Week in Review

WHO expert on NZ’s response and the next pandemic

World Health Organisation special envoy on Covid-19 David Nabarro speaks to Newsroom's Marc Daalder about New Zealand's response to the crisis and how to prepare for the next pandemic

No one was more surprised to hear the claim that World Health Organisation expert David Nabarro had told New Zealand to follow Sweden's no-lockdown strategy for Covid-19 than Nabarro himself.

The WHO's special envoy for Covid-19, who has spent decades working on global pandemic preparedness, was interviewed by Magic Talk Radio's Ryan Bridge in late August, as New Zealand struggled to wrestle its second outbreak under control and commentators urged the Government to abandon its elimination approach.

Nabarro only endorsed Sweden's ability to avoid regulation due to high trust in the population and in government and he explicitly recommended the use of lockdowns in certain scenarios (including that which New Zealand found itself in on August 11). Nonetheless, the radio station's online headline later that day blared "NZ should move to similar approach to COVID as Sweden – WHO special envoy Dr Nabarro suggests".

Nabarro eventually had to issue a statement calling the headline and a since-deleted tweet which cut out the context of his answers "misleading".

"We are all working out how to live with the threats posed by this dangerous virus. We all want to play our part in keeping it at bay.  We are not helped by misleading headlines, whatever the rationale behind them," he said in the statement.

Newsroom sat down with Nabarro over the weekend in order to clear the air about what he really thinks about New Zealand's response to the Covid-19 crisis and what lessons can be learned for preparing for whatever the next pandemic may be.

We have to change how we live

Nabarro is loathe to compare the responses of different countries. For him, it's not a competition but a common enemy that the world will have to learn to deal with. Countries may take different tacks in achieving this, but none should have tolerance for widespread transmission and mass death.

"I think more and more of us are realising that this is a virus that's arrived, announced itself in a fairly sobering and challenging way, but most importantly it's not going away. And so when we look at the performance of any community or any nation in dealing with this, we have to really not view it as dealing with an emergency, but view it as dealing with a challenge that's going to stick around and that could be particularly nasty for months or even years to come," he said.

"This virus is a common enemy for 7.8 billion people. And yet, the way in which we're dealing with it, bizarrely, has become a competition between local authorities, a competition between nations, and the solidarity that ought to be there for a common enemy of humanity - it's not there.

"We should have really recognised this with HIV. HIV when it first started was thought to be something that would come that we could deal with and then life would go back to normal. Fairly quickly, we realised that that wasn't the reality. That it was actually going to change sexual behaviour and that we needed to integrate that into our ways of being and that we could do so.

"But, basically, the virus changed the landscape within which behaviour is being practiced. Well, it's the same with this one."

Life as "normal" is an artefact of the past for Nabarro. No country in 2020, whether it's Sweden or New Zealand, will be able to "open up" and live life as if it were 2019.

It is this understanding which underpins how he views every country's response. Part of the success of each response can be understood by observing how well the virus has been contained or handled so far - that's a statistical analysis of cases, hospitalisations, recoveries and deaths. But part of it can only be appreciated through a quantitative look - does the country have a viable strategy for dealing with Covid-19 going forward?

On both measures, Nabarro scores New Zealand rather highly.

"I really appreciate the fact that the New Zealand leadership, from the start, has been absolutely unequivocal and clear and firm. I study the statements by [Director-General of Health] Ashley Bloomfield and I'm really impressed by his consistency and his clarity. I'm also really impressed that the Prime Minister has tuned in to him but has also recognised that you don't deal with this problem without engaging the people and engaging local representatives and engaging local organisations," he said.

"Bringing in all the different actors and seeking to create a collective, whole of society response that does consistently recognise that this is not a nice virus, for me represents what I consider to be really good practice. And there will be questions about the severity of certain movement restrictions and those questions are legitimate, but I think that the positioning taken by Ashley and by the Prime Minister and by the Government more generally is fundamentally correct.

New Zealand's early response meant we were able to head off a scenario where case numbers doubled every few days and quickly spiralled out of control even for lockdowns, Nabarro said. In other words, that early decision in March to move to lockdown in order to buy time to scale up contact tracing, testing and other public health interventions was the right one.

"The longer you wait before you take it seriously, the more intense the spread of the virus across society and the tougher it becomes then to be able to get ahead of it," he said.

Nabarro okay with elimination goal

Looking ahead, Nabarro also endorsed New Zealand's elimination strategy, while cautioning that elimination was a goal but not something to be taken for granted.

"The vision can be one of zero virus, but in practice, that means doing everything possible to defend against it, knowing that there will be cases that appear. Having really good protocols for dealing with those cases when they come and making it hard for the virus to move from person to person is so important," he said.

In New Zealand, that means a robust contact tracing system able to meet a wide range of key performance indicators. It means the ability to - as we saw in Auckland in mid-August - massively scale up testing to ring-fence any outbreak. It also means ongoing levels of community or surveillance testing, to catch outbreaks earlier in the chain of transmission.

The reason Auckland had to go to lockdown despite the public health scale-up during the initial lockdown was that latter missing component. On July 19, just eight people across New Zealand were tested in the community - and that's 12 days before the first known onset of symptoms in the Auckland cluster.

When the new cases were identified on August 11 with no obvious link to the border, a lockdown was needed to give officials time to identify the perimeter of the cluster. This was a strategy Nabarro himself endorsed in the Magic Talk interview, telling Bridge, "It will be necessary, from time to time, when you're nervous about what's happening and you don't know where the cases are coming from, to do a little bit of local movement restriction in order to help you to get in and work out what's happening".

"And it buys you just a little bit of time and it's a key part of the strategy. But it's absolutely not long periods - months after months - of people not being able to move around. That's what I hope we'll be able to avoid and I believe you will be able to avoid."

We weren't ready for a pandemic

Nabarro has a long history working in public health. During the 2014 ebola outbreak, he served as a special envoy for the United Nations on ebola. He has worked with both the UN and the WHO on food safety and nutrition in the developing world and helped reform the WHO's malaria programme in the late 1990s.

But he is also an expert on pandemic preparedness. After the twin scares of SARS in 2003 and the rapid spread of H5N1 avian influenza through bird populations in 2004 (though thankfully with limited transmission to humans), Nabarro was appointed an assistant secretary-general at the United Nations to coordinating the organisation's work on bird flu outbreaks.

After nine years in that role, he moved to the WHO and helped the organisation reform its own response protocols for outbreaks and emergencies. After WHO director-general Margaret Chan finished her second term, Nabarro ran for the top job and campaigned on, among other issues, pandemic preparedness.

In light of all of this, how does he think pandemic preparedness globally has influenced countries' ability to respond to Covid-19?

"I personally believe that SARS was the thing that really had an impact on the East Asian countries and it was the SARS experience that led them to adopt this multi-stakeholder preparedness approach. They were not primarily looking at it from the perspective of influenza and the nature of the disease that it causes," he said.

"So in East Asian countries, the one lesson that they had taken on from SARS was the need for speed and the need for robustness. As I look at what has happened with this current coronavirus, I am so impressed with what I'm seeing from Vietnam, Cambodia, Laos, China, Taiwan, Singapore.

"The thing that really struck me was firstly that they realised you can't do this without fully involving the people. It can't be done as government pushing people to do things. The whole focus in that part of pandemic preparedness was on people's engagement. Secondly, the recognition that you have to have a public health infrastructure at local level that can enable sickness to be identified and responded to."

Nabarro said other countries failed to adequately prepare for a pandemic that could be responded to with anything other than a mitigation approach. As Newsroom has previously reported, New Zealand was among these - the 2017 influenza pandemic plan which we ran our response off of mentions SARS four times, including once in the glossary, and doesn't mention other coronaviruses at all.

"Other countries, I think, got the point [of pandemic preparedness], but they adopt an approach which was very influenza-specific. Whereas the ASEAN countries were basically basing their preparedness on the SARS experience, which meant that they were more coronavirus-focused. There is a huge difference between how you deal with a coronavirus outbreak and an influenza outbreak," Nabarro said.

"Because in influenza, you eventually do move to a point where you say this 'thing is just going to go everywhere so we have to shift from containment to mitigation'. But for a coronavirus outbreak, because of the particular pattern of spread, you have to go on containing. You cannot shift, in a coronavirus outbreak, from containment to mitigation. If you do, essentially you're giving up."

Can we stop the next pandemic?

Although it's difficult, given the overwhelming weight of the ongoing pandemic, to look forward, Nabarro is hopeful the world will learn some lessons from our experience with Covid-19. That there will be another pandemic is a foregone conclusion - but how effectively we respond to it is still subject to change.

"Pandemics are real. They happen. And the world has to be ready. I think there's a constant need to maintain that refrain and I don't understand why it's so difficult. We don't need reminding that attacks against people for political or ideological motives happen. How come we've not managed to integrate the inevitable emergence of new disease outbreaks and possibly pandemics into the fabric of our thinking?" he said.

"We need to understand that this means that public health or population health is a really important aspect of our economic and social life and that if we don't invest properly in it, we are creating liabilities for ourselves. The result of this is that I do anticipate that there will be a much greater understanding of the risks of new pathogens and the need to be defended against them, and that this should be a part of life."

We're going to have to rethink the way our societies function and eliminate aspects which produce optimal conditions for the emergence and transmission of new pathogens, Nabarro believes.

"As the human race, we are going to have to shift. There is no alternative. We are going to have to ask ourselves, is having people living in densely populated urban areas or slums or favelas viable? Or is it something we're going to have to attend to, because otherwise this virus and viruses like it are going to be there forever? Is it viable to go on having meat production facilities where workers are employed in conditions of considerable poverty and in very overcrowded settings?

"The real lesson from this is, instead of saying this is an irritant that we're going to deal with and bat out the way and life will go back to the way it used to be, we have to be a little more comfortable about taking a leaf out of the HIV book and saying that this is a new pathogen that's going to change the environment within which we behave. That's what life is - that's evolution."

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