Chief Nathaniel E. Nsarko is Executive Director at Millennium Promise Insurance

The COVID 19 pandemic has revealed systemic and leadership failures across virtually all sectors particularly health systems, and these failures are global in nature.

These pandemics (and the SARS, EVD, and MERS outbreaks which killed 770, 11,000 and 850 persons respectively), have continuously presented world leaders with lessons and opportunities to improve upon our systems to prevent and/or minimize future outbreaks such as the COVID 19 we are currently presented with.

COVID 19 has seriously exposed our slumber, systemic and leadership failures as well as our inability and/or unwillingness to learn from previous outbreaks. Indeed, our loss of focus in maintaining and strengthening our surveillance and response systems, especially community – based systems coupled with our lack of support for good initiatives (such as the 1million community health workers’ campaign and many others) is already having devastating effects on our ability to fight outbreaks.

COVID 19 is likely to spiral out of control; taking over our streets, locking us in our homes (as it already seems to have done in other countries). Now, face to face meetings cannot be held between experts to dialogue on fighting the disease, an opportunity we obviously abused in the past.

COVID 19 has brought to fore the importance of community – based health systems and the need to strengthen them; leveraging on ICT, such as using travelers’ data to assess potential threats to the citizens of respective countries; screening of persons at the various ports of entry and departure such as airports and boarders; the need for all of us to act in unison in strengthening health systems across all regions; and for leaders and high-profile personalities who have fallen victim to the disease to come out, as this will help in demystifying the disease and promote acceptance of prevention and control measures.

The Chinese have mounted a very spirited, comprehensive and effective response in Wuhan and essentially are ending the epidemic, and this is very remarkable. But it has taken a mix of incredible organizational skills, and some form of strong will-powered great and inspirational leadership by all standards some may describe as authoritarian and a country with a long history of very strong community mobilization and organizational prowess to downsize and control this epidemic.

Ignored Warnings

In a 2015 speech given during “Ted Talk”, Microsoft Founder Bill Gates warned against complacency, reiterating that in the future, a microbe and not weapons would be responsible for the death millions. He pointed out that globally we have invested a lot in warfare and defense against any form of military attack, but are woefully unequipped of underequipped in handling any future epidemic outbreak.

He boldly stated that "We're not ready for the next epidemic," and that the world's nations do not have teams of epidemiologists ready to hit the ground running in their tens of thousands to save the Earth's population should a pandemic break out.

A clear truth the world ignored. Comparing this to the world's armies that are at-the-ready to deploy at any given moment in case of war against other humans, we, in fact, have very little support if an epidemic were to break out, he said. His words hold true, considering the fact that the world’s most important organization for all health issues, the World Health Organization (WHO) has the best specialists in various diseases and systems issues like a pandemic response but is dangerously under-financed making it impossible for this organization and its superb leadership to guide lifesaving efforts such as what is needed now.

Here we are Bill, a microbe and not weapons has brought the whole world to a standstill; helpless and hopeless.

How the world has failed humanity – the COVID 19 Disgrace

Ghana is one of the latest countries to report cases of the Coronavirus Disease (COVID 19) with sixteen (16) cases recorded so far (surely a fraction of the true number), and this brings the number of cases reported globally to 254,652[1] affecting 166 countries, areas or territories with 10,442[2] deaths (and counting). Other African countries that have reported cases include; Egypt (256), South Africa (202), Algeria 90, Morocco (66), Tunisia 54, Burkina Faso (40) and Cameroon (20). Respiratory diseases such as COVID 19, flu, and common cold can be spread to persons up to six (6) feet away[3]. In densely populated communities, an infective person moving (and sneezing and/or coughing) through a crowded marketplace can infect scores within minutes.

Non-investment, Interference has weakened our Health Systems

Non-investment in strengthening systems on a global level has now been proven to have dire consequences for the world and humanity. Segregation and politicization in command and control of systems and structures and promoting self-interests will only worsen the situation.

There are two separate type of bodies when it comes to outbreak prediction, prevention, response and control. One type is the International body, the WHO which is good but seems to be underfinanced to the point of being insufficient to the task of supporting countries in need, and the second type are individual countries national scientific advisory bodies of disease control organizations like the one in the US, the CDC. Why is it that the USA which is one of the world’s leading (if not the world’s leading) authorities in outbreak investigations unable to carry out tests for the COVID 19 and why are/were tests so expensive (at $1,331)?

It had to take the intervention of a Congresswoman at a Congressional Hearing for the CDC to agree to invoke a legal provision to authorize the use of federal funds to pay for coronavirus testing. This has paid off with President Trump approving a legislation that will expand Medicaid and unemployment benefits, mandate paid sick leave and childcare leave for certain employees, and order free coronavirus testing, in an effort to limit the damage from the pandemic [4].

Unfortunately, interference and politicization in the running of professional institutions is widespread globally and has led to the misdirection of once respected institutions and the attrition/resignation of highly competent professionals, which have contributed to the mess in which the world finds itself today.

It is probably a good thing that this disease has also hit hard at high profile personalities, making them realize that the consequences of their actions, inactions, greed, etc. will not only affect the poor and vulnerable, but can extend to them and their families. Perhaps (though it may be slow in coming) now, they would hold themselves up high to ethical and professional standards.

Our leaders, it seems, have failed us and this has caught us “pants down”. This is indeed a disgrace, especially in this era of advancement in knowledge, science and technology.

Global Historical Perspectives

If history is anything to go by, epidemics or pandemics of such respiratory illnesses are known to kill hundreds of thousands to many millions. Apart from annual influenza epidemics that cause severe illness in millions and kill between 250,000-500,000 people each year[5], other viruses have crossed over from animals to humans and have had devastating effects on mankind. Notable amongst these are:

Major modern influenza and coronavirus pandemics[6][7][8]

Name	Date	Deaths worldwide	Case fatality rate	Pandemic severity
1889–90 flu pandemic	1889–90	1 million	0.10–0.28%	2
1918 flu	1918–20	20–100 million	2–3%	5
Asian flu	1957–58	1–4 million (approx. 116,000 deaths in the USA)	<0.2%	2
Hong Kong flu	1968–69	1–4 million	<0.2%	2
Russian flu	1977–78	Unknown	Unknown	Unknown
2009 flu pandemic	2009–10	151,700–575,400	0.03%	1
Typical seasonal flu	Every year	290,000–650,000/year	<0.1%	1
2019–20 coronavirus	2019–20	6,571+	~3.89%	N/A

Pandemic Severity Index (based on CDC Severity Index Scheme) CFR = Case Fatality Rate

Level 1 - CFR < 0.1% (seasonal flu)
Level 2 - CFR 0.1% to 0.5% (Asian & Hong Kong Flu)
Level 3 - CFR 0.5% to 1.0%
Level 4 - CFR 1% to 2%
Level 5 - CFR 2% or higher (Spanish Flu) Perhaps the most notable amongst these is the 1918 – 1920 Spanish Flu with a Case Fatality Rate of 3% which killed between 25 – 50 million people with some estimating the death toll as high as 100 million. Epidemiologists and scientists have revised mortalities due to this pandemic several times since then, and each and every revision has been upward[9].

As has been shown in most of these pandemics, outbreaks occur in waves of usually three (3) and it might be safe to assume (and this is a common view shared by experts) that things may get worse before improving.

However, the pandemic in 1918 was not the first influenza pandemic, nor the only lethal one. Indeed, throughout history, there have been influenza pandemics, some of which may have rivaled 1918's lethality. A partial listing of particularly violent outbreaks likely to have been influenza include one in

1510 when a pandemic believed to come from Africa “attacked at once and raged all over Europe not missing a family and scarce a person”[10].
1580, another pandemic started in Asia, then spread to Africa, Europe, and even America (despite the fact that it took 6 weeks to cross the ocean). It was so fierce “that in the space of six weeks it afflicted almost all the nations of Europe, of whom hardly the twentieth person was free of the disease” and some Spanish cities were “nearly entirely depopulated by the disease”[11].
In 1688, influenza struck England, Ireland, and Virginia; in all these places “the people dyed … as in a plague”[12].
A mutated or new virus continued to plague Europe and America again in 1693 and Massachusetts in 1699. “The sickness extended to almost all families. Few or none escaped, and many dyed especially in Boston, and some dyed in a strange or unusual manner, in some families all were sick together, in some towns almost all were sick so that it was a time of disease”[13].
In London in 1847 and 1848, more people died from influenza than from the terrible cholera epidemic of 1832. In 1889 and 1890, a great and violent worldwide pandemic struck again[14].

Collective Selfishness?

Another very important undesirable trait exposed by the current COVID 19 is our seeming selfishness individually and somewhat collectively. Given that recent outbreaks (such as SARS, EVD, and MERS) affected particular regions of the world, meant that the focus of interventions (by global leaders) was on keeping infection contained to the affected countries and regions, and it seems, not based on much empathy (and much genuine desire) in helping the affected countries/regions alleviate the plight and suffering of those living there. Aid and technical assistance given to affected countries were not meant to strengthen the health (and other) systems of the affected countries to be resilient, but merely to keep the pathogens there.

Thus, responses were delayed, half- hearted and not global/holistic Interestingly, the global headquarters of major institutions such as the World Health Organization (WHO), and the Center for Disease Control (CDC) are located in “developed” countries and thus not much has been done to bring health systems in “underdeveloped” countries (where these outbreaks had been most devastating) up to standards of developed countries.

Also, there has been a general lack of cooperation among countries in the interventions such as lock downs, flight cancellations, closure of borders, lack of, or minimal information sharing, laboratory capacity and logistics sharing etc. Indeed, most countries/regions are acting on their own without regards to how their actions affect others, especially the less endowed (in terms of finances, logistics, infrastructure, technical capacity, etc.).

Stop the mockery! Pandemics can originate from any part of the globe

While the world is now recognizing that we indeed live in a global village and advancement in technology and global dynamics means that diseases from one part of the world can easily spread to another, some world leaders (who should know better) and citizens (who are equally at risk and have been affected), have taken to mocking other countries in what may be described as a disturbingly racial tone. Calling the coronavirus, a Chinese virus and the diseases a “Kung Flu” is disgusting and childish and should receive the condemnation it deserves.

Pathogens and the resulting diseases they cause can originate from anywhere and can spread to any other part of a country, region or the world as has been seen in other pandemics.

Globalization enhances spread of epidemics such as COVID 19

One factor that has probably enhanced the spread of COVID 19 is the economic might of countries such as China, a global economy with investments in many countries. This means a heavy international travel traffic to and from China, contributing to the spread of the disease, further exposing gaps in our health systems.

According to the Times of India, one country that has suffered the most due to COVID-19 beyond China, is Italy. An examination of factors that could connect Italy and the novel coronavirus considering the deadly virus is reported to have originated from China is the fact that Italy has the most thriving fashion industry.

The northern part of Italy has been a traditionally prosperous region due to the flourishing fashion and garment industry. Most of the big global brands like Gucci and Prada have their base in this region.

With China offering one of the cheapest manufacturing options in the world, it came as little surprise that most of these fashion brands were working with China. A large number of these Italian fashion and garment houses had outsourced their manufacturing to Chinese labour, specifically in Wuhan.

Italy also has direct flights from Wuhan and reports suggest over 100,000 Chinese citizens were working in Italian factories. Chinese made a slow and steady move into Italy and many Italian fashion firms are now owned by them as well. As per a news report, there are more than 300,000 Chinese and over 90% of them work in the Italian garment industry. As per reports, there are thousands of small companies that are active in exports.

Ad hoc decisions?

The management of these pandemics appears to be perennially ad hoc. This is typically exemplified by rushed decisions such as the unilaterally decided, wholesale banning of flights from affected countries without embarking on departure point screening for all airlines now that the disease has reached a pandemic level.

Such seemingly rushed decisions have grave consequences and might have greatly contributed to the spread of the virus and the acceleration of the disease to a pandemic. It is natural for people to avoid restrictions on their movements.

Thus, the uncoordinated planning in limiting the movement of potentially (and known) infected persons leads to attempts to find alternative roots to circumvent travel and this is achieved by travelling through non-infected countries with minimal restrictions.

From just some few cases a few weeks ago in a big world Giant and developed country like the U.S., the Covid-19 epidemic has swelled up bringing the non-sleeping New York City to sleep. The general responses of governments have ranged from incomprehensible to inconceivable.

The health system is once again tested and the results are very obvious. Professor Jeffrey Sachs in a discussion with Mehdi Hasan on 12^th March 2020, bemoans that with this pandemic, the U.S government has to be judged on its incompetence, its venality, its ignorance and it will add to the costs and dangers absolutely in an enormously depressing and significant way.

Learning from others, the resilience of the Chinese

Ghana, taking a cue from the happenings in other countries has rolled out a number of strategies to minimize the importation and spread of the virus and these include:

Travel advisory to restrict the movement of persons outside the jurisdiction of the country
Closure of entry points to persons from countries with 200 or more confirmed COVID 19 cases
Immediate quarantine of all positive cases
Contact tracing and testing of all people who came in contact with people who tested positive regardless of symptoms because in the case of this particular virus the infectivity takes place even if the person is not symptomatic

The country is in the process of deploying ICT departure and entry point screening tools to provide to aid in identifying high-risk individuals and provide real-time data and rapid decision support.

We are advocating the testing of all people with respiratory symptoms for scientific and information purpose to inform the identification and assessment of the trajectory of the epidemic; testing of some segments of the population. These may not be immediate in coming as the general shortage of test kits may not allow for this.

Apparently, with the exception of China and possibly South Korea, no country has been able to carry this out in addition to other measures because these countries have been especially hard hit. The Chinese have shown much fortitude and this is evident in the drastic reduction in community spread.

They have gone a step further in leveraging on ICT by the deployment of artificially intelligent infrared screening systems mounted in the helmets of law enforcement agents to screen the general population at minimal disruption to their daily routine at public places.

The importance of community – based health systems

The COVID 19 has brought to fore the importance of community – based health systems and the need to increase and strengthen the resources, especially human resource. It is worth remembering that community – based surveillance and interventions have been instrumental in the Smallpox and Guinea Worm Eradication efforts, as well as significant break in transmission of the polio virus.

In his opening remarks at the COVID 19 media briefing on 13^th March, 2020, the Director General of the WHO indicated that ” The experience of China, the Republic of Korea, Singapore and others clearly demonstrates that aggressive testing and contact tracing, combined with social distancing measures and community mobilization, can prevent infections and save lives”. All of these measures require extensive investment in community mobilization and organization.

I must emphasize that community cohesion and traditional structures need to be harnessed and community mobilization and surveillance should be strengthened. Some countries with strong community and social structures (e.g. Ghana, and other parts of Africa) have used these structures effectively in the past to eliminate and eradicate diseases that had plagued them for decades (examples of Guinea worm and Polio have been cited earlier).

Leveraging on ICT

My greatest concern about the coronavirus hinges upon how to minimize transmission between countries. I focus on how we can use travelers’ data to assess potential threats to the citizens of respective countries. Thus, being fully armed to the teeth to control entry and exits using excellent ICT systems to track visitors embarking and disembarking into various countries is highly recommended as a priority.

Millennium Promise Alliance (MPA) is currently working with the Government of Ghana (represented by the Ministry of Health and the Ghana Health Service) as well as other partners to advance the electronic data collection on travelers to and from Ghana.

Screening at Departure and Entry Points

Departure screening/assessment of all passengers – this involves the screening of persons at the various ports of entry and departure such as airports and boarders. This will involve the deployment of sensitive and effective screening systems, most importantly rapid diagnostic test kits and screening questionnaires.

Departure and entry point screening will also limit the number of potentially infected persons while flagging others for confirmatory screening at the point(s) of entry.

It is proposed that once people are crossing borders, by whatever means (air, road, foot, sea/water, etc.), they should be screened for the disease to reduce the risk of spreading it to innocent passengers on board and to citizens of the destination countries.

Self-Quarantine alone may not be enough

Exit and entry point screening is an essential strategy especially as self-quarantine may not reduce the rate of spread of the virus/disease as expected. Self-quarantine is carried out at personal discretion, and adherence may be difficult.

Also, it should be noted that by the time an infected person decides to self-quarantine, his/her family may have already been infected and they could potentially infect others before knowing that they are infected.

The afore mentioned travel related measures though disruptive, is necessary because; the novel coronavirus infection may not elicit symptoms in infective persons, especially during the latent phase (of about 2 days), which means that by the time a person shows symptoms of the disease/infection, many (even scores) may have been infected.

This method of transmission has been identified as contributing to the spread of the virus from one country to another. Air flow in aircrafts which are pressurized create an efficient system for spreading the virus to other passengers as well as create a pressurized container (like a spray or soda can) that can rapidly spread the virus to groundcrew (and by extension their families and work colleagues, even before showing symptoms) and other people in the airport and beyond.

High Profile COVID 19 Infections[15], a blessing in disguise

What is likely to drive home the plight of all regions and the need for an integrated, comprehensive planning and preparation process is the number of high-profile COVID 19 infections. Canadian Prime Minister Justin Trudeau has been in self-imposed quarantine after his wife tested positive, and US President Donald Trump tested negative after meeting a Brazilian official infected with COVID-19.

Australian Home Affairs Minister Peter Dutton has also announced that he had tested positive, and a delegate from the permanent mission of the Philippines to the United Nations (UN) tested positive for COVID -19, the first known case at the UN headquarters in New York. In Iran, several senior officials have contracted the novel coronavirus, including Ali Akbar Velayati, a top adviser to Iran's supreme leader, has been quarantined after showing symptoms, whilst Seyed Mohammad Mirmohammadi, a senior Iranian official infected with the virus, passed away at a Tehran hospital. In France, the Minister of Culture Franck Riester, has been quarantined at home, while in the United Kingdom, patients that have tested positive for COVID -19, include the country's Junior Health Minister Nadine Dorries.

Spain’s, parliament has suspended all activities after Minister of Equality Irene Montero tested positive for COVID-19. The country has also reported the death of Antonio Vieira Monteiro (from COVID 19), 74, who was the chairman of the Portuguese branch of Spain’s largest bank, Santander.

Hollywood is not immune to the epidemic, as Oscar winner Tom Hanks announced on Wednesday that he and his wife Rita Wilson both tested positive for COVID -19. Idris Elba, another international super action star has revealed that he has tested positive for COVID 19 even though he has not shown any signs and/or symptoms.

Global sports events have also fallen victim to the virus. Arsenal manager Mikel Arteta tested positive for COVID-19, and their London Colney training center has been closed.

U.S. media has reported that the National Basketball Association (NBA) season was postponed indefinitely after Utah Jazz superstar Rudy Gobert became the first NBA player to contract the virus.

These high-profile cases have shown that the virus transcends political, geographical, social, cultural, religious and economic boundaries and the fact that these leaders and high-profile personalities have to come out has helped in demystifying the disease and has promoted the acceptance of prevention and control measures.

It is thus logical to assert that such openness would have helped us advance the fight against other diseases such as HIV/AIDS Tuberculosis, etc.

Conclusion and call to action

After carefully examining the critical issues that research and/or reviews have revealed, and from my own personal deductions (from my little cursory research about this and other epidemics and pandemics), it is apparent that several factors (human, economic, scientific, etc.) have led to the human race being threatened by a microbe that logic suggests should not be so, considering the advancement in knowledge and the tools available to us.

Indeed, the actions/strategies used by the Chinese (i.e. travel restrictions, widespread testing, contact tracing, quarantine, community surveillance etc.) have proved effective in reducing the number of cases and underscore deductions made here.

Thus, considering the historical antecedents of epidemics of high mortality and pandemics, we call on world leaders to act in unison in strengthening health systems across all regions. Special attention should be given to strengthening community–based systems such as community health workers and the use of ICT in designing mitigation plans and interventions. Community-based systems have been proven to be effective at early screening of emerging diseases, advising at household level and real-time date reporting crucial for informing policy.

The high profile of infected persons has shown that the virus transcends political, geographical, social, cultural, religious and economic boundaries and discussions around this issue should be done in an atmosphere of neutrality. Other leaders and high-profile personalities who have fallen victim to the disease are encouraged to come out, rather than seek medical attention on the quiet side.

This will help in demystifying the disease and promote acceptance of prevention and control measures, and it is heartwarming to see some very high-profile personalities do the right thing by self-quarantining or isolating, and reporting to have themselves tested. Such examples not only show the humanity of these individuals, but also their desire to remove themselves from the equation in order to contribute to the control of the disease.

Our delay in learning from past outbreaks have laid bare our lack of preparation, weak systems and leadership structural failures as well as individual and collective selfishness.

The proposed mitigation measures are worth considering because once a critical threshold of localized spread is reached, the cascading effects in terms of morbidity and mortality can be devastating, as past events have shown.

These are hard truths that nevertheless must be told. The world needs a new way of thinking and planning for global events. Plans and preparations must encompass all regions, and groups, for, (as COVID 19 has shown), neglecting the needs and/or interest(s) of others might just be the final nail in our own coffin.

[1] https://www.worldometers.info/coronavirus/

[2] https://www.worldometers.info/coronavirus/

[3] https://www.cdc.gov/flu/about/disease/spread.htm

[4] https://www.theguardian.com/world/2020/mar/18/trump-signs-coronavirus-bill-free-testing-paid-leave

[5] https://www.theguardian.com/world/2012/mar/28/history-major-flu-pandemics

[6] Hilleman MR (August 2002). "Realities and enigmas of human viral influenza: pathogenesis, epidemiology and control"

[7] Potter CW (October 2006). "A History of Influenza". J Appl Microbiol. 91 (4): 572–79. doi:10.1046/j.1365-2672.2001.01492.x. PMID 11576290.

[8] "Ten things you need to know about pandemic influenza". World Health Organization. 14 October 2005. Archived from the original on 23 September 2009. Retrieved 26 September 2009.

[9] https://www.ncbi.nlm.nih.gov/books/NBK22148/

[15] https://www.thestar.com.my/news/regional/2020/03/14/even-top-politicians-and-celebrities-fall-victim-to-covid-19

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