Governance in emergencies

With the recent surge in novel coronavirus cases, first in Asia, then in Europe and the USA, Dr Zeynep Tufekci, a noted scholar and commentator on digital tech and society, wrote a powerful piece on how authoritarian models of governance do not work. It is an understatement to say nobody in the western world believes any information put out by Chinese media or the state. In another authoritarian regime, Iran, the situation is reportedly out of control with spiralling death rates and deaths among the highest levels of command, as further evidence supporting Dr Tufecki’s thesis. Yet the death rates in Italy and China are not dissimilar (at the time of writing, it goes without saying since this is a rapidly evolving situation), at least as reported by the World Health Organisation. Italy is not seen as an authoritarian state but one with a western democracy model of governance.

Literally no update has emerged from India, the world’s largest democracy, after the first 3 cases were reported in early February 2020. In a densely populated country like India, with varying levels of hygiene, it is almost unbelievable that there are no more infections and it is easily believable that it is down to non-monitoring and non-testing that no more cases have been reported. The guidelines are still referencing China at the time of writing and the last update on NICD is 26 February 2020*. In the United States, another large democracy, after early claims at the end of January 2020 by the President that it was “all under control” and a “very small problem”, the first death has been reported (although there was some confusion over the gender of the deceased and the CDC Director issued a clarification tweet, in itself not a great example of communication under duress) and Washington State is investigating an outbreak at a nursing facility.

Singapore, a country with a much debated and sometimes envied model of governance, is being seen as a model for coronavirus containment, with recoveries outpacing new cases at the time of writing, and they started early with their PM taking to discussing it in a calm and collected manner. South Korea, on which many of the world’s electronics supply chains rely, has reported more cases within the last few hours though some of it may be down to extensive testing — with drive-through testing pods and with testing of 200,000 members of the church believed to be at the centre of the infection — in a notable contrast to what is happening in India. Taiwan, who learnt lessons from SARS, reportedly seems to be returning to normal. Its governance model encompassing the use of data, transparency and a central command is being credited for the containment.

Meanwhile Iran has become the new epicentre of the outbreak and the death toll is high, if unverifiable, and rising. The outbreak appears to have started in Qom, home to Fatima Masumeh shrine which the government did not shut down even as Saudi Arabia suspended entry for pilgrims to Mecca and Medina (and confirmed its first case of coronavirus infection three days later). Many in Iran’s top leadership are now believed to be infected with coronavirus and a senior adviser to Iran’s supreme leader has died.

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It is clear that the governance models, though necessary, are insufficient on their own to determine what works and what does not work in an emergency such as the coronavirus scourge.

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Here are some of the questions the Director General of the World Health Organisation** said health ministers of every country should be asking about their preparedness:

  • Are we ready for the first case?
  • Do we have enough medical oxygen, ventilators and other vital equipment?
  • How will we know if there are cases in other areas of the country?
  • Do our health workers have the training and equipment they need to stay safe?
  • Do we have the right measures at airports and border crossings to test people who are sick?
  • Do our labs have the right chemicals that allow them to test samples?
  • Are we ready to treat patients with severe or critical disease?
  • Do our hospitals and clinics have the right procedures to prevent and control infections?
  • Do our people have the right information? Do they know what the disease looks like?

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These questions are about a lot more than governance models.

They are about organisational competence, resources, and skills already in place (rather than scrambling to procure under duress of the emergency). They are also about the clarity of a common vision and a decentralised approach to executing on that vision; these things oddly are especially necessary in emergencies when there is no time to convene an all-hands meeting but the trust that the leadership can rely on the foot soldiers facing the “customer”, the “end user”, the “patient”, the stakeholders to take the best decisions possible.

As emerging stories tell us, the democracy/ authoritarian divide is almost moot in this instance. It all turns on competence, resources and skills already in place.

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At the time of writing, there is one known case each in Brazil, Nigeria and New Zealand, all in the southern hemisphere.

Patient Zero in New Zealand came back from Iran prompting the country to restrict travellers from Iran.  Patient Zero in Nigeria had arrived from Milan in Italy and was reportedly not isolated for 48 hours.

However Nigeria has experience with Ebola and that is a strong point in favour of its organisational competence, preparedness and skills. The linked interview is worth reading in full but here are the most interesting excerpts:

Over the last three years, we have focused on strengthening our emergency coordination, surveillance, public health laboratory and risk communications capacities. We continue to build on this to ensure that we are better prepared in the event of an outbreak.

One of the key lessons from our response to the Ebola outbreak was the need to build systems in ‘peace time’ that can be used during outbreaks. Over the last three years, we have strengthened capacity at our National Reference Laboratory to provide molecular diagnosis for all epidemic prone diseases and highly infectious pathogens such as the Ebola virus.

We have also supported 22 states to establish emergency operations centres. These serve as coordination platforms and are networked to our national incident coordination centre. Each state is better prepared to coordinate within and across their borders in the event of an outbreak.

In December 2019, we completed the training of rapid response teams in all states in Nigeria. All 36 states have a team ready to be deployed in the event of an outbreak.

Overall, we continue to build strong systems that will enable the prevention, early detection and prompt response to infectious disease outbreaks.

The Ebola outbreak prompted the governments of many African countries to invest in the establishment of National Public Health Institutes. In these countries including Nigeria, the capacity for outbreak response is better streamlined with a clear coordination platform.

Large scale outbreaks require a high level of technical expertise, financial resources and other systems to quickly control. These institutes ensure that countries do not have to wait till there is another Ebola outbreak, before identifying resources for response.

The Ebola outbreak taught us a lot of lessons, including the urgent need for overall health system strengthening. This has improved in many countries, but with a lot of room for improvement.

Western countries which are defunding their public health infrastructure in “peace time” and choosing to dissociate from collaborative early warning systems could well take a leaf from Nigeria’s book.

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No governance models can cover for an incompetent, under-resourced and under-skilled organisation. This holds true for companies as well as countries.

UPDATES:

* India update on 2 March 2020: cases reported in Delhi, Telangana, Rajasthan and tests are sent to Pune. New travel/ airport guidelines were announced 3 March 2020.

** The WHO’s China report is worth reading.

(Disclaimer: These are my own views and do not reflect the views of the boards of JP Morgan US Smaller Co.s Investment Trust or Temple Bar Investment Trust or London Metropolitan University, where I serve as a non-exec director.)