Mar 07, 2020 Volume 395 Number 10226 p755-838, e42-e45
COVID-19: too little, too late?
Although WHO has yet to call the outbreak of SARS-CoV-2 infection a pandemic, it has confirmed that the virus is likely to spread to most, if not all, countries. Regardless of terminology, this latest coronavirus epidemic is now seeing larger increases in cases outside China. As of March 3, more than 90 000 confirmed cases of COVID-19 have been reported in 73 countries. The outbreak in northern Italy, which has seen 11 towns officially locked down and residents threatened with imprisonment if they try to leave, shocked European political leaders. Their shock turned to horror as they saw Italy become the epicentre for further spread across the continent. As the window for global containment closes, health ministers are scrambling to implement appropriate measures to delay spread of the virus. But their actions have been slow and insufficient. There is now a real danger that countries have done too little, too late to contain the epidemic.
By striking contrast, the WHO-China joint mission report calls China’s vigorous public health measures toward this new coronavirus probably the most “ambitious, agile and aggressive disease containment effort in history”. China seems to have avoided a substantial number of cases and fatalities, although there have been severe effects on the nation’s economy. In its report on the joint mission, WHO recommends that countries activate the highest level of national response management protocols to ensure the all-of-government and all-of-society approaches needed to contain viral spread. China’s success rests largely with a strong administrative system that it can mobilise in times of threat, combined with the ready agreement of the Chinese people to obey stringent public health procedures. Although other nations lack China’s command-and-control political economy, there are important lessons that presidents and prime ministers can learn from China’s experience. The signs are that those lessons have not been learned.
SARS-CoV-2 presents different challenges to high-income and low-income or middle-income countries (LMICs). A major fear over global spread is how weak health systems will cope. Some countries, such as Nigeria, have so far successfully dealt with individual cases. But large outbreaks could easily overwhelm LMIC health services. The difficult truth is that countries in most of sub-Saharan Africa, for example, are not prepared for an epidemic of coronavirus. And nor are many nations across Latin America and the Middle East. Public health measures, such as surveillance, exhaustive contact tracing, social distancing, travel restrictions, educating the public on hand hygiene, ensuring flu vaccinations for the frail and immunocompromised, and postponing non-essential operations and services will all play their part in delaying the spread of infection and dispersing pressure on hospitals. Individual governments will need to decide where they draw the line on implementing these measures. They will have to weigh the ethical, social, and economic risks versus proven health benefits.
The evidence surely indicates that political leaders should be moving faster and more aggressively. As Xiaobo Yang and colleagues have shown, the mortality of critically ill patients with SARS-CoV-2 pneumonia is substantial. As they wrote recently in The Lancet Respiratory Medicine, “The severity of SARS-CoV-2 pneumonia poses great strain on critical care resources in hospitals, especially if they are not adequately staffed or resourced.” This coronavirus is not benign. It kills. The political response to the epidemic should therefore reflect the national security threat that SARS-CoV-2 represents.
National governments have all released guidance for health-care professionals, but published advice alone is insufficient. Guidance on how to manage patients with COVID-19 must be delivered urgently to health-care workers in the form of workshops, online teaching, smart phone engagement, and peer-to-peer education. Equipment such as personal protective equipment, ventilators, oxygen, and testing kits must be made available and supply chains strengthened. The European Centre for Disease Prevention and Control recommends that hospitals set up a core team including hospital management, an infection control team member, an infectious disease expert, and specialists representing the intensive care unit and accident and emergency departments.
So far, evidence suggests that the colossal public health efforts of the Chinese Government have saved thousands of lives. High-income countries, now facing their own outbreaks, must take reasoned risks and act more decisively. They must abandon their fears of the negative short-term public and economic consequences that may follow from restricting public freedoms as part of more assertive infection control measures.