“Scotland’s First Minister Nicola Sturgeon said no one will be intentionally exposed to this virus.”

Global Public Health Professor Devi Sridhar

What should we do to save and improve WHO? What has made the difference between the strategy in countries such as England, Sweden and the Netherlands and many others across Europe? And what lessons from the first months should we apply now? I asked Devi Sridhar, professor of Global Public Health.

Reporters Online exclusive interview

It’s quite a miracle that in between all her other duties, Devi Sridhar found the opportunity to talk to a Dutch reporter. She is one of the most vocal experts on global health emergencies in the United Kingdom, on Twitter, in traditional media like the Guardian and on television, not to forget one of the most prominent advisors to the Scottish government – while also teaching and doing academic work in the meantime.

Sridhar (35) was raised in Miami, trained at Oxford University and is now a professor of global public health at University of Edinburgh in Scotland and author of a large number of scientific publications and several books about global health. She also co-chaired the Harvard/LSHTM Panel Evaluating the Global Response to Ebola and setting forth key recommendations for pandemic preparedness.

This has made her very much entitled to speak out – against the reluctance of the British and in particular the English authorities to proactively contain the virus and protect its population, against the lack of international collaboration in dealing with this international health crisis and in general – in support of solidarity.

Her assistant saw no option but to decline all my previous requests, but for an interview about the role and future of the World Health Organization Sridhar insisted to make time. On June 18th I talked with her about WHO and asked her about British and European context as well. Notwithstanding the craziness of developments during this crisis, what she told me that afternoon is still as much relevant today.

You have actually been warning for a coronavirus pandemic years before this all started. What characteristics would you not have predicted?

Well first, that we have an outbreak that spread through elite networks. Business travelers cruise ships people on ski holidays. Rather than coming from rural communities. There was the idea within research that we need to focus on very weak setting thinking and build capacity there. Now we’ve seen actually the opposite, that it’s the spread through the elite settings and richer countries first. And it’s now it is spreading to poorer countries.

And to poor communities in the richer countries like meat packing districts.
Exactly, we all have heard about shielding and cocooning strategies, and clearly it did not work. Wealth is the best shielding strategy.

What else has surprised you so far?
The next thing that is remarkable, we have all these metrics, like the Global Health Security Index, measuring how well prepared you can be and the US and UK were on top of the list…

And the Netherlands.
Yes. The Netherlands as well, just as Sweden, which was ranked 7th. These countries have suffered much more than expected. When you think of the world in developed and developing, this pandemic did not really follow that division. People in low resource environments are looking for leadership and they’re turning to East Asia and New Zealand and China. There’s going to be an interesting shift also where legitimacy comes from to talk about responding to health emergencies.

So what do you think of the role of the World Health Organization during this crisis?

To be fair to their team, they’ve been running nonstop since early January. I think the real challenge for them has been managing the geopolitical tension around China and the United States and to navigate through that. It was clear in January they needed to get information out of China and they were worried about having a repeat of not having the full picture just like with sars1.

There was a lot of coaxing and encouraging China to be a good player and to share information. And that was perceived by others as not being objective, being captured. I think it’s been diplomacy to keep China at the table. And so I said: ‘OK. They have to say China is wonderful. They want the sequence of the virus.’ Yes, the mission to China came back and it doesn’t really talk much about the human rights breaches that occurred, but it was a joint report with the Chinese government and has to be read that way.

You mean we should just be realistic about it?
Yes, you have to read it like that. Not as an independent report but as a joint WHO-China report. So I think they’ve done the best they think they could. Of course there will be scrutiny of the decisions made. They have really top people like Maria Van Kerkhove, Sylvie Briand, Mike Ryan. He especially has been around for so many outbreaks. So I always listen to all of them very, very carefully.

Now we have this discussion about the role and the efficacy of WHO. People are arguing it needs more teeth. What’s your take on that?

Yeah, well, I think that’s exactly it. It’s a member state organization and it can only do what member state delegate it to do. So in 2005, the International Health Regulations were adopted by the delegates of WHO. And these IHRs give WHO the power to ask countries when there’s an outbreak to report it. China did report on 30th December 2019 to the WHO country office. They shared information and gave the ability to convene an emergency committee of experts. WHO needed more information from China before they could announce the public health emergency of international concern, on January 30th. And I feel like as of January 30th. That’s kind of where their power ends to alert the world.

At that point, it was up to countries to prepare. Some countries were already preparing, Taiwan and South Korea had made their own decision in early January. But I think it’s unfair when people say, oh, they didn’t declare pandemic before March, because the word doesn’t mean anything operationally. The real key moment was that the global health emergency moment on January 30th.

And from then on?
And then from that, they shared all the information they received. What countries did with that, differed. If you look at New Zealand, their elimination strategy was explained in an article in The Guardian by one of their advisers, Michael Baker. He said that they were on their flu plan, just as the European countries. But they read that report from WHO on the mission to China in February and realized this was not flu. And they got a clear indication of how China had suppressed the outbreak. Elimination was possible, especially for island states where you don’t need to worry about borders. A clear route was laid out. You need to do your testing. You need to do your contact tracing. You need to watch your borders. You might need a lockdown. If you lock down do it short and do it early and use your time to prepare for the next stage. You don’t want to let this flow through the population because the clinical outcomes are so bad.

It just feels to me like several countries were not really paying attention to WHO or perhaps didn’t really read that report. And this is why countries like in Europe and the States who were not listening have struggled because they went through all the same mistakes. Like the UK delaying on the lockdown and stopping community testing because they thought it was just like a flu.

The UK and US have got the worst of both worlds: a lockdown with all its consequences and many cases and deaths.
Yeah, we’re taking about an economic disaster. And then you get your societies into two terrible debates that actually we never saw emerge in Asia. The first one was about economy versus health, because the longer this drags out, you’re killing everything, right? Harm increases every day, but as long as you’re not ready you cannot you just go out of the lockdown either.

There was this strange paradox: WHO said test, trace, isolate. Some countries could just not do it, and others just rejected the advice. They said it wasn’t for them.

By late February, early March, I could see some divergence occurring and I didn’t understand it. And experts in the UK were saying: ‘WHO is not evidence based. Their recommendations are for poor countries. We are leading the world. We have the best scientists in the world. They’ve made mistakes in the past. We can’t trust them.’ You know, on 26th March, the deputy chief medical officer in the UK did a press conference and was asked why we were not testing, testing, testing. And she said she thought of testing as a thing for poor countries which don’t have good health services. Astonishing. Some countries have a lot to teach us about how to manage outbreaks because they’ve done it many times.

This sounds rather similar to the Dutch situation actually. So what was the second debate about?

The second debate we never heard of in East Asia was whether we should focus on shielding the vulnerable instead of protecting everyone. In the UK this was very pronounced with people asking: why should the young suffer for the old? Asian countries never attempted this. Some talked about bubbles but those were not like we were taking about, it was about taking real care of them during lockdown, to make sure they have food and that they have their pharmacies and that you basically have a neighborhood during lockdown. Not an idea of locking down vulnerable and elderly people and have them isolate till there’s a vaccine or till herd immunity is reached.

We had quite a similar debate in the Netherlands. And also the Swedish, but it has some some difference. Have you been following those debates closely?

I have seen those countries and I tried to put them in different bottles. There is the elimination models which some island states are going for, to get rid of it. The New Zealand model you can call it. And then you have the suppress, control, contain, but you can’t eliminate it, German model. They can’t eliminate it because they have borders with nine countries. All they can do is what they’re incredibly successful at, to contain it as much as possible.

Be as good as possible with contact tracing?

Exactly. Their logistics are incredible to watch. And then you have, I think, the US, UK model, which is like here nor there. There’s no clarity. It started with herd immunity. Then they left that, but it’s basically an absence of leadership. So you’re getting some kind of herd immunity policy. But it’s not discussed openly anymore.

As is in the Netherlands.
Well at least as far as I see it, the Netherlands and Sweden are more open. I mean, Sweden especially, it’s been explicit from the start. And I saw the clip of a public health person in the Netherlands recently saying like, we need to let it go through. At least they said things like that openly.

Well they said it, but it was criticized and then they left out the phrase, while giving the impression that they were still aiming for it. Herd immunity has become a forbidden word.

If so, that’s like England. And Scotland’s a bit different. The Scottish government has said we go for elimination and suppression. So either we end up like Germany or we’re hoping to end up like New Zealand. We can’t do the full New Zealand model because we’re not an island as such. But this is where we are. And there is agreement among the public. So luckily, we’ve put aside the whole herd immunity now.

What are the main differences between Scottish and English policy?
Well, there are big differences. In early May, Boris Johnson released the lockdown and he moved from the stay at home to stay alert, which basically said, you can continue living your life, just be alert and use common sense. And, shops have reopened, there are huge queues. Restaurants are opening. Shielded individuals could go outside. And it’s really kind of a back to normal approach. And what you find is it’s not completely back to normal because this virus is still circulating and they’re (mid June) still having 1000 to 2000 daily new cases.

And in Scotland (on June 18), we stayed in lockdown. And the only change made until June was that you can go outside more than once. But until July, I can’t go to other people’s houses. Non-essential shops were closed until late June. Outdoor restaurants and beer gardens have just opened in July, pubs will reopen on Wednesday 15th. The general feeling is, yes, people want to comply.

There is a huge difference in articulation: Scotland’s First Minister Nicola Sturgeon said no one will be intentionally exposed to this virus. The goal is to drive the cases down. And she talks a lot about elimination as a target, not like a point, but a journey.

In England, they haven’t really articulated that. They’ve implemented better contact tracing now, but it’s not really happening. People are refusing to isolate and it’s on a voluntary basis. People who cross the border should self quarantine but it’s actually not even implemented. There’s plenty of people walking through Heathrow Airport and nobody even asked them where they’re going. They get on the tube and go home.

In 2017 Sridhar published this critical review of several global health insitutions, including WHO. She wrote it together with Chelsea Clinton

Insiders are talking about improving WHO’s emergency response. But shouldn’t it be indeed more about improving circumstances and health systems?

Yeah, I mean, it’s a really tricky one, because that’s what Dr. Tedros tried to do in his address, that is to prioritize universal health coverage, which is about health systems, is the primary health care and health security. And he said these go hand-in-hand, that in the sense that we should try to build these together. And this is the area, at least my research team worked on for a couple of years, which is how do you find the synergies to link these two agendas?

I think WHO is asked to do too many things. Right now they have become like a COVID response agency and support agency for all countries. But they’re also having to support health system. Health system stuff is crucial because, again, we’re going to see non COVID harm to overtake COVID harm, with vaccination campaigns halted and knock-on consequences.

So that will be not an easy thing to do, because we were they were already working on it, and now the all the attention will go towards that emergency role.

Yes, exactly. Which is a big worry, this is my worry as well, which is going backwards on polio eradication, polio campaigns have halted. What happens to measles, which was resurging and just basic things like childhood pneumonia and diarrhea, malnutrition. We were making progress slowly and that’s going to be put back. We saw that with Ebola in West Africa and how it put back gains in child survival. With this it’s going to be catastrophic. I think we already know that. We’re already seeing that.

I think for the developing world – I’ll use the word low resource settings – even if they know all the right things to do, even if they do all their preparation. It’s like seeing a tidal wave coming in, knowing no matter what you do, you just can’t do it because they don’t have the resources, look at how the US and the UK and Netherlands are struggling. And these are countries that are having a huge amount of resources and health staff, hospitals and testing kits.

The pandemic, in the meantime, is still accelerating. What lessons from the first months should we apply to mitigate the damage?

This is a really, really difficult puzzle because they can find a way through this for, you know, Britain. But it’s going to probably involve some kind of elimination with border control. What happens to those countries that can’t do it? Because I’m thinking of Brazil or India, which have large populations. Or Pakistan or even countries in South America, Chile, Peru, Guatemala, Honduras. Is that really feasible in those settings? And is distancing feasible, is lockdown even feasible? Lockdowns can be catastrophic without social safety net in terms of economic packages.

So far those countries have done incredibly well to try to keep the number of cases low through traditional public health, because they knew that there’s no way they could treat their way through it. I think the mistake that the UK, the Netherlands, Sweden and some other countries have made is that they tried to treat their way through this. Now we realize with that approach, this virus will paralyze society for months, aside from the death and all the complications.


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