Covid-19 has forced a reckoning—the UK has much to learn from low income settings

The UK should draw from some of the low cost, high impact strategies used in countries that have recently experienced epidemics, say Samuel Boland, Gillian McKay, Benjamin Black, and Susannah H Mayhew

The scale of the covid-19 pandemic outstrips the capacities of almost all nations, including the wealthiest. In the UK, we struggle to maintain supplies of personal protective equipment, are still not adequately testing, and abandoned labour-intensive surveillance and contact tracing methods early on in favour of inexact but straightforward strategies like broad social lockdown measures. These lockdown measures are themselves problematic. They do not reach every community and there is mounting evidence of a disproportionate negative impact on certain populations who are not reached by government messaging campaigns, struggling with severe social and economic hardship, and are over-represented in fatality rates.

When a public health system becomes overwhelmed due to a disease outbreak in this way, countries often turn to the World Health Organization’s (WHO) Health Emergencies Programme (WHE) for support. WHE was established in 2016 to support overwhelmed public health systems in developing  response systems during emergencies. It represents the core of our global architecture for responding to emergencies, such as disease outbreaks.

However, the ongoing pandemic of SARS-CoV-2 highlights a fundamental flaw in this system. As standard outbreak response tools like contact tracing are hugely labour intensive, the UK requires substantial numbers of personnel to respond to this outbreak with acuity. At the same time, so does almost every other country. However, WHE does not have a limitless army of health professionals. It relies on a roster system that draws on experts from other organisations and governments, using mechanisms like the Global Outbreak Alert and Response Network (GOARN) to fulfil needs when health crises emerge. Currently, most of these experts are preoccupied with responding to SARS-CoV-2 in their home countries, and significantly scaling up further capacity is impossible: there are not enough trained personnel considered qualified to join WHE’s rosters and there are insufficient funds to finance it.

So how can the UK respond to such a demanding crisis without WHE’s backstop? 

Tangible examples of low cost, high impact strategies can be drawn from countries that have recently experienced large epidemics. Crucially, they employed a top-down response guided by experts alongside a ground-up strategy of locally driven and owned interventions.

Comprehensive community engagement

In Sierra Leone’s Ebola outbreak, a massive community engagement effort was established. Many thousands of locally hired and trained individuals were employed (or volunteered) to work within their own areas with local leaders, families, and youth networks to develop locally appropriate response plans. This included placing and maintaining handwashing stations at every street and outside every business, hotel, and restaurant (a strategy also used in cholera); the identification of local isolation spaces; helping oversee compliance of emergency bylaws, like restrictions on movement; and helping collate information on rumours and myths about the disease. This was complemented by mass media outreach, including presidential press releases; no-contact door to door visits; as well as educational radio programming, murals, and music.

Decentralised service delivery

During the Ebola outbreaks in the Democratic Republic of Congo (DRC) and Sierra Leone, many services were decentralised to move them as close to affected populations as possible. For example, despite the availability of and consideration given to using contact tracing apps in both outbreaks, the decision was made to keep case investigations and contact tracing human and local. Thousands of people (often unemployed college graduates) were hired. Short training sessions and regular oversight were more than sufficient to ensure robust and effective surveillance using this localised design. 

Hiring local people not only provided sustainable employment, but actually improved surveillance in many ways, as affected people trusted their community surveillance officers and contact tracers more than someone from the capital or abroad. The offices coordinating the response were highly decentralised so that they could retain oversight of these networks, and ensure the response was sensitive to local demographics and needs.

Recognition of “all of government” and “whole of society” approaches

In both Sierra Leone and DRC, there was a recognition that disease outbreaks affect all parts of a society and the responses reflect this. Community engagement, risk communication, psychosocial and survivor care, quarantine support (including food delivery and financial aid), logistics, planning, and partnerships were equally central to testing, surveillance, quarantine compliance, and case management. Central coordinating bodies with each of these functions were mirrored at the local level to ensure efficient and targeted efforts, and a consistent message that was disseminated through multiple channels.

These efforts helped mobilise communities to take control of their own health decision making and behaviour, at a time when central capacities were in short supply. Experts from the UK government, academic institutions, and non-governmental organisations advocated for and supported these interventions in Sierra Leone and DRC. On this basis, these are not foreign concepts, proposals, or methodologies to British specialists, and should not be dismissed as interventions only suited for low income countries. These solutions are scalable and effective in any setting—whether resource constrained or not. 

Some high resource settings have already engaged these back-to-basics concepts: Massachusetts (one of the wealthiest US states per capita and home to academic and tech giants like Harvard and MIT) has eschewed mobile contact tracing apps, electing to hire 1000 local contact tracers instead. France has elected to use a similar contact tracing strategy. The UK has also engaged with some of these ideas by encouraging and providing guidance for home care for mild cases. The NHS Volunteer Responder network (with more than 750 000 individuals to date) is also a promising start, but is hugely underused: in addition to valuable services like food and medicine deliveries, volunteers could perform contact tracing, community engagement and education, health assistant functions, and more.

The UK should consider community level interventions as not only financially viable, but also epidemiologically effective—and invest in and validate them accordingly. Furthermore, we must also acknowledge that covid-19 has highlighted a lack of sufficient resilience in the UK’s public health emergency response capacity. 

As we consider how to better prepare the UK for future health crises, we must acknowledge that health systems strengthening does not only mean better funding for the NHS. It also means strengthening integrated community-level public health systems that are not beholden to centralised bodies, but rather locally engaged and technically able to implement community appropriate interventions like the ones proposed here.

Samuel Boland is at the London School of Hygiene & Tropical Medicine where he researches civil-military dynamics and best practice during disease outbreak response. He worked in the Sierra Leone and DRC Ebola responses. Twitter @samuelboland

Competing interests: None declared.

Gillian McKay is at the London School of Hygiene and Tropical Medicine where she researches the impacts of outbreaks on reproductive health. Twitter @gillianleemckay

Competing interests: None declared.

Benjamin Black is a consultant in reproductive health for humanitarian contexts, and obstetrician and gynaecologist at the Whittington Hospital, London. Twitter @benjamblack

Competing interests: None declared.

Susannah H Mayhew is professor of health policy and systems at the London School of Hygiene & Tropical Medicine. She had led multi-country research projects across sub-Saharan Africa, including an MRC funded study, Ebola Gbalo, analysing the Ebola response in Sierra Leone.

Competing interests: None declared.