10 key lessons for the future to be learned from fighting Covid-19

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A picture is emerging of the kind of society needed to withstand the future outbreaks scientists say are inevitable

People keep saying it: everything has changed.

As the days spent in our homes blur together and become indistinguishable, outside in the world huge shifts in consciousness are happening.

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World news | The Guardian

People keep saying it: everything has changed.

As the days spent in our homes blur together and become indistinguishable, outside in the world huge shifts in consciousness are happening.

Just as it was unimaginable that things could go back to normal after the 9/11 terrorist attacks in the US, so it is that policy, investments and our collective imaginations over the coming years will be overshadowed by a virus that took fewer than 100 days to shut the world down.

These strange months may be the first of an era defined by hyper-awareness of the threat posed by pandemics. It is too soon to say what that will look like. Each day brings shocks and possibilities, illuminates a little more of our new reality. Epidemiologists will study the past five months for decades; historians even longer.

But already we can see the rough contours forming. We are learning what works against Covid-19. And, surveying the wreckage of the third coronavirus to become an epidemic this century – along with two animal influenzas and several waves of Ebola – lessons are emerging about the kinds of societies that will be required to withstand the future outbreaks that scientists tell us are inevitable, and increasing.

You must move fast

Officials use thermal scanners to screen passengers arriving in Taiwan on a flight from Wuhan in January. Photograph: Chen Chi-Chuan/AFP/Getty Images

China announced the discovery of a “pneumonia of unknown origin” on the afternoon of 31 December. The announcement barely registered in a world preparing to celebrate the end of the decade.

But that same day in Taiwan, the government in Taipei ordered any planes arriving from Wuhan to remain on the tarmac so airport staff could inspect the health of all those onboard.

China resisted implementing country-wide health screenings or taking temperature readings in Hubei province, where Wuhan is located, for the next fortnight, even as doctors in the city were reporting floods of patients struggling to breathe, and as leaders in Beijing became aware they were confronting “the most severe challenge” since Sars.

In the meantime, Taiwan’s Centers for Disease Control was monitoring arrivals from Wuhan, quarantining any person with a fever or cough and urging its citizens to avoid any unnecessary travel to Hubei.

In China cases would have been cut by 95% acting three weeks earlier

A study released in March underlined the importance of acting fast. Had China implemented widespread testing, a cordon sanitaire around Hubei and other measures a week earlier, it would have reduced China’s caseload by 66%, the researchers argued. Acting three weeks earlier would have cut cases by 95%.

As of this week, Taiwan has confirmed 429 positive coronavirus cases and six deaths.

The lesson for governments was underlined by Michael Ryan, a surgeon and the executive director of the World Health Organization’s health emergencies programme, in a press conference in March. “Be fast. Have no regrets. You must be the first mover. The virus will always get you if you don’t move quickly,” he said. “If you need to be right before you move, you will never win … Speed trumps perfection.”

We know what works to contain it …

Workers queue for coronavirus tests at a temporary facility in Seoul in South Korea. Photograph: Jung Yeon-Je/AFP/Getty Images

Months into this epidemic, even basic information about the coronavirus is still unclear. How infectious is it? How deadly? Leaders make life-and-death decisions based on best guesses. “We are flying the plane as it’s being built,” says Ashley Arabasadi, a policy adviser at the US-based institute Management Sciences for Health.

Yet the basic principles for containing a disease, developed and refined with reference to hundreds of previous epidemics, have held true for Covid-19.

“The successful examples and failed examples in containing the spread of the virus have something in common,” says Yanzhong Huang, the director of the Centre for Global Health Studies at Seton Hall University in the US.

The countries that have implemented early and extensive testing, such as South Korea and Iceland, have been able to keep their societies relatively open, without loosing the virus into their populations.

Singapore kept a lid on its initial wave by diligently retracing the steps of people who tested positive for Covid-19. Those they came into sustained contact with were often put in home isolation, with harsh penalties for breaking it. The sick were quarantined in hospitals, even if their symptoms were mild.

When containing cases is no longer possible, early evidence from Europe shows that physical distancing measures, implemented early, “flatten the curve” and reduce the overall size of a country’s outbreak.

“Irrespective of the society, the level of development, the preparedness of the health system, early lockdown worked in containing the epidemic, whereas a late lockdown led to a massive outbreak,” says Joel Ruet, the president of the Bridge Tank thinktank, which conducted the research.

… the hard part is implementing it

Police patrol a roadblock in Guardamiglio in northern Italy. Guardamiglio was placed under lockdown after infections spread throughout the Lombardy region. Photograph: Emanuele Cremaschi/Getty Images

In 2014, as Ebola was spreading in west Africa, Rebecca Katz remembers hearing frustrations from some of the countries helping to fund the response.

“They would be asking things like: ‘How dare Sierra Leone not close schools during an Ebola outbreak?’” says the director of the Center for Global Health Science and Security at Georgetown University Medical Center. “For a long time it’s been easy for donor countries to cast judgment on recipient countries for their behaviour in disease transmission.”

The coronavirus outbreak has made clear that it is a universal problem: even countries that know what works, and have the capacity to act, still hesitate.

Some with strong liberal traditions, such as Britain, balked initially at the prospect of drastically curbing civil rights. Italian industry groups are reported to have strongly resisted the idea of shutting down Lombardy, one of the engines of the country’s economy. Developing countries such as Pakistan have had to balance slowing the spread of the disease with the disastrous consequences of closing the farms and construction sites where the poorest work.

“It’s really easy for me to say, hey, we should institute social distancing measures and close schools and cut the link between those susceptible to the disease and the infectious,” says Katz. “Knowing what the larger societal impact is makes it harder to pull the trigger.”

There were blind spots in the way countries prepared. A global index released in October concluded the US was more ready than anywhere else to fight a pandemic. But the scorecard, based on WHO methodology, focused more on technical capacity than government processes, says Alexandra Phelan, an adjunct professor at Georgetown University Law Center.

Official figures show the US has had the largest and most deadly outbreak, exacerbated by a slow initial response, mismanagement of testing and poor coordination between states and the federal government.

“As this outbreak has demonstrated, you can have the best labs in the world, the best notification systems and software, but if you don’t have the appropriate governance of when to use these powers … they don’t function,” Phelan says.

Civil liberties face their greatest test in a generation

A drone used by Indian police for surveillance in Bhopal during lockdown. Photograph: Sanjeev Gupta/EPA

Digital surveillance tools that might have been closely scrutinised in normal times have been urgently rolled out over recent weeks. More than 40 countries have implemented some form of surveillance or censorship in the name of fighting the coronavirus, according to one estimate.

These tools have created a world that might have appeared dystopian a few months ago. In Hong Kong and Bahrain, people in quarantine are being issued with electronic bracelets that track their movements. Drones equipped with cameras hover over some Indian neighbourhoods warning residents they are being watched. Israel has revealed it has secretly been amassing people’s phone data and is tapping that database to find potential coronavirus cases.

"Drones equipped with cameras hover over some Indian neighbourhoods warning residents they are being watched"

South Korea credited its advanced use of technology with helping to uncover clusters of cases that would otherwise have gone undetected. About 81% of Koreans approve of the surveillance measures there, according to one poll.

Human rights advocates acknowledge we are living through an emergency, but worry governments will use fears of future outbreaks to justify keeping many of these tools in place – whether or not they help.

“We are facing an immense challenge, but necessity is the question,” says Akshaya Kumar, the director of crisis advocacy at Human Rights Watch. “Some of these measures are just peering into people’s lives and taking power without a clear sunset clause, and without a sense that they’re really needed to combat the virus.”

“The potential for abuse is high,” the UN warned in a report last week. “What is justified during an emergency now may become normalised once the crisis has passed.”

Public trust is a government’s most valuable asset. The next months will strain it

Suspects are arrested for defying the lockdown during an operation in Johannesburg in South Africa. Photograph: Michele Spatari/AFP /Getty Images

There is no precedent for half the world’s population living under some kind of lockdown. It might just be the single largest collective act undertaken by humanity.

Its successful execution requires extraordinary public trust in their governments, says Lars Trägårdh, a Swedish historian who studies trust in institutions over time. “If you trust the government is working for your good, and you trust other citizens to follow the rules, you have huge advantages for collective action,” he says.

Mobility in Sweden’s parks and gardens

In places where trust in government is weak, fear has worked to clear the streets. In South Africa, police used whips to enforce a national curfew. Indian migrant labourers walking home were made to squat and crawl as punishment for being outside, while in Jordan, more than 1,600 people were imprisoned in the first three days of quarantine.

But restrictions implemented in low-trust societies could engender a backlash, says Trägårdh. “And that’s what happening in Southern Europe and the US right now where you see a lot of disobedience.”

Over the next months, governments are going to allow people to resume their lives amid the worst economic conditions since the Great Depression. Should new waves of the virus be detected, states may again ask their citizens to return home.

Managing this is going to require significant stores of public trust, that in some places are quickly eroding. “If people agree to do something in the long term, without a threat hanging over their heads, they are more likely to keep doing it,” Trägårdh says. “The alternative is fear, distrust, and chaos, and that isn’t good, no matter what the policy might be.”

Leaders who deny science are a liability

Slogans denouncing Jair Bolsonaro’s response to the pandemic are projected on to a building in São Paulo in Brazil. Photograph: Amanda Perobelli/Reuters

Many leaders have enjoyed what may be a temporary surge in popularity as frightened citizens rally around them in a crisis. Two notable exceptions have been the US president, Donald Trump, and his Brazilian counterpart, Jair Bolsonaro, whose ratings have declined sharply.

Both men, rightwing populists who frame their presidencies as revolts against the elites, including scientific authorities, have been highly skilled at influencing the media environment. But the coronavirus is a unique test. It spreads and kills regardless of how it is being framed online or in the media. It emphasises the importance of experts. Success depends on rallying the country together.

Retail and recreation mobility

“Leaders such as Trump deploy simple messages: insider versus outsider, us versus them,” says Sanjoy Chakravorty, a professor at Temple University in the US, who studies the politics of information. “And they are having an ideological crisis in how to manage the message here. This is a very complicated information sphere, which you can’t put into ‘us and them’ boxes … because in this case everybody is the ‘us’.”

Rather than rewarding bravado, the moment appears to favour leaders who can be honest about the uncertainty inherent in fighting a virus, says Kathleen Bachynski, an assistant professor of public health at Muhlenberg College. “If leaders are not willing or able to be honest about these limitations, there will be this loss of credibility – and it won’t be because they are wrong, it’s because information is changing.”

Those overseeing some of the more successful responses, such as Germany’s Angela Merkel or Jacinda Ardern of New Zealand, have been praised for their ability to project empathy and communicate complex ideas.

Asked to explain Germany’s metrics for deciding when to ease the lockdown, Merkel fluently explained the need to bring down the “reproducibility number” of the virus so that the health system can cope with its continued spread.

In a press conference a few days earlier, Trump answered the same question by pointing to his head. “The metrics right here,” he said. “That’s my metrics.”

The responses to the virus in both Brazil and the US are increasingly being led by state leaders, who are bypassing the federal government and coordinating directly with each other.

Self-sufficiency matters again …

Soldiers prepare to load a military cargo plane with personal protective equipment donated by Turkey to help the US. Photograph: AP

Governments will not soon forget the desperate global scramble for personal protective equipment and medical supplies they have engaged in these past months. Nor the sight of doctors and nurses forced to guard against infection using bin bags and homemade masks.

Several countries have already restricted the exporting of some pharmaceuticals and more than a dozen have imposed bans on selling some food abroad. The UN has warned that if quarantines persist, food supply chains in some places might start to be disrupted from this month.

Baseline mobility in grocery areas

The message is being received. EU countries are emphasising the importance of increasing the “strategic autonomy” of the bloc and ensuring it produces its own essential goods.

Narendra Modi, the Indian prime minister, told village leaders last week the most important lesson from the pandemic was the need for self-reliance. “We should not look to other countries to satisfy our needs,” he said.

Australia is one of several countries said to be re-examining the exposure of food, fuel and medical supplies in particular to global supply chains, the fragility of which have been exposed.

… but the world cannot beat the virus without cooperating

A transmission electron microscope image of the coronavirus.
Photograph: NIAID-RML/Reuters

The coronavirus got lucky: it emerged at a low point for global cooperation.

Countries recognised after Sars that sharing information, coordinating responses and pooling resources such as protective gear, medicine and tests was vital. A set of international regulations that came into force in 2007 laid the groundwork for this cooperation.

As Covid-19 started to spread, the regulations were virtually ignored. “The biggest surprise was how quickly the plans were not at all consulted,” Katz says. “The world was quick to throw out the global governance tools we had so carefully negotiated.”

The lack of cooperation has weakened the world’s response, public health experts argue. A global stimulus package might have put a floor under the economic catastrophe unfolding in many countries. Coordinated shutdowns and reopenings would have slowed the spread of the virus and could speed up the recovery.

We might have avoided chaos in the global market for medical and protective equipment, with reports of the US waving wads of cash to re-divert planeloads of masks bound for France, and Israel running clandestine spy operations to source testing kits.

“The last four years have seen a profound shift to governments that are protectionist and nationalistic and who argue the multilateral system doesn’t benefit them,” Phelan says. “Those of us who work in global health or other international problems know we’re interconnected. That global problems required global solutions.”

Austerity and inequality make us less resilient

A worker makes scrubs for frontline NHS staff in O’Neills sportswear factory in Strabane in Northern Ireland. Photograph: Paul Faith/AFP/Getty Images

No economy could withstand the shock of a large slice of the workforce suddenly ordered home. But the virus has irradiated weaknesses that have made the outbreak deadlier, and will make its aftermath hurt more.

The problems with tying health insurance to employment in the US have become even more obvious: the 26 million Americans who have filed for benefits over the past month did not just lose their jobs, many also lost their medical coverage.

Britain has the NHS, but a decade of austerity had weakened the system and left the country in demonstrably worse health when the virus struck.

The rise of precarious gig-economy jobs and zero-hours contracts has created a mass of workers without access to sick and paid leave, incentivising some to keep working when the entire community needs them to stay home. Insecure work and barriers to healthcare disproportionately burden people from ethnic minorities and poor people: both are dying from Covid-19 at a higher rate in the US and Britain.

Governments that have spent decades scaling back social welfare systems are now scrambling to build new ones on the fly. “The world is realising that there are many millions of workers who have fallen through the cracks of the existing social protection systems,” says Luca Pellerano, a senior social protection specialist with the International Labour Organisation.

“They are not in forms of protected employment, yet they are not poor enough to fall into the often quite narrow and shallow [existing] anti-poverty programmes. Countries with very fragile systems, with big coverage gaps, are scrambling to find solutions and are clearly behind the curve.”

The poor and migrants cannot be invisible

Foreign workers wait to be transferred from their dormitory in Singapore after an outbreak among migrant workers. Photograph: Suhaimi Abdullah/Getty Images

Singapore’s response has been lauded as a model. Its government moved fast, utilising technology, exemplary public communication and the traditional tools of outbreak control to corral its first wave of cases to about 200.

Then last week, it announced it had discovered thousands of new infections, almost all of them among migrant workers living in dormitories on industrial estates on the outskirts of the sleek city-state. Rights groups say little attention was paid to the more than 1 million migrant workers, even as restrictions on crowding and movement were rolled out.

Viruses can see the people who are usually invisible to policymakers and the public. The conditions in which they work and live are everyone’s problem.

The same is true of the residents of Dharavi, a Mumbai slum where almost 1 million people are crammed together within sight of the skyscrapers and penthouses apartments of some of the wealthiest people in Asia. More than 200 cases have been discovered so far. City authorities acknowledge it will be virtually impossible to halt the spread of the disease among these communities.

“Ten to 15 people stay in one room,” one official, Kiran Dighavkar, told New Delhi Television last week. “How is it possible to enforce social distancing?”

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