr Mike Ryan
Is that to me or David, and I think both can answer?
Emma Ross
Both can answer, you’ve both got the info. Mike, why don’t you have a go.
Dr Mike Ryan
Okay, well, the numbers – the reported numbers have dropped off on the African Continent, and to a great extent, because the numbers have dropped off in South Africa. A couple of things, I mean, Africa is certainly not out of the woods, and the drop off in numbers is something that needs to be interpreted carefully across the continent. While Africa has done extremely well to develop laboratory-based diagnostics across the whole continent, and while surveillance has been put in place, clearly, the resources – it’s not well enough resourced to do the kind of testing and surveillance that other countries, in the Northern Hemisphere, are capable of doing. So, there is an element of under-detection. However, we’re not seeing the same death rates as we’ve seen in other places, and to an extent, this is understandable because the median age, the 50% of the population of the African Continent I think is under 19 years of age or, you know, under 18 years of age. So, the reality is that the demographic of Africa may sustain transmission but is unlikely to reach the same mortality rates as the rest of the world, just by nature of its demographic footprint.
Our concerns have been in that situation where when this COVID met with HIV, and COVID got into refugee camps, with very vulnerable individuals, to undernourished kids, what the impact of that would be, and that still remains to be seen, and we still have to worry that there are many sub-populations. And again, we don’t want to see Africa, the African Continent, as one big amorphous mass, you know, there are 54 countries on that continent, and each and every one is unique and different, with different levels of vulnerability, different scales of resources. So, it’s very important we don’t see the whole of Africa as just a one-size-fits-all approach.
We should be grateful that we’re not seeing, and we are grateful that we’re not seeing, these massive impacts. But the impacts that Africa’s suffering, beyond the COVID impact, is the impact of its general health services, the shutdown in overseas development assistance, the difficulties in humanitarian assistance and funding programmes, and the fact that a lot of money that may have been used for other purposes getting diverted into COVID response and COVID preparedness and those things. And the economic losses due to, you know, lack of remittances coming back to some countries, that’s had a major impact on some African countries. So, economically it’s having an impact, in terms of people not being able to move and trade, and the relative impact of that, on small businesses in Africa, is very high. So, I think there are a lot of impacts on Africa, they’re not all seen now through the lens of COVID, but they are there. And there are still, as the disease continues to spread, we may see more and more vulnerable populations having higher death rates, and we need to try and avoid that as best we can. So, that would be how I would characterise the situation there, Emma.
Emma Ross
Thank you. David, you can take the next question, and it’s the next most upvoted question, from Prashant Rao at The Atlantic, and it’s we’ve covered some of this before, but I think there may be more to squeeze out of you both. But, David, with the benefit of six-plus months of experience, what would you say have been the characteristics of societies that have successfully contained the coronavirus, from a public health but also potentially cultural, technological and political point of view, and the characteristics of societies that have not?
Professor David Heymann CBE
Well, I think number one of all of this, is clear communication by governments, as to what their strategies are and engagement, as we said earlier, at the community level. People need to understand that they’re at the base of this response, and they need to be taking charge of the response, with facilitation by governments, as Mike has said earlier. So, that’s number one, we need to really see that governments have good strategies, solid strategies in place, and are explaining these to the people and so that the people can then grab hold of these and understand what they need to do to make things work out better.
In the long-term, I think we’ll see that those countries that have done this are the ones that are able to sustain their response in a valid manner and as Mike said earlier, it’s not a good strategy to say, “We will suppress the virus until there’s a vaccine.” We don’t know yet whether there will be a vaccine, and if there is a vaccine, whether this vaccine will prevent against future infection or modify disease in some way, but it’s a very valuable tool. But despite the availability of a vaccine, we still have to learn to deal with this pandemic and live with this pandemic at present while we’re waiting to see what comes in the future. But a good vaccine or a good therapeutic would certainly be important in the response. So, Emma, I’m coming back to you, can you give me some more elements of what that response, my response should include?
Emma Ross
Well, it should include whatever you think, David, but what’s being asked is the characteristics of societies that have coped and responded well, and the characteristics of the ones that really haven’t.
Professor David Heymann CBE
Okay.
Emma Ross
Not asking you to name countries, good or bad.
Professor David Heymann CBE
One word I think summarises it all, and that is solidarity. Solidarity among the people, with a will to deal with this pandemic, which will continue at least for a time, and while we’re waiting for other things, such as vaccines, and therapeutics to come into force. Mike will have another, maybe even a better, response than I have, and I’m sure, I’d like to turn it over to Mike now, and see what Mike has to say.
Dr Mike Ryan
Yeah, there are lots of words. I think the ability of people to think as a community, rather than always to think as individuals. That, to me, has been the unique and defining feature of this, of success versus lack of success. Regardless of the politics, regardless of the regime, regardless of the social contract, we’ve seen it in left-leaning, right-leaning, all over the world. Where communities, individuals have sublimated their individual needs over the community’s benefit, I think we’ve seen – and I would say, just to use a few words that characterise success and the opposite that have characterised less success or failure, I think unity, I think clarity, and I think empathy, I think ambition, determination, commitment, staying power, these are the things that have, you know, defined success, both within communities and within governments and the scientific response. And I think, ultimately, I would agree with David, if I’d one word that encapsulates all of that, I think is solidarity.
Emma Ross
Okay, well, that’s good stuff there, very easy to understand. The next upvoted question is from Sarah Bosley at The Guardian, and she is asking, “The surge in numbers in Europe began before the colder weather began, why do you think that is? Was it a mistake to encourage people to get back out to work and spend money in the summer months?” And I could tack on there, if you could, after you’ve answered Sarah’s question ‘cause it’s related, and that is the whole winter is coming fear, of the double whammy of flu and what’s the concern about that, and is it warranted or is it an exaggeration? So, if you could answer Sarah’s bit first. Mike, shall we start with you?
Dr Mike Ryan
Yeah, I think almost no matter what governments do, they’re in the dock because if they err completely on the side of preventing all infections and restricting movements, then they’re killing the economy and not allowing – you know, and therefore, that’s a problem. If they open up and allow the economy to return to complete normality, then they risk the infection spreading and then they’re in the dock for that. It’s finding that sweet spot, finding that balance between the two and no-one predicted that once the disease was coming under control at the beginning of the summer that it would just disappear, right? Well, maybe some people were. But the fact is, this is a virus that spreads between people and no-one suspected that we would not see a continued incidence of disease, through the summer months, as we saw. And we were very clear, and others were very clear, that we would likely see small outbreaks, recurrences of disease in specific situations, superspreading events, and what we hoped to do is that bumpy road to zero, in other words, you come off the big mountain and then you’re in the foothills, and you hope they stay foothills and you’re not seeing the next mountain ahead of you, right? But you accept that we’re going to have to traverse some difficult terrain, but it’s not going to be that massive mountain again and we can make it so. And I think you’re right, the disease, the number of cases started to rise before the winter months aren’t even here yet, and that is a factor of people mixing back together again, that is a factor of disease beginning to re-establish itself in communities. And then, the question was, would we be able to avoid that rising to a level where lockdowns were required, and the whole principle was that countries would have in place the necessary public health surveillance, and the necessary behavioural contract with people, so that public health surveillance, the testing tracing, isolating, working in tandem with the properly educated, empowered community, willing without coercion to do the things they need to do to reduce the risk of transmission, if those two things came together, we could reach a point where we would have control on this virus, living with this virus, and our economies could reopen.
And I think it’s not that the re-opening has caused the disease to spread, that’s not the case, the reopening was always going to cause the disease to have a chance to rise up, the question was, did we have the risk management measures in place to deal with that reality? ‘Cause otherwise, this is just yin-yang, otherwise it’s just closed, disease goes away, open, disease comes back, and then we’re open, close, open, close. What changes that cycle? What changes that vicious cycle of lockdown, open, lockdown, open? The only thing that changes that cycle, and David is right, there’s no prospect of a vaccine right now, the only thing that changes that cycle is inserting effective public health surveillance and effective community action. You put those two new things, or those two effective ingredients into the soup, then you avoid the lockdowns. And I just don’t think we, collectively, have got far enough in implementing the public health meas – the public health surveillance, or have been successful enough at both educating and involving communities in understanding behavioural changes and sustaining those changes that have been needed.
With regard to flu, I think we need to be careful too, and people have suffered enough with the sky’s going to fall in, right? We don’t need to add influenza as another existential threat. We do need to recognise that if we have an outbreak of COVID and we have an outbreak of influenza at the same time, that that may place healthcare facilities under extreme pressure, right, that’s for sure. But what we do know at community level is the same things that prevent the spread of COVID, will prevent the spread of influenza. The public health interventions are essentially the same, and we have an advantage in flu, we actually have a vaccine. So, there are things that people can do.
The one thing in a crisis, and David, you know this better than anyone, in any crisis situation, the most important thing you can do is give people things they can do. People don’t need to be told you should, you should. You need to give people practical things they can do. So, for example, right now in the UK or in Europe, countries have policies for influenza vaccination, and they have purchased vaccine for their most vulnerable people. We should be encouraging everyone, who’s eligible for a vaccine in any country, to go and get that vaccine, and that governments will deliver that vaccine. We should not use influenza as another black shroud to wave in front of our communities, we just need to be really careful on our communication here, ‘cause it’s not fair. People are concerned enough with this COVID-19. Yes, we need to add it into the mix, but we need to do practical things about that prospect, not just, as I say, raise the ante again and raise the level of community concern, without giving solutions for how we’re going to deal with that. So, it’s important we talk about it, Emma, but it’s important that we take practical actions and just not raise the already stratospheric levels of fear and confusion out there.
Emma Ross
Anything you want to add to that, David.
Professor David Heymann CBE
Yeah, I’d just, Sarah, you know, summer months exist in some countries all year round and in those countries, they’ve shown that you can keep the level low constantly, in many of those countries, because, as Mike says, the transmission is due to population dynamics. It’s not due to a climate or a temperature, as many people speculated, and misled many times the response because they said, “Well, this will decrease in the summer months in the Northern Hemisphere.” And it will decrease if population dynamics are such, that people are outdoors, that people are not close together and are physically distancing. What may be happening now is that people are now longer taking those lessons, and they are not physically distancing, and it’s, again, why it’s very important that populations understand that they must be at the basis of the response. Summer months exist everywhere, countries with summer months right now are having good control efforts, and they will maybe continue that throughout their summer months throughout the year. So, looking at it from that point of view, I think the most important thing, as Mike says, is population dynamics, which determine the reproductive number.
Emma Ross
Okay, thank you. Here’s one from Simon Carswell from The Irish Times, but I think Mike has already answered it, which is how – it basically is with the waning public buy-in to measures and the COVID fatigue, what are the strategies? What can governments do to get the communities back onboard? If you could summarise that, ‘cause it’s an upvoted question.
Dr Mike Ryan
Yeah, it’s probably the toughest question that’s been asked, quite frankly. Ask me an epidemiologic question. It had to be an Irish person asking the toughest question, you see. So, it is, and it is I think at the centre of the success now. Because this will apply now to compliance with social measures, this will apply, as you said, Emma, earlier, to compliance with what people do, when they’re a contact or a case. This speaks to vaccine acceptance down the line when we do get a vaccine and the current risk we run is of an essentially – an existential breach in public trust and, as we’ve said previously, without trust, you can’t contain epidemics, it just doesn’t happen. So, I do think there’s a tremendous amount of work to be done, but I also, quite frankly, think that governments need to come together with an all-of-government approach. I mean, you know, it’s easy to undermine a Minister of Health, ‘cause everyone gets to take the pot-shots, everyone gets to say what they’re doing wrong, right? And if people are constantly taking shots at that person who’s trying to lead a response, or the public health agency trying to lead the response, then that erodes confidence in those agencies and in those leaders. And I think opposition and others need to be really careful of what the motivation is.
Criticism should be there, constructive criticism and pointing out errors and mistakes. But everyone needs to look inside their heart and say, why am, I doing this? Is this going to help us stop this disease or is this aimed at scoring some points, right? Because unless there’s an all – I mean, if you go to use the, the war analogy, countries don’t go to war as a multiparty approach. I mean, countries that have been successful in defending themselves in wars have come together and acted together, right? And they’ve put aside their political and scientific and social differences, in order to collectively survive, in order to collectively succeed and I think everyone needs to take a step back and try and see how do we move forward? Because it’s one thing to say, yes, there’s an erosion of public trust in government, and I think that to an extent is true. But what’s driving that? Is it purely the government’s performance, or is it other factors? And where governments do well, and where individuals in government do well, and public health, are they getting the necessary praise and support and reaffirment and reinforcement of the positive, or is everyone just sitting in the wings waiting to be negative? And I’m not trying to defend governments, or WHO, or anyone else, because that’s not the game we’re in.
But if we really want to rebuild trust with communities, then we’re going to have to do better in the government sector and in the scientific sector, and not fighting amongst ourselves and then expecting individuals and communities to comply with our advice. It’s like, if parents are constantly bickering and fighting with each other, well, you know, go figure the kids really stop listening to them, you know, and it’s the same in any social environment. When people who are supposed to be responsible and in authority are constantly at each other’s throats, how does that help community public – and public trust? And I think that’s where we have to ask some tough questions of all of us.
Emma Ross
Okay, great, thank you. Unfortunately, we’re nearing the end. Actually, I just wanted to squish in a one-liner from each of you to finish off with. This has been a great conversation, but I kind of saved this ‘til last and I’ll start with you, Mike, and end with David, is you’ve both been in the field and seen a lot of outbreaks, and outbreak responses. Is there anything that has really surprised you about the way we have responded to this one? A quickie one-liner.
Dr Mike Ryan
I don’t know, Emma, asking me for a one-liner.
Emma Ross
Come on.
Dr Mike Ryan
And she knows me well, that’s the worst thing about the question.
Emma Ross
Otherwise you’ll be stealing David’s time.
Dr Mike Ryan
Yeah. No, I think the only thing I – it’s hard. I think this response has been upside down, in the sense that all the predictions were off. I think we need to reassess what does preparedness actually mean? Because all of – by all of the measures of being ready, they don’t seem to have correlated very well with the act of actually being ready itself, right? So, has preparedness translated into readiness, and has readiness actually translated into effective response? And I think the jury’s still out on that, and maybe that’s something Chatham House needs to be really looking at in connecting those dots.
The other thing for me is – the one word for me that has made, and I see this at every level of the system, that has made a huge difference, is courage. The courageous…
Emma Ross
That’s a surprise. That’s a surprise.
Dr Mike Ryan
Well, ‘cause I’ve seen that courage, well yes, our frontline health workers are always, they’re so courageous. But, you know, we’ve seen that the shop workers, and the people, the essential services people, and the people went out to work every day during the lockdowns around the world, and we’ve seen courageous Politicians, and we’ve seen courageous public health leaders, and we’ve seen courageous community leaders, and I think, for me – and it’s not a surprise to me. It’s just a hope, actually, more a hope. I mean – and I just – the one thing I would say, Emma, is, and when this over and it will be over, and you’ve been around this a lot of years as well, we never truly learnt the lessons of the SARS, and the Ebolas, and the pandemics, and the H5N1 and everything else. And, you know, these are existential threats, not just health-wise now, but economically, socially, does anyone need any more proof that biologic threats are real, and they can destroy our social and economic systems? And equally so, as we faced the imminent threat of climate change, and climate-mediated social and economic and political stress, and are we really going to be able to sit down and have a conversation about – I’m ashamed that we’re handing over a planet to our children in the state it’s in.
Emma Ross
Okay, right, and I’m afraid I’m giving you a C for one-liner.
Dr Mike Ryan
Yeah. Very, well, you asked for it.
Emma Ross
And a parting shot to David, hoping he will get a better grade. What have you been surprised about, about this epidemic, and please, you know, compete with Mike on this?
Professor David Heymann CBE
Emma, I’ve been surprised at the promises that have been made by many people about what’s coming along in the future. Nobody can predict what will happen with this pandemic, and what we’re seeing now is international travel is beginning again, we’re seeing that businesses and the economic sectors and schools are opening, and we’ve learned, from the experiences of many countries around the world. So, my parting comment is, we need to learn how to use the tools we have today, to better deal with this pandemic because we can do it, and we must be positive in moving forward.
Emma Ross
Okay, thank you. That’s definitely better. I give you an A- for that one.
Professor David Heymann CBE
Sorry, Mike.
Dr Mike Ryan
I’ll take my F home with me, Emma, okay?
Emma Ross
Yeah, but that’s all we have time for today. I’m sorry we didn’t get to all the questions, but Mike, seriously, thank you so much for taking the time to join us. I know you’ve got a lot on your plate today, and it’s always a pleasure to engage with you and grill you. So, thank you for taking it and for all the insight you’ve offered us today. and David, as ever, thank you as well. And just to let you all know that the recording of this will be on the Chatham House YouTube channel, in case you want to listen to it again, and for the next one, which is in two weeks, we’ll be talking about COVID opportunism and international security. So, Mike and David, thank you so much. Mike, thank you.
Dr Mike Ryan
I would easily have said no to this to David, but I couldn’t have said no to you, Emma. I don’t know whether that is both a mixture of mutual respect, with a little bit of fear, so, I’m really glad to have joined you today.
Emma Ross
What a pussycat. Okay, thank you so much Mike and David, and all of you have a great rest of the day. Bye.
Professor David Heymann CBE
Thank you. Bye.
