PDISAS-100109; No of Pages 11
Progress in Disaster Science 7 (2020) 100109

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COVID-19 Risk Assessment Tool: Dual application of risk communication
and risk governance⁎Ranit Chatterjee a,b, Sukhreet Bajwa a, Disha Dwivedi a, Repaul Kanji c, Moniruddin Ahammed d, Rajib Shaw a,e,a

Resilience Innovation Knowledge Academy (RIKA), India
Kyoto University, Japan
Gujarat Institute of Disaster Management, IndiadAmazon Web Service, Indiae
Keio University, Japanbc

A R T I C L E

I N F O

Article history:
Received 16 May 2020
Accepted 22 May 2020
Available online 02 June 2020
Keywords:
COVID-19 pandemic
Risk governanceRisk communication
Awareness generation
Social behaviour

A B S T R A C T

Risk awareness is the best way to prevent and slow-down the transmission of the COVID-19 pandemic. Risk awarenessis achieved through communication of risk assessment. Effective risk communication is an important measure to control the infodemic. Most risk assessment tools focus on either tracking the affected patients or diagnosing a probablehealth condition through symptoms. RIKA India introduces an innovative Risk Assessment Tool which goes beyond
the symptom detection and patient tracking. It includes four factors in assessment of risk: Health, Behaviour, Exposureand Social Policy. Each of these four factors have sub-factors which help to assess the overall risk in a more comprehensive way and also present it to the user in a simpliﬁed way. The paper discusses the importance of the Risk Assessment Tool for awareness generation and decision making. Further, the datasets generated through the tool have been
analysed to understand the key intervention areas for COVID-19 response and management.
© 2020 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction
The coronavirus pandemic has yet again shown that we as a global society are not fully resilient to a health emergency of such a scale. The world
has previously seen global health emergencies of Ebola virus in 2014,
H1N1 (Swine Flu) in 2009 and SARS in 2003. Having faced such serious
outbreaks, there are many lessons for the affected countries and the restof the world to adapt to, and come out of this as a resilient society. The
Novel Coronavirus (2019-nCoV ) later named as COVID-19 disease, began
as an outbreak in Wuhan province of China, before making its way
around-the world in a matter of months and becoming a pandemic. As
per Shaw et al. [1] this pandemic is characterised by: i) rapid spread, ii)
aged and low immune people are more vulnerable and iii) differential recovery rate. As currently there is no vaccine for COVID-19, neither isthere any conﬁrmed treatment, therefore, the best way to prevent andslow down the transmission is to be well informed about its causes andhow it spreads. WHO declared COVID-19 as a Public Health Emergency
of International Concern (PHEIC) on the 30th of January 2020. This declaration means that the disease outbreak concerns more than one country andthus requires a coordinated international response [2]. While writing this

⁎ Corrresponding author at: Resilience Innovation Knowledge Academy (RIKA), India.
E-mail address: shaw@sfc.keio.ac.jp. (R. Shaw).

paper the latest data of number of affected people of COVID-19 stands
more than 4 million people with number of mortalities at 300,000 [3].
COVID-19 pandemic, as a public health emergency, has brought into
light many challenges in our lives and livelihoods. It has brought into picture the need for a trans-disciplinary view of the current crises through various angles of global governance, technology and risk communication [4].
COVID-19 has posed not only health but economic and geo-political crises
too. It is thereby a humanitarian challenge [5]. While health organisations
and governments advise many preventive measures like social distancing
and personal hygiene, one of the foremost strategies remains risk communication and awareness generation to break the chain of spread. Awarenessand understanding of the risk at the community level goes a long way in enhancing prevention. In this regard, various risk assessment tools in the formof mobile applications or online surveys are being actively used. Such tools
are intended to analyze the probable risk of the respondents based on information provided on current health status. Most of the tools majorly focus on
the health diagnostics aspect of the risk wherein the observed symptoms
are assessed to assign a category of risk with some platforms providing
GIS based analysis of the geospatial risk based on current location of the
conﬁrmed cases. This leaves the understanding of risk limited to medical
conditions. However, Cheng and Kwang [6] points out at the role ofmany inter-connecting factors such as social behaviour and exposure
which contribute to the risk of contracting the disease as observed in thecase of SARS. In case of COVID19 also, observing personal hygiene like

http://dx.doi.org/10.1016/j.pdisas.2020.100109
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assessment is done through risk communication. Community based activism such as aggressively ﬁnding suspected cases and supporting vulnerable
groups was a successful advantage of South Korea to overcome the crises[36]. Japan's 26 national resilience working groups includes a high-level“STOP Pandemics 2020 Strategy Committee” which made many recommendations including on risk-communication so as to have a better integration of pandemic risks into all-hazard national resilience [9].
Risk Communication is the effective and accurate exchange of information about health risks and hazards often during an emergency [10]. The
aim of risk communication is to advance risk awareness and understanding
and to promote health-protective behaviour among individuals, communities, and institutions. The ultimate purpose of risk communication is to enable people at risk to take informed decisions to protect themselves andtheir loved ones. Risk communication is an essential part of the risk mitigation measures since it drives the public understanding, trust, acceptanceand compliance with the measures. Risk mitigation is an interdisciplinary
decision-making process based on information from risk and exposure assessment [11]. Risk Communication involves stakeholders like risk assessors, managers, news media, volunteer groups and the community. Risk
communication uses many communications techniques ranging frommedia and social media communications, mass communications and community engagement. It requires a sound understanding of people's perceptions, concerns and beliefs as well as their knowledge and practices. As
per Barry [12], if people had accurate information about the risks faced
and the knowledge of prevention, they often performed heroically and increase the compliance to public safety advisory of the government. Risk
communication, speciﬁcally, mass communication of public health information, can however have limitations of cultural issues as well as linguistic
barriers, especially for the migrant communities.
In March 2020, WHO setup a ‘WhatsApp’ group for providing information and risk mitigation instructions [11]. Various countries also launchednational communication measures structured in news and information
websites/platforms jointly combatting fake news, aiming to encourageawareness, understanding and compliance towards restrictions. As part ofsuch risk communication strategies, the mobile apps have come up as ameans for risk communication. A summary of some of the available risk assessment tools and apps in the market is given in the Table 1.
The above-mentioned risk assessment tools are mostly based on the premise of either tracking the affected patients or diagnosing a probable condition through symptoms. These tools and apps help the government as wellas the community in knowing if they have been in contact with an affected
person. Amidst the concerns for privacy, many private apps have come up
to aid in individual assessment of risk and contact tracing.
The RIKA's COVID-19 Risk Assessment Tool goes beyond the symptom
detection and patient tracking. It intends to provide information on social
behaviour and also assesses the people's compliance for the government advisory. The risk assessment score also includes the exposure of people
through the type of residence, the behaviour of hand-washing and wearing
mask as well as the current implementation status of restricted movement
guidelines of the government.
In comparison to the Arogya Setu App by Government of India, the
COVID-19 Risk assessment tool, provides awareness information in theform of questions which are also used to assess the risk based on behaviourand social compliance. Further, the COVID-19 Risk Assessment Tool generates information on anxiety levels to understand the need for psycho-social
care as part of overall response. The inclusion of smoking as a risk behaviour is also not considered in Arogya Setu app or any other Risk Assessment
Tool available in Asia or in the other continents. Another unique feature is
the assessment of exposure based on residential type which is again missed
in other available applications and tools.

avoiding to touch face, wearing masks, frequent washing of hands as well associal/physical distancing is prescribed. All these factors essentially are partof community and social behaviour and become part of the governance. As
per Shaw et al. [1] citizen compliance and behaviour resulted in containment of the spread in China and other countries.
Amidst the management and response to the COVID-19 pandemic, thispaper has two speciﬁc objectives. One is to explores the use of innovationand technology in assessing the people's behaviour in pandemic response.
Two to see how four parameters (health, exposure, Behaviour and Social
Policy) are linked. The paper introduces Covid19 Risk Assessment Tool developed by RIKA India (Indian based social entrepreneurship start up,
which works on disaster risk reduction, environmental management andsustainable development) as an innovative strategy for risk assessment,
communication, decision-making and awareness. The ﬁrst part explores
the risk assessment and risk communication in the context of emergencies
and speciﬁcally for COVID-19 pandemic. It undertakes a review of existingrisk assessment and information tools available online in the form of apps
and surveys. The second part concentrates on key features of RIKA's
COVID19 Risk Assessment Tool and discusses the methodology used for development of the tool. The third part focusses on data analysis based on the
responses of the Risk Assessment Tool. The data analysis uses Pearson's correlation coefﬁcient to understand if there exists any linear relation between
two variables and also to identify the strength of such relationship, if it exists. The analysis is followed by key inferences and conclusion.
2. Overview of existing COVID-19 related tools
Risk assessment is an important step in disaster risk reduction where it
enhances the understanding of risk and allows information to decide on adequate preventive and mitigation measures. Core methodologies for disaster risk assessment include hazard, exposure and vulnerability
assessment. Risk assessment is also widely used in the context of health,safety and environment. It involves evaluation of existing conditions of vulnerability, the impending hazard, existing exposure and current capacities
for prevention. Risk models specify the factors which are needed to assess
risk and the relationship among those factors, producing a sort of template
for risk assessors to use in their assessments. Health risk assessment tools
have been developed to assess individual risk for particular diseases.
Shaw et al. [1] points out the need to have a proper risk assessment including factors of health risk, governance, exposure and citizen behaviour.
To strengthen the community level response, a coordinated approach of disaster risk governance from Sendai Framework point of view is needed to
manage this public health emergency. In the case of China, emerging technologies like Artiﬁcial Intelligence (AI), Big Data, 5G technologies, drones,
automated vehicles, robotics etc. were used to track, monitor and support
logistics in management of Covid19 [ibid]. Technological risk assessment
models can quickly analyze irregular symptoms and other similar red
ﬂags and thus alarm the community and the healthcare authorities. This
helps to improve the planning, and awareness activities for patients on anevidence-based model. Further it helps to provide faster decision making,which is cost-effective. Such tools can help analyze the extent of infection
spread by this virus by identifying the clusters and hot spots and can successfully do the contact tracing and monitor of the individuals [7].
COVID-19 is as much a pandemic as it is an infodemic [5]. WHO Information Network for Epidemics (EPI-WIN) [8] was launched as a new information platform to share customized information with speciﬁc target
groups. The data on COVID-19 is dynamic and changing at a fast pace.
COVID-19 hotspots (areas with affected cases of COVID19) are changing dynamically. This makes a control of information difﬁcult. Social media in thisregard tends to be ﬂooded with messages many of which are not veriﬁed. As
per Hua and Shaw [5], the media use for information access for the COVID19 increased tremendously. However, the right information is the key to success in mitigation measures. The Chinese and Singapore government in thisregard have checked the fake news and kept control on rumour spreading.
Risk assessment generally remains in the domain of science and technology, academia and policy makers. Providing public access to the risk

3. Key features of COVID-19 risk assessment tool
The COVID-19 Risk Assessment Tool is a simple online tool which canbe used to assess the risk based on multiple linked factors. The main features of the tool are that it is simple and free to use. The simplicity of the2

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Table 1
Summary of online risk assessment tools.
S.
Name of the toolno.

Main features1.
2.

Identiﬁes coronavirus symptoms and provides further information regarding COVID-19 concerns.
It asks questions on following parameters and provides analysis of risk:

3.
4.
5.

Infermedica [13]Health Engine [14]6.

Henryford [15]Docsapp
WHO Mass Gathering Religious Addendum Risk
Assessment Tool in the context of COVID-19
Humandx.org [16]7.

Arogya Setu [17]8.

TraceTogether [17]9.

CovidWatch [17]10. HaMagen [17]11. The Corona DataSpende [17]12. PeduliLindungi [17]13. COVID Safe

• Travel History• Corona Positive patient contact history• Symptoms of Fever etc.
It asks questions on symptoms, with travel history and contact to provide risk analysis
It is an online doctor consultation app to provide information on symptoms and whether to consult a doctor.
• It is an ofﬂine Risk Assessment Tool for organisers and planners• It Includes Mitigation Checklist for planning mass gatherings and events.
It asks questions on age, travel history, symptoms, being in healthcare profession and co-morbidities. The assessment
summary provides information on preventive steps, the need to visit doctor, get tested etc.
The app veriﬁes symptoms and notiﬁes the users if they are in vicinity of a diagnosed positive patient. Tracking isdone via Bluetooth and a location-generated graph that charts proximity with anyone infected. The app also provides
self-quarantine instructions.
It is a contact tracing app that uses Bluetooth to track infected people and notify those who were in close proximity tothem during the past 15 days.
It uses Bluetooth signals to detect users when they are in proximity to each other and alerts them anonymously if they
were in contact with someone who has tested positive. One unique feature of the app is that any third party, including
the government does not have access to the data of who was exposed by whom.
This is launched by the Health Ministry of Israel. It uses contact tracing to contain the spread of the deadly contagion.
The app allows users to know if in the past 15 days they were close to anyone who has been diagnosed with the virus.
It is a German smartwatch app which monitors the spread of coronavirus by collecting symptoms like pulse rate, bodytemperature, sleep patterns to detect any early signs of warning. It is done through wearing a smartwatch or a ﬁtness
tracker.
It is developed by the Indonesian government. It enables users to compile data related to the spread of COVID-19 in
the community and helps conﬁrmed and suspected cases. It cross-references data stored on mobile device throughBluetooth. It enables an anonymous exchange of identities when in vicinity of another positive patient.
The Australian app helps state and territory health ofﬁcials to quickly contact people who may have been exposed to
COVID-19. The COVID Safe app speeds up the current manual process of ﬁnding people who have been in close
contact with someone with COVID-19.

is currently available in seven languages. The tool also adheres to the privacy norm by not collecting any personal information of the user likephone number or email ID.

app lies in the fact that there is minimal data entry. The tool prominently
includes questions related to awareness behaviour of the user in order to inculcate awareness. Key questions on whether social distancing is being
maintained reiterate the importance of such measures. The tool ensures
the implementation of risk communication to the end users. Further, thetool presents the analysis of risk in a visual format which is more appealing
to the people. The tool assesses the prevalence of co-morbidities in the users
which might increase their risk. As per Yang et al. [18], underlying diseases(Comorbidities), including hypertension, respiratory system disease andcardiovascular disease could be the risk factors for severe patients compared with non-severe patients of COVID-19.
Shaw et al. [1] notes that pandemic is global but its response is local. It
is also pointed out that a major part of the response depends upon the culture and citizen behaviour [19]. [ibid], also notes that in Japan, people
with colds, ﬂu, or allergic, wear surgical masks as a cultural norm to prevent
others from getting sick. The Japanese do not have emotional resistance towearing masks, whereas people in other countries need to be informed on
the need of wearing mask to prevent themselves as well as others. The survey assessment tool assesses the people's behaviour in wearing masks andcan help overcome emotional resistance to adhering to government guidelines on restricted movements and sanitation practices. The study of Cheng
and Kwang [6] demonstrated that although knowledge is important for
performing SARS-preventive behaviours, social norm is also an importantfactor.
The assessment tool allows the users to take adequate measures with respect to the risk outcomes of high, moderate and low. The assessment tool
also allows the measurement of risk perception through the level of anxiety
shown by the user in the current scenario. The Risk Assessment Tool ﬁghts
the infodemic. It shares the personalized risk assessment information. The
data analysis can also provide insights into how many people are taking
hand-washing seriously. It can detect the need for mental health risk assessment through anxiety level. The tool is a low-cost technology-based solution to provide assessment of individual risk as well as increase
community awareness. The tool is customizable in various languages and3.1. Methodology for tool development
The COVID-19 Risk Assessment Tool is broadly based on four major factors of health, exposure, behaviour and social policy. Each of these factors
have sub-factors which are based on ﬁndings from studies conducted in
China and Italy [27]. The various parameters used to develop the assessment tool can be categorised as shown in Table 2 below.
Each of the parameters are assigned linear weights based on the responses in the given options (Annex-1 for details). The given weights foreach parameter except for health are summed up and then average is calculated. The calculation is listed in Table 3 below.
The basic premise for calculation is that age and health is the inherent
individual vulnerability that is being exacerbated due to individual exposures and individual behavioural elements. Gender has also been found to
be a prevalent determiner of risk to COVID-19. The behaviour factor be5
and be6 are not scored for calculation of risk. Based on the above weightage
the risk is calculated as:
Risk ¼ ðHR  0:5Þ þ ðBe  0:2Þ þ ðEx  0:2Þ þ ðSP  0:1ÞThe output based on the above calculation gives us three different scenarios of risk as depicted at the end of the assessment: low, moderate andhigh risk along-with a general information advisory (Fig. 1 below).
This application has been deployed on Amazon Web Services (AWS).
AWS Simple Storage Solution (S3) is used to host the user interface (website). The user interface has been developed using AngularJS and Responsive Web Design. To distribute the web site content AWS CloudFront (Content Distribution Network, CDN) is used so that customers across the world
can access it with low latency and high transfer speed. Survey Data is submitted from https://www.covid19risk.net web site to AWS API Gateway,3

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Progress in Disaster Science 7 (2020) 100109

Table 2
Factors of risk assessment.
Health (HR)Behaviour (Be)Exposure (Ex)Social policy (SP)Age(A)
Co-Morbidities (Cm)Gender(G)Smoking Habit (Sm)Use of Mask (Be1)
Hand-washing (Be2)
Sanitizing before touching face (Be3)
Practicing Social-distancing norm (Be4)
Anxiety based on current situation (Be5)
Trust in government's measures (Be6)

Residential Type (Ex1)
Occupation (Ex2)
Travel History and Mass Gatherings (Ex3)

Effectiveness of Lockdown (SP1)
Community Compliance of social distancing and mask use (SP2)3.2. Methodology for data analysis
Table 3Calculation for risk assessment factors.
FactorCalculation

Weightage

Health Risk (HR)Behaviour (Be)Exposure (Ex)Social Policy (SP)Summation of A, Cm, G and Sm
Summation of four Be(s) and then divide by 4a
Summation of all Ex(s) and then divide by 3
Summation of all SP(s) and then divide by 2

50%
20%
10%
10%

The COVID-19 Risk Assessment Tool was launched in India on 11th
April 2020. Between 11th April and 4th May 2020, a total of 2216 responses were recorded. Of these, the data of test users and users with identiﬁed repetition was excluded to have unique response. This was done byapplication of ﬁlters in the data set using SPSS software. Two ﬁlters: IP address and Names were used to exclude the duplicate entries. As a result, a
total of 1293 respondents' data is used to analyze the emerging trends
and patterns.
The Statistical analysis used SPSS software (IBM Statistics 20) to sort thedata and understand relationship between variables using percentages,
graphs and Pearson Correlation. The Pearson correlation analysis wasused so as to understand the linearity between variables. As observed in[22], the Pearson Correlation can provide understanding on the relationship between variables. The assessment measured the variables of behaviour across different age groups, between variables of behaviour witheach other, between social policy and behaviour, between behaviour andexposure, between co-morbidities and age and other differenta
For behaviour factor, Be1, Be2, Be3 and Be4 are only considered to calculate
risk. Be5 and Be6 are not calculated owing to their dynamic and qualitative nature.

which internally calls AWS Lambda function to store the survey data into
Amazon DynamoDB Database. Entire application is serverless and it scales
out and scales in automatically based on the usage. The cost associated withthis kind of architecture is very minimal. Further, the geotagged locations
for each respondent are plotted on a map to show the respondents the probable risk around that location and also the pre-identiﬁed hotspots by thegovernment.

(b) Moderate Risk Output(a) Low Risk Output(c) High Risk Output(d) General Advisory

Fig. 1. (a) Low risk output, (b) moderate risk output, (c) high risk output, and (d) general advisory.
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Progress in Disaster Science 7 (2020) 100109

access to mobile phone usage being especially high among the youth andyoung professionals (Table 4).
It is observed that 93% entries ﬁlled for the COVID-19 Risk Assessment
Tool have been done by using mobile phone device. This is mainly attributed to ease of use of mobile phone and circulation of the Risk Assessment
Tool through social media messages. As per Telecom statistics report of
TRAI (Telecom Regulatory Authority of India), India's active mobile users
reached 1026.37 million in 2018 [25,26].
Further, it suggests that the tool can thus be possibly enhanced as a mobile based application owing to the vast use of mobile phone devices. The
mobile based application and a greater number of users would aid to
crowd-sourcing of vital details to map the high-risk areas. The number of
entries from foreign countries is 12.5%. This implies that the Tool has
wide application where one can use it not only in India but also by NonResident Indians (NRIs) keen to check on the status of their friends and families in India. In addition, the tool can be used to take multiple surveys forfamily members who stay distantly. This is applicable to aged population
who are not technology savvy and would need assistance of their children
or other family members to ﬁll up the survey.
As per ECDC [27], there is an increased mortality rate among males incomparison to females as have been observed among the COVID-19 patients. From the analysis of the data, only 12 people among the respondents
featured in high risk and 11 of them are male, and one being the other gender. The ﬁndings are consistent with immune system variance among male,
female and other gender [35]. The other gender has high risk due to compromised immune system. Further, 585 respondents fall within the medium
risk category. Within this category also, the total constitution of men andother gender stands at 91%. The third category i.e. low risk has 696 of
the respondents. Within this category the percentage of men stands at
68%. Thus, it re-establishes that females are comparatively at lower risk
as they do not feature in high-risk category and in moderate risk also
their percentage is only 9%.
Within the high-risk category, all the respondents are found to be
above the age of 60 years. As per [ibid], the risk increases with an increase in age as observed in cases from China and South Korea. For
Germany, Italy and Spain, the crude-case fatality increases particularly
after the age of 60 years. However, there is an exception, where there
are three cases in the age-group of 0–9 who fall under the medium
risk. This is largely due to their residential type of an informal settlement and low compliance on behaviour factor of wearing mask, handwashing and sanitizing hands before touching face. Further, there arethree cases of individuals aged 80 years and above falling in medium
risk. This is attributed to higher compliance of behavioural factors andlow co-morbidity score.

combinations to understand and quantify the relationship of variables.
Pearson's correlation coefﬁcient was calculated to compare quantitatively
the similarity between tow variables and to indicate quantitative discrepancies in the similarity. Pearson's correlation coefﬁcient (ranging from −1 to+1) is a measure of the strength of the association between the two variables. A value of +1 is the result of a perfect positive relationship between
these variables. Annexure-2 presents a summary of the results obtained
from applying the correlation coefﬁcient for different variables. The correlation coefﬁcient is studied as per [24]. If the coefﬁcient value lies between±0.50 and ± 1, then it is said to be a strong correlation. If the value lies
between ±0.30 and ±0.49, then it is said to be a moderate correlation.
When the value lies below ±0.29, then it is said to be a weak correlation.
There is no correlation when the value is zero.
3.3. Data collection strategy
A spoke and wheel propagation strategy were adopted for disseminating the tool. The tool was shared with various groups through WhatsApp,
Facebook and through personal networks over email. Further, it was requested for the users to share it further within their own networks. The featuring of the tool on International Science Council and GDFRR Newslettergave it wider audience and credibility.
3.4. Limitations
The limitations of the study pertain to limited sample size of analysis
with 1293 samples. Further, the data from the survey tool may not be
equally represented from each state, thus giving partial spatial analysis.
The study uses the weighted variable to understand trends and patterns inplace of absolute numbers. This is because the tool is meant to categoriserisk based on the information and not for the survey as a primary objective.
4. COVID-19 risk assessment tool in India and key ﬁndings
The COVID-19 Risk Assessment Tool has been promoted and widelyused in India. India, the second most populous country, currently has
90,000 active cases of the COVID-19 as on May 15, 2020 [20]. The stringof measures taken by the Indian government have so far proved successful
in containing the spread of the disease. A timeline series analysis of themeasures and increase in cases is as given in Fig. 2 below. As observed, despite the strict measures, the cases of affected patients are still on a rise.
A total of 2216 respondents used the tool across various States in India
between its launch and 4th of May 2020. A majority of the respondents fallin the age group of 10–39 followed by 40–49. This is possibly due to theFig. 2. Timeline Series Analysis of measures taken in India and an increase in affected cases [21].
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nose and mouth, 63% people are practicing it (Fig. 4c). It is often seenthat we inadvertently tend to touch our face while being engaged in othertasks. As per the data reports, social distancing at individual level is being
well-followed with 88% complying to it (Fig. 4d). Considering that there
is no conﬁrmed cure for the COVID-19 diseases, risk preventive behaviouris the key to mitigate and contain the spread of the disease.
Regarding the question on response to the COVID-19 outbreak, 51%
people responded with the need to have new measures to bring it undercontrol (Fig. 5) and 32% people believed that current measures are sufﬁcient to bring it under control. This leaves scope for citizens to provide feedback with suggestions to improve the current measures of response.
With respect to anxiety, as depicted in Fig. 6, within the high risk category, there are 66.66% people who have reported being anxious due topresence of positive cases in their locality (i.e. scoring for Be5 in level 1),
within the medium risk category, 36.92% people have reported similarlevels of anxiety and within the low risk category, 25.67% have reported
to be anxious. This states that there is more anxiety within high risk category people followed by medium and low risk categories.
In terms of effectiveness of lockdown, 75% of people have reported it tobe followed with maximum compliance (Fig. 7a). In terms of mask wearing
and maintenance of social distancing, 47% reported more than 80% people
are following it while % people responded that some people (50–80%) arefollowing it (Fig. 7b). Hence, while effectiveness of lockdown is being ensured, the community level compliance of wearing mask and maintenanceof social distance needs to be improved.
With respect to respondent data regarding the type of residence, 40%
reported it from detached houses, 30% from high rise complexes, 21%from Mohalla/chawl/shared accommodations and 8% from informal settlements (Fig. 8). As suggested in [28] building types have direct impact on
the risk of spread of pandemic. The informal settlements and shared accommodations are at most risk. The high-rise apartments also increase the aggregation of people in less space.
The Exposure component is also measured in terms of occupation type(Fig. 9a). It is observed that maximum respondents (48%) did not fall inhigh risk occupation types (Medical and emergency professionals). Closely
followed are the essential service providers (41%) who are at risk of exposure. Another important variable of exposure is the travel history including
use of public transport or chauffeur driven cab and attendance of public
meeting, mass congregation or wedding/conference. The 90% of the respondents have not been involved in any of these activities in the last
14 days (Fig. 9b).
Table 5 below depicts the important correlation aspects as observed
from the Pearson's Correlation Analysis (Annex-2). The factors of age andco-morbidities has shown a positive and moderate correlation with coefﬁcient of 0.434. As per Divo et al. [29] ageing population tends to be more
affected by multiple morbidities. The same result is depicted by a negative

Table 4
Descriptive statistics of respondents.
Total number of respondent data considered
Total number of respondent data
Number of duplicate and test entries
Total number of data considered for analysis

2216
923
1293

Gender disaggregated data
Number of males
Number of females
Others1012
272
9

Age-group categorisation
0–9
10–39
40–49
50–59
60–69
70–79
80 & above

5
853
202
126
62
38
7

Smoking habit
Number of smokers

205

Co-morbidities
Cardio-vascular diseases (heart problem)
Renal diseases (issues with kidney)
Diabetes
Respiratory disease chronic obstructive pulmonary disease (emphysema,
bronchitis)/asthma, lung cancer
Tuberculosis
Cancer (in last 5 years) (except lung cancer)
Hypertension

64
34
125
73
34
24
164

Risk categorisation
High risk
Moderate risk
Low risk

12
585
696

Spatially, maximum data entries have been received from the states of
Uttar Pradesh, followed by Maharashtra, West Bengal and Gujarat(Fig. 3). While writing this paper, the state of Maharashtra has the highest
number of COVID-19 affected cases with its capital Mumbai being the worst
hit. Spatial analysis allows to identify areas which have maximum cases of
the Covid-19 diseases and also allow the maps which are generated fromcrowd-sourced data to be more representative in nature.
The ﬁndings on the individual behaviour suggest that 89% people use
mask and 87% people use sanitiser every time after coming home (Fig. 4a
and b). However, when it comes to sanitizing hands before touching eyes,

Fig. 3. State wise spatial distribution of respondents (` = 1293).
6

R. Chatterjee et al.

Progress in Disaster Science 7 (2020) 100109

Fig. 4. (a): Use of mask; (b): use of hand-sanitiser; (c): sanitizing before touching face; (d): Social distancing (n = 1293).

correlation coefﬁcient of −0.420 age-group with no disease factor. This relationship between age-group and co-morbidities is an important risk factor
for Covid-19 disease too as it places the elderly population with existing disease at a higher risk of mortality. As observed, the age-group and total risk
depict a strong positive correlation with coefﬁcient of 0.835. Similarly, comorbidities and total risk also have strong correlation with a coefﬁcient of
0.678. Within the co-morbidities, hypertension stands-out most with amoderate positive correlation of coefﬁcient 0.418. Diabetes also has a moderate positive correlation with a coefﬁcient of 0.400. This means hypertension and diabetes are two important factors which increase the overall
health risk. The tool gives maximum weightage to health factor in assessing
the risk and this is also shown with a strong positive correlation coefﬁcientof 0.98 between health and total risk.
With respect to individual behaviour, wearing of mask and following ofsocial distancing norm has a weak correlation with a coefﬁcient of 0.298.

This depicts that while one may practice social distancing but might notcomply with mask wearing or vice versa. However, washing hands andcompliance of social-distancing has a slightly higher correlation coefﬁcientof 0.364. The gender and behaviour show negligible correlation with a coefﬁcient of 0.017 which means behaviour factors are not dependent on gender. Similarly, age-group and behaviour have negligible correlation with a
coefﬁcient of 0.048.
The study [27] states the need to reduce smoking as a possible preventable determinant of the Covid-19. Hence, the tool places smoking habit at ahigher risk and as observed from correlation coefﬁcient of 0.302, there is amoderate positive correlation between smoking and total risk.
There are two components considered in social policy factor: effective
lockdown and community compliance of wearing of mask and practicing
social distancing. Ideally, the two factors should have a strong positive correlation. However, as observed, there is a positive moderate correlation
with a coefﬁcient of 0.363 between the two factors. Further, the social

Fig. 5. Description of current measures (n = 1293).

Fig. 6. Anxiety within different Risk Categories (n = 1293).
7

R. Chatterjee et al.

Progress in Disaster Science 7 (2020) 100109

Fig. 7. Social policy compliance: (a) effectiveness of lockdown, 7(b) wearing mask and social distancing in locality (n = 1293).

governance mechanisms [ibid]. The COVID-19 Risk Assessment tool isaimed at awareness generation, risk communication and aiding indecision-making. As per Lin et al. [23], increase in information gatheringwith respect to google searches on hand-washing and wearing masks correlated with lowering the speed of COVID-19. The role of technology has
emerged as of great importance in emergency management specially forrisk communication. The important issue is how the technology can beused with proper governance mechanisms so as to enhance the capacityof the decision-makers in government set-up. The study has shown thatthe risk assessment tool is majorly being used via mobile devices and canthus be possibly enhanced as a mobile based app. Further, as per Silver
et al. [31] the younger population are more likely to own a phone than
the adults. This also features in the higher number of entries received
from the age-group pf 10–39 than the other age-groups.
The study has re-iterated the characteristics of the COVID-19 pandemic
as mentioned in [1] by showing strong correlation of total risk with age andco-morbidities. In terms of co-morbidities, hypertension followed by diabetes has appeared to be major factor in adding to the total risk. As per
Sivasubramanian et al. [32], there is a high prevalence of hypertension,
with almost one in every three Indian adults affected. In addition to it,
smokers are found to be more at risk with a moderate correlation between
smoking and total risk. This ﬁnding corroborates with the study in [27]which portrays smoking as a risk factor contributing to the COVID-19 fatalities. In terms of gender, males remain more susceptible than female in highrisk category. Anxiety in general has appeared as a major cause of concern

policy and individual behaviour also depict a positive and moderate correlation with a coefﬁcient of 0.266.

5. Discussion
Effective risk communication measures can result in increasing theawareness and creating social trust in the authorities [30]. Providing theright information can result in risk preventive behaviour and enhance risk

Fig. 8. Exposure based on residential type (n = 1293).

Fig. 9. (a): occupation type, (b): travel and public event attendance history (n = 1293).
8

R. Chatterjee et al.

Progress in Disaster Science 7 (2020) 100109

Table 5Pearson correlation analysis (n = 1293).
Variables

Strength ofcorrelation

Pearsoncorrelation
coefﬁcient

Age-group and Co-morbidities
Age-Group and No disease
Age-Group and Total Risk
Wearing of mask and following of Social Distancing norm (Individual behaviour variables be1 and be4)
Washing hands and compliance of social distancing norms (Individual behaviour variables be2 and be4)
Co-morbidities and Total Risk
Co-morbidities and hypertension
Co-morbidities and diabetes
Gender and Behaviour (be score - all four individual behaviour variables)
Age-Group and Behaviour
Gender and Health (health score accounting all variables of health factor)
Total Risk and Health Score
Smoking and Total Risk
Social Policy Variables- Sp1 Effective Lockdown and Sp2 Community compliance of wearing mask and social distancing
Social Policy Score and Behaviour Score

Positive and moderate correlation
Negative relation with a moderate strength
Positive and strong correlation
Positive and weak correlation
Positive and moderate correlation
Positive and strong correlation
Positive and moderate correlation
Positive and moderate correlation
Negligible correlation
Negligible correlation
Positive and moderate correlation
Positive and moderate correlation
Positive and moderate correlation
Positive and moderate correlation
Positive and moderate correlation

0.434−0.420
0.835
0.298
0.364
0.678
0.418
0.400
0.017
0.048
0.346
0.983
0.302
0.363
0.266

Lack of national data privacy laws and non-transparency in governance ofsuch data collected are some of the issues ﬂagged by people as part of resistance to use the Arogya Setu app of Government of India [34]. RIKA's
COVID-19 Risk Assessment Tool addresses the concern by not collecting
any personal data like mobile number or accessing the location history of
the user.
Artiﬁcial intelligence has been used for emergency data management,
especially for managing social networks and big data. The people areusing digital technologies to support disaster management. Crowdsourcing
is helping to add vital details to maps of disaster areas. Citizen science is becoming more popular and effective before, during, and after disasters.
Grassroots or demand-driven innovation has been practiced in many countries in recent years. In this aspect, the COVID-19 Risk Assessment Tool presents itself as an innovative approach of using science and technology forenhancing community preparedness. The crowd-sourced data and maps
generated allow the stakeholders like Government agencies and NGOs toplan the response and interventions. The Risk Assessment tool is ﬂexible
and it has a simple user-interface. This allows it to be contextualised tocater to any target community with speciﬁc need. This adaptability of thetool places it as a unique innovation coming from the citizen science approach. The two-way data interface in the form of feedback mechanism provides platform for participation of citizens in decision-making for the
response strategies. As observed from ﬁndings, 51% people have marked
for the need of new measures to control the pandemic. This paves way fora more participatory approach for the decision-makers in planning an intervention at the local level. To re-iterate Shaw et al. [1] the pandemic isglobal but the response is local, this tool allows for a more contextualised
and community speciﬁc response.

and adequate mental health counselling measures are needed to be in placeespecially in areas where cases have been detected.
As the paper states, the COVID-19 Risk assessment tool goes beyond the
medical symptoms and considers factors of individual behaviour and social
policy. In this regard, it is observed that there is a weak correlation between
individual behaviour and social policy. Also, there is weak correlation between individual behaviour of wearing mask and practicing social distancing. Cheng and Kwang [6] states the importance of social behaviour incontribution to the risk of contracting the disease as observed in the caseof SARS. Thereby, a weak correlation between individual behaviour and social policy compliance depicts a gap in the governance and implementation
mechanism. This implies that there is a need for more awareness generation
among community. Since a major part of response of pandemic depends on
culture and citizen behaviour [19], the decision-makers need to design
targeted intervention policies for creating the risk preventive behaviour
and increasing the community compliance of the social policy measures.
The ﬁnding regarding the lower age group (0–9 years) being in moderaterisk category depict that there is a need to educate children about touching
the face without sanitizing their hands as they might do it more frequently
than adults. Further, children speciﬁc risk communication means can be developed so as to ingrain the preventive behaviour. As noted in [33] people's
behaviour is inﬂuenced by social norms: what they perceive that others are
doing or what they think that others approve or disapprove of. Risk perception can be changed by promoting public messages reinforcing positive
health-promoting norms[ibid]. Public knowledge of risk allows for change
in perspective and more social compliance in terms of adoption of risk preventive behaviour. The interventions can focus on targeting well-connectedindividuals and making their behaviour change visible and salient forothers to copy.
As only 8% people have responded from informal settlements, this depicts a wide gap in digital divide in the country. Many of the respondents
living in informal settlements reﬂect the bottom most layer of the social
and income structure. Inequalities in access to resources affect not only
who is at greatest risk of infection, developing symptoms or succumbing
to the disease, but also who is able to adopt recommendations to slow the
spread of the disease. Such communities may be more likely to be wary
about the public health information they receive, less willing to adopt recommended safety measures and potentially more susceptible to ‘fakenews’[ibid]. In this regard, community-oriented tools of risk awarenessneed to be more popularized so that risk communication reaches the last
mile. Tashiro and Shaw [19] mentions a human-centric society where technology connects people and tries to reduce the barrier of digital divide. The
COVID-19 Risk Assessment Tool is multi-lingual tool which helps the communities to access the advisory and understand the individual risk in a simpliﬁed way. This is particularly helpful for migrants who need tounderstand the risk in their own language. Citizens might also be wary ofusing the government supported tools and apps for the concerns of privacy.

6. Conclusion
While writing this paper, the number of affected cases in India is still on
a rise while countries like Singapore, South Korea, China and a few otherare expecting a second wave of pandemic. In this backdrop, the preventive
measures need to be strengthened at all costs and citizen's behaviour as has
been seen in South Korea and Japan is an important factors to break the
chain. For a populous country like India, where it is difﬁcult for the current
health infrastructure to accommodate and treat an exponential increase
number of the patients as had been seen also in Italy, China and UnitedStates of America for treatment, it is best to follow the preventive strategies.
RIKA's COVID-19 Risk Assessment Tool can be used to reach the last milecommunity, ascertain the individual behaviour, social compliance and exposure factors in order to ﬁnd out relevant areas of intervention and at
the same time increase awareness generation among the community. As
rightly pointed out by [4], the management of COVID-19 pandemic is interwoven within the global governance, technology and risk communication.
This pandemic is witnessing a change in the social norm and a new normal
9

R. Chatterjee et al.

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is being established. This is also an opportunity for new innovative technologies to break the digital divide and increase the resilience of the most vulnerable communities through democratic information access andparticipatory decision-making to develop a local level response strategy.
CRediT authorship contribution statement
Ranit Chatterjee: Conceptualization, Methodology, Writing - originaldraft, Writing - review & editing. Sukhreet Bajwa: Formal analysis, Writing - original draft, Writing - review & editing. Disha Dwivedi: Formal
analysis, Writing - original draft, Writing - review & editing. Repaul
Kanji: Methodology. Moniruddin Ahammed: Investigation. Rajib
Shaw: Conceptualization, Methodology, Writing - original draft, Writing review & editing.
Declaration of competing interest
The authors declare that they have no known competing ﬁnancial interests or personal relationships that could have appeared to inﬂuence thework reported in this paper.
Acknowledgements
We thankfully acknowledge the inputs from Prof. Emily Chan, Professorand Associate Director (External Affairs and Collaborations); Head, Division of Global Health and Humanitarian Medicine JC School of Public
Health and Primary Care Centre. We acknowledge Mr. Amit Chowdhury,
Mr. Tushar Kumawat and Mr. Dipanjan Bhowmik and the team of Profecia
Links for the survey page design.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.pdisas.2020.100109.
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Progress in Disaster Science 6 (2020) 100080

Contents lists available at ScienceDirect

Progress in Disaster Sciencejournal homepage: www.elsevier.com/locate/pdisas

Invited ViewPoint

Building resilience against biological hazards and pandemics: COVID-19 andits implications for the Sendai Framework⁎

Riyanti Djalante a,b, Rajib Shaw b,c, , Andrew DeWit daAcademic Programme Ofﬁcer, United Nations University-Institute for the Advances Study of Sustainability (UNU-IAS), Japan
Integrated Research on Disaster Risk (IRDR), Japan
Graduate School of Media and Governance, Keio University, JapandSchool of Economic Policy Studies, Rikkyo University, Japanbc

A R T I C L E

I N F O

Article history:
Received 20 March 2020
Accepted 23 March 2020
Available online 24 March 2020
Keywords:
Sendai Framework for Disaster Risk Reduction(SFDRR)
COVID-19
Health-emergency disaster risk management(Health-EDRM)
Resilience
Disaster
Pandemic

A B S T R A C T

2020 has become the year of coping with COVID-19. This year was to be the “super year” for sustainability, a year ofstrengthening global actions to accelerate the transformations required for achieving the 2030 agenda. We argue that2020 can and must be a year of both. Thus we call for more utilisation of the health-emergency disaster risk management (Health-EDRM) framework to complement current responses to COVID-19 and the patent risk of similar phenomena in the future. To make our case, we examine current responses to COVID-19 and their implications for the SFDRR.
We argue that current mechanisms and strategies for disaster resilience, as outlined in the SFDRR, can enhance responses to epidemics or global pandemics such as COVID-19. In this regard, we make several general and DRRspeciﬁc recommendations. These recommendations concern knowledge and science provision in understanding disaster and health-related emergency risks, the extension of disaster risk governance to manage both disaster risks and potential health-emergencies, particularly for humanitarian coordination aspects; and the strengthening of communitylevel preparedness and response.

Contents
1.
2.

3.

Introduction: SFDRR and Health Emergency and Disaster Risk Management (Health-EDRM) . . . . . . . . . . . . . . .
Responses to COVID-19 from global to national level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.1.
Global level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.2.
Regional level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.3.
National level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.3.1.
Asia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.3.2.
Europe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.3.3.
North America . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Recommendations on how current strategies for disaster resilience can contribute to responses to COVID-19 . . . . . . . .
3.1.
General responses and societal adjustments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.1.1.
Legal aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.1.2.
Health and science aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.1.3.
Lifestyle aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.1.4.
Learning from prior experiences makes a difference . . . . . . . . . . . . . . . . . . . . . . . . .
3.2.
DRR-speciﬁc recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.2.1.
Stronger knowledge and science provision in understanding disaster and health-related emergency risks . .
3.2.2.
Mobilise existing disaster risk governance structure to manage disaster risk and potential health-emergencies
3.2.3.
Utilise existing disaster coordination mechanisms at regional level to inform epidemic response . . . . . .
3.2.4.
Understand COVID-19 economic implications and resilience. . . . . . . . . . . . . . . . . . . . . .

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⁎ Corresponding author at: Graduate School of Media and Governance, Keio University, Japan.
E-mail addresses: djalante@unu.edu, (R. Djalante), shaw@sfc.keio.ac.jp, (R. Shaw), dewit@rikkyo.ac.jp. (A. DeWit).

http://dx.doi.org/10.1016/j.pdisas.2020.100080
2590-0617/© 2020 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

R. Djalante et al.

Progress in Disaster Science 6 (2020) 100080

Contents lists available at ScienceDirect

Progress in Disaster Sciencejournal homepage: www.elsevier.com/locate/pdisas
3.2.5.
Prepare inclusive early recovery plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.2.6.
Strengthen community-level preparedness and response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1. Introduction: SFDRR and Health Emergency and Disaster Risk Management (Health-EDRM)
COVID-19 has rapidly morphed into an unprecedented health, economic
and geopolitical crisis. It surely underscores the imperative of accelerating the
integration of multiple global policy frameworks, not least those at the centreof the 2030 Agenda. Prior to the emergence of COVID-19, the UN Secretary
General had positioned 2020 as the “super year” for action on sustainability(UN, 2020). The Sustainable Development Goals (SDGs), Paris Agreement
on Climate Change, and the New Urban Agenda, alongside the SFDRR were
all adopted in 2015–2016. March 18th, 2020 marks the ﬁfth anniversary of
implementation of the 2015–2030 Sendai Framework for Disaster Risk Reduction (SFDRR). The SFDRR aims to enhance national and community capacity to cope with disaster risks. It emphasizes a comprehensive approach,to address multiple hazards (technological, biological and environmental)
that impact at different scales, frequency, and intensity (UNISDR, 2015).
Human health cross-cuts all the global frameworks. The SFDRR explicitly includes epidemics and pandemics among biological hazards (UNISDR,2015) [1–3]. Moreover, SDG 3 is devoted to “good health and well-being”,
with an emphasis on “early warning, risk reduction and management of national and global health risks” (UN, 2015). For its part, the Paris Agreement
and the Intergovernmental Panel on Climate Change Assessment Reporthighlights that climate change exacerbates health risks including pandemics (see e.g. [4,5]). The recently edited book by Chan and Shaw [6]on Public Health and Disasters is timely since it highlights the progress
and importance of the Health-EDRM framework adopted by the WHO in
2019. Health-EDRM refers to the “systematic analysis and management ofhealth risks, posed by emergencies and disasters, through a combinationof (1) hazard and vulnerability reduction to prevent and mitigate risks,(2) preparedness, (3) response and (4) recovery measures” (WHO 2019).
Health-EDRM is thus an umbrella term, which the WHO uses to refer tothe broad intersection of health and disaster risk management (DRM). It
also comprises such areas as emergency and disaster medicine, bolsteredhealth systems and resilience, disaster risk reduction, humanitarian response, and community health resilience [7].
Against the backdrop of still-worsening COVID-19 impacts, this paper
discusses resilience building for pandemics and related biological hazards.
We examine ongoing efforts to respond to COVID-19 and these efforts' implications for the Sendai Framework. Our analysis reveals speciﬁc areas of
rapid response to COVID-19. But we ﬁnd lamentably few actions by DRRrelated organisations, in spite of the SFDRR's call for building resilience tobiological hazards. Moreover, the current WHO-led coordinated response
reveals little implementation of the WHO Thematic Platform for HealthEDRM adopted in 2019. Existing mechanisms and strategies for disaster resilience, such as those detailed in the SFDRR, offer concrete means to respond effectively to epidemics and even global pandemics such as COVID-

666

19. We thus put forward general and DRR-speciﬁc recommendations for
short and long-term resilience.
This viewpoint is structured as follows. In the introduction, we present
the motivation for the paper along with brief reviews of the recent progressof SFDRR and Health-EDRM implementation. Section 2 reviews global responses to COVID-19 complemented with discussion of responses by agencies related to DRR. Section 3 elaborates our recommendations supportedwith examples and cases.
2. Responses to COVID-19 from global to national level
This section brieﬂy investigates current responses to COVID-19 from theglobal, regional to national levels. We do not engage in an exhaustive review of approaches at any level, and instead use representative cases todemonstrate our key argument. That is, we focus our analysis on whether
a given level - global, regional or national - includes signiﬁcant input
from DRR-related agencies. To us, the evidence suggests that COVID-19
has yet to elicit early and rapid action from the DRR-related organisations.
We believe this passivity belies the SFDRR's call for building resilienceagainst all hazards, including biological hazards.
2.1. Global level
The global level of response includes the UN's COVID-19 communications wherein the Secretary General has called for “coordinated, decisive,
and innovative policy action” on COVID-19. The World Health Organization, under Director-General Dr. Tedros Adhanom Ghebreyesus, leads thecoordinated response for COVID-19. On the 11th of March, the DG announced that COVID-19 is a global pandemic. As of March 20, WHO's
front page focuses on the COVID-19 outbreak (https://www.who.int/
emergencies/diseases/novel-coronavirus-2019) (Fig. 1). The WHO hascalled for at least US$675 million to fund critical response efforts in countries most in need of help through April 2020.
The above and other content indicate that the WHO (2019) framework
on Health Emergency and Disaster Risk Management (Health-EDRM) has
no apparent role in the current response strategies. Certainly there is no
mention of disaster at all within the WHO Coronavirus disease (COVID19) technical guidance, particularly on the COVID-19 Strategic Preparedness and Response Plan, regarding Operational Planning Guidelines to Support Country Preparedness and Response (WHO, 2020).
Also at the global level, the UN Ofﬁce for DRR [8] issued a press releaseon the 12th of March 2020 urging disaster management agencies to prioritize biological hazards. The UNDRR asked national disaster management
agencies to continue with the development of their preparedness and response capacities to include health emergencies as a top priority, alongsideearthquakes, ﬂoods, storms and other natural hazards (UNDRR, 2020). It

http://dx.doi.org/10.1016/j.pdisas.2020.100080
2590-0617/© 2020 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

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Progress in Disaster Science 6 (2020) 100080

Centre) is involved in the ASEAN's response to COVID-19. AHA Centre isan inter-governmental organisation which aims to facilitate cooperationand coordination among ASEAN Member States and with the United Nations and international organisations for disaster management and emergency response in ASEAN region. Leadership is beyond the mandate of
the AHA Center (see https://ahacentre.org/about-us/). But its plethora ofexisting mechanisms can and should be used. These mechanisms include
the Emergency Operations Centre (EOC), the Standard Operating Procedure for Regional Standby Arrangements and Coordination of Joint Disaster Relief and Emergency Response Operations (SASOP), the ASEAN Joint
Disaster Response Plan (AJDRP), the Disaster Emergency Logistics System
for ASEAN (DELSA), the Emergency Response and Assessment Team(ERAT), the ASEAN Regional Disaster Emergency Response Simulation Exercise (ARDEX), ASEAN-ERAT (ASEAN-Emergency Response and Assessment Team) and the AHA Centre Executive (ACE) Programme (REF).
Globally, the ASEAN region is one of the most vulnerable to disasters, and
the AHA Center has been praised for its role in strengthening DRM in theregion (e.g. [9,10]). These competencies surely ought to be deployed in addressing the rapid emergence of COVID-19 as well as building resilienceagainst a repeat.
Another item of note is the South Asian Association for Regional Cooperation (SAARC). SAARC is the regional intergovernmental organisationand geopolitical union of states in South Asia. Its member states are
Afghanistan, Bangladesh, Bhutan, India, the Maldives, Nepal, Pakistan
and Sri Lanka. The SAARC leaders held a video conference on 15 March
2020 to discuss measures to contain the spread of COVID-19 in the region(GoI, 2020). India's Prime Minister initiated the conference, calling upon
SAARC leaders to work collectively to ﬁght the spread of the pandemic in
the region. India called for the creation of a COVID-19 Emergency Fund,with voluntary contributions from all Member States. India itself pledged
US$ 10 million as an initial contribution. There is no further information
available. To be sure, SAARC developed a Comprehensive Framework on
Disaster Management and Disaster Prevention in 2005 and established anumber of SAARC centres, chieﬂy the SAARC Centre for Disaster Management and Preparedness (SDMC) to implement the framework. Yet progress
to build the DRM capacities of South Asian states through regional cooperation has been slow (Brookings-LSE, 2015). There have long been doubts
about SAARC's effectiveness (e.g.[11]) and readiness [12], so it may not
be up to the task of coordinating a regional response to COVID-19.
In Africa, WHO-African region coordinates the response, with its latest
Situational Report announced as of 18 March 2020. A total of 345 conﬁrmed COVID-19 cases have been reported across 27 countries in the region (WHO-AFRO, 2020). Financially, Melinda and Gates' foundation
issued USD 115 million in aid for COVID-19 with USD 100 million pledged
to Africa and South Asia.

also highlighted the importance of silo-breaking in disaster prevention andmanagement, notably the silos between disaster management and healthworkers. The UNDRR reiterates that the Sendai Framework emphasizes
the need for resilient health systems and the integration of disaster risk
management into health care provision at all levels. After all, Sendai turns
the focus from disaster response and management to preparedness, surveillance and disaster risk management in the health context (UNDRR, 2020).
Yet it is not clear whether COVID-19 is leading to collaboration between the
WHO and the UNDRR.
We appraise the speed and scale by which COVID-19 response funds are
made available. International funding organisations, regional government
bodies and private entities have proposed major ﬁnancial measures. The International Monetary Fund (IMF) made $50 billion in loans available todeal with the coronavirus, including $10 billion of zero-interest loans to
the poorest IMF member countries (IMF, 2020). The EU Commission President Ursula von der Leyen announced a €25 billion coronavirus investment fund for the health care sector, labour market and SMEs (EU, 2020).
The World Bank Group increases COVID-19 Response to $14 billion to
help sustain economies and protect jobs. The Asian Development Bank
(ADB) announces $6.5 billion initial response to COVID-19 pandemic(ADB, 2020). The UN announced $15 million dollars from the UN's Central
Emergency Fund to help fund global efforts to contain the spread of the
COVID-19 coronavirus, particularly vulnerable countries with weak healthcare systems (UN, 2020). It is important to note that in the SFDRR, investment and ﬁnance are at the core of Sendai Framework, in terms of the resilience investment needed for countries and communities.
2.2. Regional level
We separate the regional level into Europe, Asia, and Africa. Concerning
the former, the European Commission (EC) leads the planning and implementation of European Union (EU) strategy, its role in setting priorities,
and its implementation through EU policy. A dedicated website is https://
ec.europa.eu/info/live-work-travel-eu/health/coronavirus-response_en.
The EU has established a common European response to the outbreak of
COVID-19, focusing on public health sectors and socio-economic impact
particularly mobility and economy in the European Union (EU, 19th
March 2020). Italy is the most severely impacted country in the EU. The
EC support for the Sendai Framework identiﬁes health as one of the issues
interlinked with DRR (EC Web, 2020). Yet it is unclear whether the EU response to COVID-19 features coordinated involvement by DRR-related
agencies and mechanisms. The opportunity for integration may be possible
through the Integrated Political Crisis Response (IPCR). The IPRC provides
a ﬂexible crisis mechanism for supporting the presidency of the Council of
the European Union in dealing with major natural or man-made crosssectorial disasters, as well as acts of terrorism. The IPCR works throughcommon Monitoring and Information-sharing (EU, 2016).
In Asia, the response of the Association of Southeast Asian Nations, or
ASEAN, is instructive. The ASEAN was established on 8 August 1967 in
Bangkok, Thailand, with the signing of the ASEAN Declaration (Bangkok
Declaration) by Indonesia, Malaysia, Philippines, Singapore and Thailand.
The ASEAN now includes 10 member countries and coordinates regional
action. Concerning COVID-19, ASEAN has issued ASEAN Health Sector Efforts in the Prevention, Detection and Response to Coronavirus Disease2019 (ASEAN, 2020). Guided by the ASEAN Post-2015 Health Development Agenda (APHDA) and its Governance and Implementation Mechanism (GIM), the ASEAN Health Sector Cooperation deployed andoperationalized the established and existing health mechanisms for technical exchanges, information sharing, and updates on policy-related measuresin responding to COVID-19. ASEAN specialised agencies involved are theASEAN Emergency Operations Centre Network for public health emergencies (ASEAN EOC Network), ASEAN Senior Ofﬁcials for Health Development (SOMHD) of ASEAN and China, Japan and Republic of Korea (Plus
Three Countries), and ASEAN BioDioaspora Regional Virtual Centre(ABVC) (ASEAN, 2020). There is no indication that the ASEAN Coordinating Centre for Humanitarian Assistance on disaster management (AHA

2.3. National level
It is very clear that responses to COVID-19 centre on actions at the
global and national level. We organise the review by the regions.
2.3.1. Asia
The ﬁrst known case of COVID-19 emerged in the Chinese city of
Wuhan on December 12,019 and was deemed an emergency in the third
week of January 2020. WHO declared COVID-19 (the “new coronavirus”)
a Public Health Emergency of International Concern (PHEIC) on 31st ofJanuary 2020, and ﬁnally a pandemic on 11th March 2020. Based on Chinese newspaper, social media and other digital platform data, Hua andShaw [13] analyse the timeline of key actions taken by the government
and people over three months in ﬁve different phases: the very earlyphase (up to 31st of December 2019), the investigation phase (up to 20th
January 2020), the early identiﬁcation phase (up to 31st of January), thecriticism, agony and depression phase (up to 14th February), and lastly
the positive preventive and curative control phase (up to 29th February).
Their analysis details the initial delay in responding, but also highlights
key factors in China's efforts to combat COVID-19. These factors include3

R. Djalante et al.

Progress in Disaster Science 6 (2020) 100080

Fig. 1. Frontpage of WHO website on March 19th, 2020 (WHO, 2020).

succeeded in signiﬁcantly limiting the number of newly infected people.
Singapore has set aside 5.6 billion Singapore dollars ($4.02 billion) in the
coming year to help businesses and households.
Other ASEAN countries, including Indonesia, provide a promising example of integrating Health-EDRM. The Indonesian COVID-19 task force(Gugus Tugas Percepatan Penanganan COVID-19) has been formed to coordinate the national COVID-19 response. A single coordinated source of information in Indonesia is presented through its dedicated website www.
covid19.go.id. This task force is led by the chief of the National Disaster
Management Agency (BNPB), General Doni Monardo. Beyond that, it remains unclear whether there is a deeper coordination of different agencies/ministries, and whether this extends to response mechanisms fromthe national, provincial and local governments. The Indonesian government has prepared a budget of Rp 1 trillion, or around $70 million, to bechannelled through the Health Ministry to try to contain the Covid-19 outbreak and care.
India, with the second largest population in the world, has taken earlyprecautionary measures through travel and visa bans on foreigners fromcertain countries, mandatory health checks and self-quarantine for
14 days. The Indian Prime Minister, in a national address, encouraged citizens to observe self-curfew and community vigilance at the initial stage.
These actions appear to have limited community spread in this highly populated country. While PM Modi has announced India's contribution to
SAARC, information for the national fund is not available.
Iran, on the other hand, has seen a drastic rise in the number of affected
people and deaths, the largest in Asia (outside China). The Iranian outbreakhas mainly been attributed to a lack of initial responses by the government,
limited public awareness of the risk of contagion, and lack of mandatory
self-quarantine. Public attitudes are a key issue underlying Iran's highdeath rate (roughly 10% of globally infected people, as compared toChina's 30%).

strong governance, strict regulation, strong community vigilance and citizen participation, and wise use of big data and digital technologies.
Japan came under the spotlight in January 2020, when the luxury
cruise ship Diamond Princess was docked in Yokohama, and symptoms of
COVID-19 were detected in several persons. Complex issues of governanceand strict regulation complicated the initial response, leading to a wide
spread of the COVID-19 among the passengers and crew. Subsequently,
COVID-19 began being reported in persons returning to Japan from abroad,mainly from China. The Hokkaido region is particularly affected. An epidemic cluster approach has marked the Japanese government's response,
limiting testing. A strict government response followed, including school
closures from early March, telework from home, ﬂexible working time to
avoid crowded trains, and an epidemic cluster approach. Communities
and people followed this “request” from the government (which was notcompulsory) apparently limiting the spread of COVID-19 and the numberof deaths. Thus, the combination of government request and strong selfdiscipline within people and communities has evidently led to desirable results. The dedicated website http://japan.kantei.go.jp/index.html provides
timely updates from the Prime Minister, with Japan having passed two
packages of small business loans, one $4.6 billion package in February,
and a $15 billion one on March 11, 2020.
In sharp contrast, South Korea was a surprise case of sudden high increase in affected people and high number of deaths (over 9,000 cases).
Several cases of community spread, notably from religious organisations,which went out of control. However, through a strict screening and testing
system, aided with advanced technology, South Korea was able to bring
down the number of affected people as well as number of deaths. The country allocated more than $13 billion in emergency funds to stoke economic
activity.
Taiwan, on the other hand, used 2003 SARS experience to prepare fromthe beginning through strict countermeasures as well as big data analysis ofpeople's movement and thereby identifying the possible areas of spread of
COVID-19.
Singapore is another case where an initial surge was observed in thenumber of affected people. The country took strict regulatory measures
for quarantine, tracing infected people's movement. These measures

2.3.2. Europe
In Europe, Italy is the worst hit with a comparatively high percentage ofdeaths among the infected. This outcome has been attributed to lack of regulation and testing, which prompted the community spreading. Gradually,4

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Progress in Disaster Science 6 (2020) 100080

3.1.2. Health and science aspects
It is imperative to strengthen information sharing and other coordinating mechanisms for health-related humanitarian issues. This includes sharing examples and experiences of preventive and treatment systems, newvaccine and preventive medicine information, means to protect the community from spreading through breaking the line of infection, and also
basic awareness on sanitation. Future complexities and uncertainties on
global health, along with environmental and societal changes will only increase in the future. The scientiﬁc methodologies to deal with uncertainties
are being developed and should be utilised further in decision making. As
stated in a March 17 editorial in Nature, it is critical to “Follow World
Health Organization advice, end secrecy in decision-making and cooperate
globally” [14].

stricter government regulation and vigilance systems have been implemented and enforced, along with social distancing among the people. However, the open border among the EU countries has helped in spreading thedisease to Spain, France, Germany and Switzerland, as well as to the UK.
The European Union (EU) has been surprisingly slow in coordinating a response to the outbreak. High rates of infection and deaths eventuallyprompted the European Commission to coordinate a common European response to the outbreak. The response includes resolute action to reinforce
the country's public health sectors and mitigate the socio-economic impact
in the European Union. In terms of funding, the French announced $49 billion, Italy announced a $28 billion plan on March 11 to be divided over two
separate spending packages, while the UK announced a £5 billion COVID19 fund (UKGov, 2020).
2.3.3. North America
The impact on North America was delayed and the threat taken quite
lightly. The most signiﬁcant action for some time was airlift of infected passengers from the cruise ship in Japan in February 2020. However, no travel
ban was imposed. This policy resulted in free travel to Europe and Asian
countries, leading to a sudden increase in the number of infected people
in both Canada and the USA. Once WHO declared COVID-19 a pandemic
in the second week of March, the USA also declared a national emergency,
although some of the states declared state emergency at an earlier stage.
Travel bans have since been imposed and screening, testing, mandatory
quarantine practices are in place. The US government's website on
COVID-19 is https://www.usa.gov/coronavirus. US President Trump
signed an $8.3 billion spending bill, currently called “Phase One” of stimulus efforts, and up to $50 billion in aid to states, cities, and territories(USAGov, 2020).
In Canada, the Prime Minister convened an Incident Response Groupon coronavirus, which has been meeting since the end of January. On
March 5, he created a Cabinet Committee on the federal response to the coronavirus disease (COVID-19). Chaired by the Deputy Prime Minister andvice-chaired by the President of the Treasury Board, the committee meetsregularly to ensure whole-of-government leadership, coordination, andpreparedness to limit the health, economic and social impacts of thevirus. The Canadian federal government released $1.1 billion in emergency
response, with a larger ﬁscal stimulus planned (Gov of Canada, 2020).
In summary, countries took dramatically different approaches in managing the pandemic. The variation is marked by prior experiences and preparation, early reinforcement of strict vigilance, testing and isolation, late
law enforcement, strong vs weak public awareness, self-restraint, commitments, and other factors. Some aspects of risk perception, awareness and response is a cultural issue, and powerfully linked to the socio-economic
structure of the country and community. But in a strongly interconnectedworld, there surely needs to be a global standard and protocol for regionaland national response. It is imperative to build mechanisms that decreaserisks of infection and enhance community safety and resilience.

3.1.3. Lifestyle aspects
First, good hygiene and a robust immune system are key to coping withany virus, and COVID-19 is no exception. Thus healthy lifestyles are prominent in enhancing resilience. Also, telework, the use of AI and other new
technologies for work which can be done remotely needs to be promoted.
These measures are consistent with emergent means of collaborating andproducing science. These include working from home, collaborating online,
online meeting and teaching, social media engagements by scientists, andengagement of social science. This diffusion of cooperation can also help
behavioural science understand societal responses, foster risk communication experts, science-policy advice.

3.1.4. Learning from prior experiences makes a difference
Some countries and regions such as Singapore, Vietnam, Taiwan
learned from the bitter experience of SARS of 2003. The recent past
incentivised them to act promptly and no doubt inclined their citizens to cooperate, which paid off in reducing COVID-19's spread.

3.2. DRR-speciﬁc recommendations
3.2.1. Stronger knowledge and science provision in understanding disaster andhealth-related emergency risks
Disaster Risk assessment is a standard approach in DRR. Core methodologies for disaster risk assessment include hazard and vulnerability assessment. These methods can be utilised for COVID-19 risk assessment. In
addition, the health sciences should be more involved in the communityof disaster risk management, to advance our understanding of outbreaks
and pandemics, the health impacts of all hazards, and improve data collection [15]. Science is recognised especially in modelling disease spread, dataon affected people, and the rush for vaccines. Open data, Open Science andOpen Map are being advocated. Existing spatial and remote sensing capacity for disaster can be used for mapping pandemics. The UN-SPIDER (Spacebased Information for Disaster Management and Emergency Response)
knowledge portal recognises epidemics as a source of hazard. The existingregional tsunami early warning systems can also be tasked for healthrelated emergencies. The systems include the Paciﬁc Tsunami Warning
Center (PTWC); the Indian Ocean Tsunami Warning System (IOTWS);
and the North Eastern Atlantic, the Mediterranean and connected Seas
(NEAMTWS). There is strong recognition for integration on DRR and CCA
and appropriate adaptation can greatly reduce the health burden resulting
from climate change and disasters [16]. The Sendai Framework takes an interconnected and pluralistic approach to understanding risk (UNDRR,
2019). The nature of current risks is complex and systemic, and can also
be compound, interconnected, infracting and cascading risks [17]. Natural,technological and biological hazard disasters can occur in these fashions, as
shown in the triple disasters of earthquake, tsunami and nuclear power
plant failure in March 11, 2011 in Japan. Countries like Japan, orIndonesia, despite having to respond to current COVID-19, they also need
to be ready should an earthquake or tsunami occur.

3. Recommendations on how current strategies for disaster resiliencecan contribute to responses to COVID-19
In this section, we put forward some recommendations on how current
strategies for disaster resilience can contribute to responses to COVID-19.
These are grouped into DRR-related health emergencies and recommendations in general.
3.1. General responses and societal adjustments
3.1.1. Legal aspects
There is an urgent need for global protocols, agreed and signed by thegovernments, to respond to global pandemic. A global pandemic is not
merely a health issue, but also demonstrates a profound inﬂuence on the
global economy. The lack of science-based decisions, resort to ad-hoc travelbans, and other uninformed and uncoordinated responses, worsened thispandemic both as a health crisis and an economic crisis.
5

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3.2.6. Strengthen community-level preparedness and response
Methods from Community-based DRM can be used for COVID risk assessment. Community-based disaster preparedness and management[21,22] is crucial in reducing disaster deaths and losses. The last mile approach in disaster EWS, where community networks, communication systems, can be utilised for pandemic EWS at the community level. In
disaster literature, risk perception strongly inﬂuences willingness to prepare for emergencies. Social linkages in communities may play an important role in focusing risk perceptions [23], while disaster type, gender,
and previously experienced disasters are good predictors of victims' attitudes toward natural disasters [24].
In summary, we have examined current and unfolding responses to
COVID-19 and their implications for the Sendai Framework. Core to our argument are strategies for resilience building against biological hazards andpandemic. We reiterate our assertion that there is a lack of early and rapid
actions from the DRR-related organisations, despite the SFDRR's call forbuilding resilience including from biological hazards. The SFDRR's ultimate
goal is a substantial reduction of risk and losses, coupled with laying the essential foundations for rapid and sustained recovery and sustainable development. We hope the evidence we have added shows the crisis of COVID19 could be used to make 2020 a “super year” of great progress on thesegoals.

3.2.2. Mobilise existing disaster risk governance structure to manage disaster risk
and potential health-emergencies
Multi-stakeholder engagements have been established, especially in disaster vulnerable countries. The same engagements can be utilised for addressing pandemic risks. One key agency is the International Federationof Red Cross and Red Crescent Societies (IFRC). The IFRC combines a
wealth of knowledge on disaster risk reduction, with expertise in ﬁghting
the spread of diseases, combat discrimination and violence, and promoting
human rights and assistance for migrants. For example, the IFRC issued an
Appeal for Global COVID-19 Outbreak, and the IFRC, UNICEF and WHO issued new guidance to help protect children and schools from transmissionof the COVID-19 virus (IFRC, 19 March 2020).
3.2.3. Utilise existing disaster coordination mechanisms at regional level to inform epidemic response
The regional bodies like ASEAN, SAARC, European Union (EU) need toenact regional protocols, coupled with information portals on pandemic
risk. Trafﬁc is quite high within the region, especially among countries
with land borders. Thus proper protocol on human movement information
sharing is required. The information sharing needs to be open and transparent, which enhances safer regional, cross border as well as global
movement.
3.2.4. Understand COVID-19 economic implications and resilience
COVID-19 and its effects afford ample evidence of the imperative ofbringing health into DRR. The economic fall-out from COVID-19 appears
to be profound, at least $20 trillion in a few short weeks, and may exceed
the 2008–2009 Great Recession. The direct costs of COVID-19 travelbans, social distancing, and other responses are merely one aspect. Far
more devastating is the uncertainty that has gripped capital markets. Declining economic activity and large drops in capital markets have a mutually reinforcing impact, undermining the capacity of heavily indebted
businesses and households to cover their debts. Uncertainty is the primary
driver of such crises, and stems in large measure from lack of close coordination and science-based decision-making. Were there more certainty,
households, investors and other economic agents would be less inclined
to panic. COVID-19 appears certain to become a very costly lesson thatDRR does indeed save many more multiples in avoided costs than its initialinvestment. An additional point in this regard is that health is a critical infrastructure. The resilience of critical infrastructure is well identiﬁed in
DRR literature (e.g. [18,19]). Resilience is fostered not just by sciencebased decisions and coordination, but also via redundancy to ensure buffer
capacity when a particular system collapses [20]. Disaster-illiterate economic policy tends to see redundancy as inefﬁciency. But in order to copewith COVID-19 and alleviate - if not prevent - future emergencies, supply
chains for at least some critical items need to be more local. In tandem,
governments and private businesses will have to broaden their crisis planning to ensure timely availability of items essential to limiting pandemicrisks.

Declaration of competing interest
The authors declare that they have no known competing ﬁnancial interests or personal relationships that could have appeared to inﬂuence thework reported in this paper.
References[1] **Aitsi-Selmi A, Murray V. Protecting the health and well-being of populations from disasters: health and health care in The Sendai Framework for Disaster Risk Reduction
2015–2030. Prehospital and Disaster Medicine 2016;31(1):74–8 [A set of papers were
written by the authors outlining health consideration in the SFDRR].
[2] Aitsi-Selmi A, Egawa S, Sasaki H, Wannous C, Murray V. The Sendai framework for disaster risk reduction: renewing the global commitment to people's resilience, health, andwell-being. International Journal of Disaster Risk Science 2015;6(2):164–76.
[3] **Chan EY, Murray V. What are the health research needs for the Sendai Framework?
The Lancet 2017;390(10106):e35–6 [The authors have been inﬂuential in advocating
for health consideration in the SFDRR].
[4] **IPCC, 2018: Global warming of 1.5°C. An IPCC Special Report on the impacts of global
warming of 1.5°C above pre-industrial levels and related global greenhouse gas emission
pathways, in the context of strengthening the global response to the threat of climatechange, sustainable development, and efforts to eradicate poverty [V. MassonDelmotte, P. Zhai, H. O. Pörtner, D. Roberts, J. Skea, P.R. Shukla, A. Pirani, W.
Moufouma-Okia, C. Péan, R. Pidcock, S. Connors, J. B. R. Matthews, Y. Chen, X. Zhou,
M. I. Gomis, E. Lonnoy, T. Maycock, M. Tignor, T. Waterﬁeld. [in press, this is the
IPCC publication dedicated on impacts of 1.5 and 2, as outlined in the Paris Agreement].
[5] **Hoegh-Guldberg O, Jacob D, Taylor M, Bindi M, Brown S, Camilloni I, et al. Impactsof 1.5 C global warming on natural and human systems. Global warming of 1.5° C: an
IPCC special report. IPCC Secretariat; 2018. p. 175–311 [This chapter is within the
IPCC Special Report on 1.5 degree warming discussing impact on the natural andhuman systems including health].
[6] **Chan EYY, Shaw R. Public health and disasters: health emergency and disaster risk
management in Asia. Singapore: Springer; 2020 [This is the ﬁrst book discussing
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[7] **Lo STT, Chan EYY, Chan GKW, Murray V, Abrahams J, Ardalan A, et al. Health emergency and disaster risk management (Health-EDRM): developing the research ﬁeld
within the Sendai framework paradigm. International Journal of Disaster Risk Science
2017;8(2):145–9 [This is another important paper discussing health and disasters written by the Health-EDRM science working group members].
[8] UNDRR. The 2019 Global Assessment Report (GAR); 2000 (300 p, Geneva).
[9] di Floristella AP. Dealing with natural disasters: risk society and ASEAN: a new approachto disaster management. The Paciﬁc Review 2016;29(2):283–305.
[10] Petz D. Brookings-LSE Project on internal displacement, strengthening regional and national capacity for disaster risk management: the case of ASEAN; 2014.
[11] Murthy P. Relevance of SAARC. Strategic Analysis 2000;23(10):1781–96.
[12] Lamichhane S. Enhancing SAARC disaster management: a comparative study with
ASEAN coordinating centre for humanitarian assistance on disaster management.
Naval Postgraduate School Monterey United States; 2016.
[13] Hua J, Shaw R. Coronavirus (COVID-19) “infodemic” and emerging issues through adata lens: the case of China. International Journal of Environmental Research and Public
Health 2020 [in press, under review].

3.2.5. Prepare inclusive early recovery plans
At present, the data suggest that in some countries, including China,
Korea, Japan, and a couple of other Asian countries, the peak of the
COVID-19 may be over. It is imperative to continue taking precautions, including screening, isolation of suspected cases and social distancing. However, it is also important to start developing early recovery planning, whichneeds to be gender and disability inclusive. The socio-economic fall-out
from this crisis is already high, and quite literally rising by the day. Concerns about preventing a protracted global recession, if not outright depression, are leading to focused intervention in capital markets and other areas.
Aviation, energy, hotels, and other concerns that appear - to their investors
and to policymakers - to be too big to allow to fail seem about to be given
relief. Yet pandemic risks increase when general community health andwell-being weaken. Thus it is critical that measures also be taken to identify
the most vulnerable and include them in recovery packages.
6

R. Djalante et al.

Progress in Disaster Science 6 (2020) 100080[6] EU. European Union support to the Sendai Framework for Disaster Risk Reduction(2015–2030); 2015.
[7] EU. Sendai Framework for disaster risk reduction 2015–2030; 2015.
[8] EU. The EU integrated political crisis response – IPCR – arrangements; 2016.
[9] Government of Canada. Government of Canada takes action on COVID-19; 20 March
2020.
[10] Government of Indonesia. Covid19.go.id: Home; 20 March 2020.
[11] Government of Indonesia. Indonesia Sets Aside $70 Million to Fight Covid-19; 18 March
2020.
[12] Government of Japan. Information related to COVID-19. http://japan.kantei.go.jp/
index.html; 20 March 2020.
[13] Government of the United Kingdom. Support for those affected by Covid-19; 19 March
2020.
[14] Government of the United States of America. Government Response to Coronavirus,
COVID-19; 20 March 2020.
[15] **UN. Transforming our world: the 2030 agenda for sustainable development; 2015.
[16] **UN. The global goals; 20 March 2020.
[17] UN. UN releases emergency funds to help vulnerable countries ﬁght COVID-19. https://
news.un.org/en/story/2020/03/1058391?fbclid=IwAR3AmO9Jt_BYJxJ-FY_
1kVH9jz7YW_5oOwibBTXpcM09wBPj1wz5cAht7N8; 1 March 2020.
[18] IFRC. COVID-19: IFRC, UNICEF and WHO issue guidance to protect children and support safe school operations; 12 March 2020.
[19] IMF. IMF makes available $50 billion to help address coronavirus; 10 March 2020.
[20] *UNDRR. UNDRR urges disaster management agencies to prioritize biological; 12
March 2020.
[21] **UNISDR. Sendai Framework for disaster risk reduction 2015–2030; 2015.
[22] WB. World Bank Group increases COVID-19 response to $14 billion to help sustain economies, protect jobs; 17 March 2020.
[23] WHO. Operational planning guidelines to support country preparedness and response;
19 March 2020.
[24] **WHO. Health emergency and disaster risk management framework pdf, 1.04Mb;
2019.
[25] WHO-A. Coronavirus (COVID-19) | WHO | Regional Ofﬁce for Africa; 18 March 2020.
[26] WHO. COVID-19 response fund; 18 March 2020.
[27] Melinda and Gates Foundation. COVID-19; 12 March 2020.

[14] *Nature Journal Editorial. Coronavirus: three things all governments and their scienceadvisers must do now. https://www.nature.com/articles/d41586-020-00772-4; 17
March 2020.
[15] Poljansek K, Marín Ferrer M, De Groeve T, Clark I. Science for disaster risk management
2017: knowing better and losing less. ETH Zurich; 2017.
[16] Banwell N, Rutherford S, Mackey B, Chu C. Towards improved linkage of disaster risk
reduction and climate change adaptation in health: a review. Int J Environ Res Public
Health 2018;15(4).
[17] Pescaroli G, Alexander D. Understanding compound, interconnected, interacting, andcascading risks: a holistic framework. Risk Anal 2018;38(11):2245–57.
[18] Boin A, McConnell A. Preparing for critical infrastructure breakdowns: the limits of crisis management and the need for resilience. Journal of contingencies and crisis management 2007;15(1):50–9.
[19] ***Garschagen M, Hagenlocher M, Comes M, Dubbert M, Sabelfeld R, Lee YJ, et al.
World risk report 2016: critical infrastructure and resilience. UNU-EHS; 2016.
[20] Sterbenz JP, Hutchison D, Çetinkaya EK, Jabbar A, Rohrer JP, Schöller M, et al. Redundancy, diversity, and connectivity to achieve multilevel network resilience, survivability, and disruption tolerance invited paper. Telecommunication Systems 2014;56(1):17–31.
[21] Allen KM. Community-based disaster preparedness and climate adaptation: local
capacity-building in the Philippines. Disasters 2006;30(1):81–101.
[22] *Shaw R, editor. Community based disaster risk reduction. Emerald Group Publishing;
2012.
[23] Scherer CW, Cho H. A social network contagion theory of risk perception. Risk Analysis:
An International Journal 2003;23(2):261–7.
[24] Ho MC, Shaw D, Lin S, Chiu YC. How do disaster characteristics inﬂuence risk perception? Risk Analysis: An International Journal 2008;28(3):635–43.

Key organisations' websites[1] ADB. COVID-19 (coronavirus): ADB'S response; 20 March 2020.
[2] AHA Center. About us; 20 March 2020.
[3] ASEAN. ASEAN health sector efforts in the prevention, detection and response tocoronavirus disease 2019 (COVID-19); 20 March 2020.
[4] ASEAN. ASEAN | One vision one identity one community; 20 March 2020.
[5] EU. Coronavirus response; 20 March 2020.

7

The Asia-Pacific Journal | Japan Focus

Volume 18 | Issue 7 | Number 3 | Article ID 5386 | Apr 01, 2020

Building Holistic Resilience: Tokyo’s 2050 Strategy
Andrew DeWit, Riyanti Djalante, Rajib Shaw
strategy is multi-sectoral and pragmatic, rather
than overly reliant on idealistic energy visions.
Third, Tokyo is investing heavily in the people
and critical infrastructure essential to realizing
its ambitions. Its increasingly aggressive andsmart fiscal policy affords a benchmark for anage of economic and ecosystem disruption
coupled with accelerating technologicalinnovation. As many unprepared cities andnations are discovering, well-targeted
preparatory investment is particularly essential
in the face of COVID-19 and future pandemics.
Fourth, Tokyo emphasizes integrated andinclusive governance, which enhances theprospects for implementation and continued
policy evolution. Fifth, studying Tokyo’s
strategy opens windows on the platform
collaborations that Japanese “silo-breakers”2have been building since 3-11, to maximize
holistic resilience. In this paper, we review theevidence and make three key points. We argue
that Tokyo’s ambition is credible, in large part
because it already deploys resilient anddecarbonizing critical infrastructure networks
that simultaneously mitigate and adapt toclimate change, resource crises, and otherchallenges. We also argue that Tokyo’s
integrated and well-funded strategy offers amodel, not just for melding the Paris
Agreement, Sustainable Development Goals(SDGs), and the Sendai Framework for Disaster
Risk Reduction, but also keeping them on trackin the face of unprecedented uncertainty. Andin our conclusions, we urge Tokyo to adopt
several recommendations to bolster its strategy
in light of emerging needs and opportunities.

Abstract: The paper examines Japan’s capital
city of Tokyo’s “Zero Emission Tokyo Strategy.”
Our work shows that Tokyo’s strategy isparticularly important in light of the 2030
Agenda’s emphasis on greenhouse-gas
emissions reduction, equitable sustainability,and building holistic resilience against all
hazards. The data indicate that Tokyo’s
ambitions are built on a track record of global
leadership in resource efficient water systems,
transit networks, and other criticalinfrastructure. Moreover, Tokyo is part ofJapan’s zero-emission communities, smart
cities, all-hazard resilience, and othermultilevel and silo-breaking collaborative
platforms. Our analysis also makes
recommendations for bolstering Tokyo’s
strategy, to enhance co-benefits from
integrating climate change mitigation andadaptation, in addition to strengthening
pandemic response.

Introduction
On December 27, 2019, Japan’s capital city ofTokyo committed itself to a “Zero Emission
Tokyo Strategy.”1 The strategy aims to achieve
net zero greenhouse gas emissions by 2050.
Like all other climate strategies, Tokyo’s is awork in progress. It has yet to adequately detailco-benefits from integrating climate change
mitigation and adaptation, notably in the areaof human health. But Tokyo’s example isimportant for a host of reasons. First, Tokyo is
the world’s largest megacity. What it does
influences other Japanese municipalities andindeed other global cities. Second, Tokyo’s

Tokyo’s 2050 strategy1

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Key to Tokyo’s zero emission strategy(hereafter “TMG 2050”) is integration. TMG
2050 builds on an institutional legacy of
metropolitan governance and a multiplicity of
past and present initiatives in energy, disasterrisk reduction, waste, transport, and otherareas. Tokyo Metropolitan Government’s (TMG)
transport, sewerage, and other planningsuccesses have made it one of the world’s mostenergy- and material-efficient city-regions.
What is new is TMG 2050’s integration ofclimate mitigation and adaptation towards
achieving zero emissions. TMG 2050 thus
differs from previous sector-specificenvironmental initiatives. It puts cross-sectoral
initiatives at the heart of comprehensive city
planning by focusing planning, finance, andcollaboration on zero emissions.

2050 target. The first sector is energy(electricity and heat), globally responsible forjust under a third of greenhouse gas GHG
emissions. Yet note that TMG 2050 does notrely on glib promises of achieving 100%
renewable energy in power and heat in a
decade or even by 2050. Such bold pledges arecommon, according to the American Council for
an Energy-Efficient Economy, but generally notmonitored for progress or actual GHG
3reductions. Incredibly, even Boston, the topranked US zero-emission city, does not have a4“quantitative municipal energy goal.” And thecity of Berlin, the heart of Germany’s “energy
transition,” is ostensibly committed to 100%
renewables by 2050, but is evidently doing
little to get there. The most current data fromthe German Federal Renewable Energies
Agency show that by 2016 Berlin had achieved
only 4% renewables in primary energy (2.5% ingross electricity consumption), only a marginalincrease from 3.7% in 2013. And Berlin’s percapita CO2 (not GHG emissions in total)
emissions had only declined from 5.3 tonnes in2013 to 4.7 tonnes in 2016.5
It therefore seems commendable that TMG
2050 does not rely on 100% renewables toachieve decarbonization commitments, butinstead aims at achievable, cross-sectoral goals
that link technology and inclusive governance.
The figure shows that TMG 2050 positions
renewable energy as a “major energy source”
rather than the only source. In fact, the detailsof TMG’s energy planning show that relianceon renewable energy is to be roughly doubled,from 14.1% in 2017 to 30% by 2050.6

Figure 1: TMG 2050 and Tokyo
Metropolitan Government (Click toenlarge)

Simultaneously, looking at the second and third
sectors outlined in figure 1, TMG 2050 plans adrastic cut in emissions from the building andtransport sectors. These sectors are major
sources of GHG emissions, not just throughconsumption of liquid fuels but also the use of
power for lighting, thermal comfort, and otherbuilding operations. TMG 2050’s aims in these
two sectors are a significant acceleration of the

Figure 1 shows that TMG 2050 also melds the“hard” infrastructure of technology with the“soft” infrastructure of inclusive governance.
The figure outlines the six main sectors
involved in reducing emissions towards the2

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GHG reductions it has already achieved since2015, which marks TMG’s post-Fukushima
7
peak of GHG emissions. In other words, TMG’sratcheting-up of ambitions credibly builds on
demonstrated prior performance.

Japan – and the world’s – first urban cap andtrade scheme that includes the commercial andindustrial sector, “including office buildings,
11
which are often concentrated in megacities.”
TMG and other large Japanese cities – notable
Fukuoka – are generally built in a compact
manner that fosters efficient resource use andlimits urban sprawl.

In the resource/industry sector, 4th in figure 1,
TMG aims to ramp up its already aggressive
policies of reduce, reuse and recycle (3Rs),
particularly in plastics, food waste andfluorocarbons. These latter two – food waste
and fluorocarbons – are especially important
for any viable strategy of drawing down GHG
emissions.8

The importance of TMG-style resourceefficiency is seen in the UNEP’s International
Resource Panel (IRP) 2018 report on “The
Weight of Cities: Resource Requirements of
Future Urbanization.” The IRP calculate thehistoric trajectory for urban sprawl to be about
2%/yr, a pace that – if continued - would see
urban land use expand from 1 million km2 atpresent to 2.5 million sq2 by 2050. That extra
1.5 million sq2 of urban space would beapproximately 3 times the 506,000 km2 area ofthe entire country of Spain. In tandem with
that, urban material consumption is on track togrow from 40 billion tonnes in 2010 to 90
billion tonnes by 2050.

The fifth sector in the figure is “climate change
adaptation.” TMG 2050 positions adaptation as
an explicit part of achieving zero emissions.
Indeed, green infrastructure and myriad otheradaptation initiatives also enhance mitigation,
thereby multiplying co-benefits, reducing perunit costs, and maximizing societal agreement
on action.9
Finally, figure 1’s sixth sector of “engagement
and inclusion” outlines a programme ofworking with civil society, other levels ofgovernment, and international subnational
governments and non-state actors. Thisinstitutional and societal collaboration isembedded in TMG’s role as a metropolitan
government, integrating 23 special wards and39 municipalities. It is also evident in themultiple collaborative platforms – SDG cities,
smart cities, national resilience – we describe
later below.

Those numbers are daunting. But the IRP argue
that “compact, resource-efficient cities” could
reduce these totals by 36-45%. As a benchmark
for better performance, the IRP report notesthat “Japanese cities have the densest and mostconnected street patterns,” with Tokyo’s “levelof transit connectivity and intensity of use”
being the highest in the world. These structural
factors give Japan “the highest world energy
productivity (ratio of energy consumption to
added value), close to three times the global
average.” 12 Zooming in on TMG, we see one
clear example of this resource-efficiency. The
Tokyo Metro transit network’s 382 kilometersof track is far less than Shanghai’s 639
kilometers, and even New York’s 401
kilometers; but in 2018 its annual ridership of3.463 billion was the world’s largest, dwarfingthat of second-ranked Moscow (2.369 billion),
3rd-ranked Shanghai (2.044 billion), and 6th13
ranked New York City (1.806 billion).

TMG 2050 and Tokyo Resource-Efficiency
We suggested earlier that TMG 2050 is not
mere virtue-signaling, but rather builds on
TMG’s strengths. A few examples shall suffice.
TMG’s per-capita energy, water and waste
flows are considerable below the average ofsuch peers as Shanghai, New York City,
London, Paris, and others.10 TMG also installed3

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TMG 2050.

TMG’s water supply is another area of
demonstrated resilience and resourceefficiency. As in any city, TMG’s water-related
systems (e.g., sewerages) are energy-intensive
and crucial to public health. Moving aroundhuge volumes of water (for TMG, a daily
average of 4.13 million cubic liters in 2018),
whether for consumption or for wastetreatment, requires prodigious amounts ofenergy. And poorly designed or badly managed
water systems pose enormous health anddisaster risks, in addition to wasting precious
14
resources. TMG’s replacement of its leaky
lead and iron pipe network with stainless steel
brought its water loss down from 17% in the
1970s to an incredibly low 2% in the 2010s. At
present, TMG’s rate of water loss is well under
the double-digit leakage rates that OECD
reports on “Water and Cities” indicate are15
common even in developed countries. TMG’s
capacity to plan and operate its water networks
on a metropolitan scale - coupled withinstitutionalized consultation with its special
wards and cities - allows expert informationand other scarce resources to be focused on
the macro-level management challenge. Rather
than leaving each local actor to – as it were –reinvent the wheel on its own, strong
metropolitan governance affords the capacity
to devise and deploy best-practice solutions.

TMG 2050 and Public Finance
TMG also puts its money where its mouth is, so
to speak. Its commitment to TMG 2050 is seenin the scale and focus of its multi-year funds
and annual budgets. As to the former, since FY
2017 TMG has adopted a triad approach torolling out modernized urban amenities: “safety
city,” “smart city,” and “diver-city” (the latter a
combination, in Japanese script, of “diverse”
and “city”). To support these initiatives, TMG
amalgamated its multi-trillion yen funds, 17
under these three rubrics of safe, smart anddiverse. Well before the unfolding global
pandemic, TMG had targeted roughly JPY 1
trillion in spending on these initiatives, outsideof the annual budgets, between 2017 and2020.
In 2019, TMG further sharpened the focus on
categories critical to TMG 2050. It createdthree new special purpose funds in 2019,
totaling JPY 110 billion. Of this total, JPY 50
billion is devoted to realizing a Society 5.0type 1 8 smart city, JPY 30 billion to zero
emissions projects such as fuel-cell vehicles,
and JPY 30 billion to greening of TMG.
Moreover, these new financing vehicles bringthe cumulative total (at end of FY 2020) of therelevant funds to JPY 1.77 trillion. Of this JPY
1.77 trillion total, fully JPY 733.2 billion is to be
spent within FY 2020 alone for modernizedcritical infrastructure (waterworks, transport,
communications, medical, and other areas),disaster resilience, pandemic response, andother public goods. These investment areas are
all pertinent to achieving TMG 2050’s crosssectoral goals.19

The importance of collaborative governanceneeds to be underscored in light of global
sustainability challenges. Experts on urban
systems argue for a ‘one-water approach.’ Key
to this approach is integration of governanceand technology, as it “seeks to integratevarious water supply, treatment andmanagement infrastructures into a single
infrastructure system perspective thatconsiders the full life cycle of waterprovisioning in urban areas, [that] cansimultaneously deliver livability, resilience andsustainability benefits.”16 TMG does this with
its water networks and other criticalinfrastructure, scaling up the “system ofsystems” cross-sector integration that is core to

The annual spending in TMG’s general accountis JPY 7.3 trillion. As in previous years,
spending from the FY 2020 general accountalso features the triad of “safety city,” “smart
city,” and “diver-city.” But in comparison to4

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from January of 2020, TMG responded rapidly
with supplementary budgets. On February 18
of 2020, TMG announced that an initial JPY 6.4
billion in countermeasures, added to the FY
2019 budget, would be more than quintupled to
JPY 33.7 billion as a special addition to FY
2020. Both of these spending packages are
directed at a spate of measures, including tests
and other supplies in addition to alleviating the
economic impact on small firms. Comparing
these two supplementary spending measures,
we see that the largest increase is the JPY 10
million to JPY 2.6 billion rise for stockpiling
medical supplies, readying medical facilities,
and other measures.22

previous years, the FY 2020 investments show
dramatic increases.20 The summary details are
as follows:

1. The safety-city budget overall is JPY 328
billion (versus JPY 300 billion in FY 2019)
centred on disaster-resilient water
networks and bolstering structures
against seismic threats and risks ofcascading fires.
2. The smart city component of the FY 2020
budget totals JPY 654.8 billion, double
the JPY 326 billion total in 2019. Much ofthis spending focuses on building up
transport efficiency by integrating telework, transit-demand management andother smart initiatives. The most striking
aspect is the 8-fold increase over theprevious year in spending on 5G wirelesstransmission and other core technologies
of a “Smart Tokyo.”

In summary, TMG’s investments belie the hoary
depiction of Japanese public works as “bridges
to nowhere.” They also provide an importantmodel. In the face of COVID-19, most countries
have moved rapidly towards very activist fiscal
policy. As of this writing, the G-20 total for
fiscal countermeasures is USD 5 trillion, which
is roughly the size of the Japanese economy.23
In many countries, the initial focus on
supporting businesses and households in theface of simultaneous supply and demand shocks
will almost inevitably move to infrastructure
investment. For example, analysts indicate thatthe broad range of categories encompassed bysmart cities are likely to become an even strong
focus of public and private investment.24 TMG’s
fiscal data suggest that it already offers
multiple yardsticks of how to invest so as toachieve multiple decarbonizing co-benefits
simultaneously.

3. The diversity-city aspect totals JPY 550.5
billion, a dramatic increase from 353
billion in 2019. Significant investments
are focused on foreigners, the disabled,and other potentially vulnerable
members of the community. And fully JPY
174 billion is devoted to augmenting thenational government’s initiatives
providing free child-care andkindergarten education. To someobservers, these items may seem
extraneous to climate objectives. But
relieving child poverty, increasing
women’s opportunities, enhancing worklife balance are in fact crucial elementsof emissions reduction andsustainability. 2 1

TMG 2050 and Other Japanese Cases
In pursuing zero-emissions, TMG is not alone
among Japanese subnational governments.
Indeed, one prominent area of collaboration in
Japan is its national alliance for 2050 zerocarbon cities (with the Ministry of theEnvironment, but as part of larger

TMG has also been quick to fill in safety-city
gaps in pandemic response. As the COVID-19
pandemic threat emerged and then worsened5

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horizontal/vertical collaboration). As of March24, 2020, 86 of Japan’s subnational
governments – representing 48.5% of thecountry’s population – had adopted thestrategy. Figure 2 displays most of the 26
prefectures (of Japan’s total 47 prefectures)that have adopted the strategy, and also showsthat many large and small cities are acting
independently of their prefecture. One example
is the city of Koriyama’s commitment to thestrategy, in advance of any announcement by
the prefecture of Fukushima. At nearly the
opposite end of the archipelago, the prefectureof Kumamoto has essentially organized 18 of its
45 municipalities into a coordinated bloc.

1. zero deaths due to disasters
2. zero emissions, especially through hydroand forest biomass
3. zero blackouts due to disasters, via useof microgrids and other smart
infrastructure
4. zero plastic waste, through recycling andreduction of use
5. z e r o f o o d l o s s , p a r t i c u l a r l y b yrepurposing food that currently goes into
the waste stream

Like TMG 2050, Gunma’s goals build on
multilevel collaborations detailed below,
including SDGs, smart city, and national
resilience.

Other Multilevel Collaborations in Japan
TMG has been a global first-mover on
implementing the UN’s Sustainable
Development Goals (SDGs), a major part of the2030 Agenda. 2 7 But so has the national
government, via the cabinet office and otheragencies. Developed countries tend to view theSDGs as a template to guide assistance todeveloping countries. However, Japan’s Cabinet
Office has quite deliberately28 built a platform
for subnational (prefectural and municipal)
29
models of “local revitalization” SDGs. Since
2017, the multi-level collaboration has beenusing the 17 goals and 169 targets of the SDGs
as means to focus Japanese initiatives to copewith myriad domestic challenges while
simultaneously enhancing opportunities foroverseas engagement and contributions. Within
the Cabinet Office’s facility, Japan’s
subnational governments compete to be one of

Figure 2: 2050 Zero Carbon Cities in Japan(as of March 24, 2020)25
Source: MoE, 2020

Within this nexus of collaboration, increasingly
ambitious but doable targets are emerging. For
example, on December 25 of 2019, Gunma
Prefecture announced a 5-zero by 2050
programme.26 The goals include the following:6

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the 100 designated SDG initiatives. The
Japanese platform distills the multiplicity of
SDG goals into 8 areas: inclusiveness andgender-equality, health and longevity,
economic growth with innovation, sustainable
and resilient critical infrastructure, resilientand decarbonizing energy, biodiversity andecosystem conservation, global peace andsecurity, and global engagement for promoting
the SDGs. In tandem, the national government
has linked its Society 5.0 industrial policy andrelated initiatives to the SDGs as a means offostering silo-breaking policy coherence intandem with expanded global collaboration.30

addressed to demographic and otherchallenges. Based on national and international
evidence, it evaluates risks and vulnerabilities,
selects and prioritizes countermeasures, andthen monitors progress on these measures. As
shown in figure 3, the NRP are umbrella plans:
as of 2019, 46 other national plans refer to the
NRP. These plans include energy,
environmental, city-planning, ageing society,forestry, space, and other plans. An additional
18 plans are slated to be added to the list,
including the Comprehensive Innovation
Strategy, the Global Warming CounterMeasures Plan, and the Basic Plan on Ocean
Policy.34 The broad reach of the NRP allows it
to address disaster, demographic and otherhazards. Comprehensive and integrated
planning also allows the NRP cycle toemphasize cost-effective, cross-sectoral
adaptation to multiple risks while alsoachieving broader socio-economic sustainability
and decarbonization.

A related multi-level platform approach applies
to Japan’s smart city collaboration. Since its
creation in 2019, Japan’s Smart City platform
has grown to 570 members and 170 industrial
policy initiatives. The members are composedof 113 local governments, 356 firms andresearch institutes (including universities), 11
central agencies, and 2 economic associations.
Like the SDGs platform, the Smart City
platform is a locus for integrating governanceand technology, a venue for facilitating
collaborative learning and diffusion of bestpractice solutions to domestic and global
challenges. TMG’s projects are prominent in
the platform, and are thus well-positioned as
31
models for other local governments.
Perhaps most importantly, the national
government, TMG and other subnational
governments are also closely linked in an
expanding portfolio of national and subnational“National Resilience Plans” (NRPs) that havelegal precedence over other plans. 3 2 This
platformhasseveralyearsofinstitutionalization. Japan’s NRP is based on
the National Resilience Law passed by the Dieton December 4 of 2013.33 The NRP iscomprehensive, inclusive and transparent. It isaimed at bolstering the country’s resilience tonatural disasters and other hazards, as well as
fostering the capacity to recover from suchdisasters when they occur. It is also explicitly

Figure 3: Planning and Japan National
Resilience
Source: Japanese Cabinet Office (Click to
expand)As figure 4 indicates, the NRP is also a “wholeof government” approach to planning. In 2014,
the NRP was worked up into a plan by thegoverning LDP politicians and disasterresilience technocrats in the Cabinet
Secretariat’s National Resilience Promotion7

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Office (NRPO). It was also studied by the
National Resilience (Disaster Prevention andReduction) Deliberation Committee (NRDC).
The NRDC first met on March 5, 2013 and had
its 53rd meeting on March 23, 2020. It has
played a prominent role in overseeing 2
iterations (2014, 2018) of the NRP Basic Planas well as 6 annual action plans that decide andthen monitor the PDCA planning cycle and theachievement of Key Performance Indicators(KPI). These KPIs include hard measures, suchas reinforcing water-treatment systems, andsoft measures, such as skill-building and means
to break down governance silos. In the 2019revision of the original 5-year NRP basic plan,
the number of KPIs had increased to 179.
These KPIs cover a very broad range of hardand soft measures to secure holistic andinclusive resilience.

Figure 4: Whole of Government andNational Resilience
Source: Japanese Cabinet Office (Click to
expand)A key test of any such ostensibly collaborative
initiative is how well it diffuses and how
purposefully engaged the actors are. By thatmeasure, national resilience is even more
successful than the SDGs and Smart City
platforms described earlier. By March 1 of2020, all of Japan’s 47 prefectures had adopted
their own regional versions of the NRP.
Moreover, 1,355 of Japan’s 1741 cities andtowns had either adopted their own local
versions of the NRP or were formulating plans.
This number of cities, towns and villages doing
NRPs was more than a quintupling of the 196
total from June of 2019.36 That startling rate ofincrease, in well under a year, was testament to
the rapid spread of risk-awareness in Japan.
Recent years of repeated typhoons, floods andother disasters have led to a consensus on theneed for comprehensive planning andintegrated counter-measures.

The NRDC’s membership is drawn primarily
from the top ranks of Japanese academe,business, and subnational government. Its
specialists advise on ageing, primaryindustries, local communities, local
administration, risk communication, industrial
structure, the environment, disasterprevention, finance, national lands, andinformation services. These people andinstitutions are silo-breakers, in that theircollaboration brings together often balkanizedsectors. Their silo-breaking role is clear fromstudying the plans they have built and continue
to refine. Indeed, in a laudable exercise intransparency, the minutes from NRDC
meetings and the materials it deliberates are
uploaded to its dedicated web site, generally
within a week of its 7-9 meetings each year.35

As to subnational engagement, that is evident
in the content of their planning andimplementation. All the prefectural and local
plans are formulated on the basis of local risk
assessments, built on the advice of local
experts, open meetings, and responsiveness topublic comments on planning proposals. In
other words, the local plans are not “cookie8

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cutter” versions of the national plan, mere
passive compliance with central-government
directives in order to maximize public works.
Japanese resilience is certainly well-funded, atroughly JPY 5 trillion per year. But theinvestments finance soft and hard measures in
addition to training and international
engagement. The national and subnational
plans, budgets, committee representation, andother aspects are all open to inspection andinput from civil society. Spending categories
and performance indicators are presented in
37graphic and tabular formats.

agreement, in June of 2019, to Principles for
Quality Infrastructure Investment that include
comprehensive quantification of lifecycle costs.
These principles are non-binding but meld
environmental, societal, fiscal and other modesof sustainability. Close observers of G20
processes regard them as one of the key
developments in 2019.39 Indeed, it is difficult to
exaggerate the significance of bringing the2030 Agenda into the highest levels of decision
making on global infrastructure, which isroutinely assessed to represent a cumulative
USD 80 trillion in investment by 2040.

In addition to the above platforms on SDG
cities, smart cities, and resilience, we could
have outlined Japan’s platforms for compact
cities, green infrastructure, and other elementsof holistic resilience. But we think the examples
suffice to show that TMG’s policymakers workin a variety of multilevel collaborations. Most ofthese platforms include all levels ofgovernment and reach deeply into civil society.

One example of the prodigious body of researchhighlighting the importance of resilient
infrastructure is the October, 2018
collaboration between Oxford University andthe United Nations Office for Project Services,in their report “Infrastructure Underpinning
Sustainable Development.” 4 0 They place
infrastructure investments in a broader mix ofcritical public goods. These latter include
investments in health, education and foodsecurity, underpinned by sustainable
management of water resources. Like TMG
2050, these integrated initiatives offer noregret pragmatism: in the face of climate,geopolitical and business uncertainty, there canbe no doubt that providing children with cleanwater and other public goods will improve theirhealth and alleviate pandemic risks.

TMG’s Broader SignificanceJapan seeks to export its collaborative, resilient
and resource-efficient urbanization. One
indicator of this is seen in Japan’s cooperation
with the World Bank on disaster-resilient urban“lifeline” infrastructure. The World Bank has
long argued that compact design affords more
green space, enhances the efficiency ofmaterial use, and reduces disaster and otherrisks. In June of 2019, the World Bank
quantified the benefit of this kind of
urbanization, in low and middle-income
countries, as potentially USD 4.2 trillion in
avoided costs from damage and disruptions.
The ratio of initial investment cost versus
avoided costs was calculated at 1:4, meaning
investment in resilient infrastructure more than
paid for itself over the lifecycle.38

Further Integrated Resilience and the TMG
Paradigm
We have seen that TMG 2050 is part of a larger
paradigm of platforms. Japan offers lessons ingovernance and the integration of technology,
to help cope with multiple challenges
simultaneously. Climate change is a wicked
problem and very likely an existential crisis.
Assessing and addressing climate change isalways fraught with disagreements anddistractions, because short-term thinking is so
greatly advantaged over long-term planning.

Japan’s active collaboration with the WorldBank came in tandem with its securing G20
9

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APJ | JF

The unfolding pandemic and economic crisis
seem likely to worsen that structural problem
by impeding “super year” 2020’s multiple
important negotiations over biodiversity, theoceans, and COP 26. 41 But Japan’s example
suggests powerful coalitions can be built by
including a variety of no-regret “solutions”
framed in terms of the 2030 Agenda.

America, not to mention Brazil, India, Indonesia
and other populous countries. The US appears
to be in particularly dire straits, which isespecially surprising in light of its 2019 ranking
as the world’s most advanced case of healthsecurity.42
Whether Japan’s current comparatively low
levels of COVID-19 infection, hospitalization,and mortality are due to good policy, good luckor simply poor data cannot yet be conclusively
determined. In any event, there are many areas
for improvement. On this, Japan’s 26 national
resilience working groups include a high-level
43“STOP Pandemics 2020 Strategy Committee.”
The Committee is chaired by highly respected
Professor Kaku Mitsuo of Tohoku Medical andPharmaceutical University and lead author of
the February 25, 2020 “Citizen’s Handbook” on
avoiding COVID-19 infection.44 In a February
10, 2020 forum, the working group made anumber of recommendations concerning better
integration of pandemic risks into all-hazard
National Resilience. It also maderecommendations on risk-communication,
preparedness, and related items.45 It is slated
to provide further recommendations in April,with presumably more specific protocols in
addition to how to better integrate pandemic
risk-reduction into Japan’s resilience paradigm.

Figure 5: Global Spread of Coronavirus (asof March 26, 2020)
Source: Financial Times, March 26, 2020
(Click to expand)Yet in light of COVID-19, it is imperative that
there be tighter integration of pandemic riskreduction and response in TMG 2050 and othermultilevel collaboration. Though Japan’s
response to COVID-19 has generally been
derided in international and domestic media
reports, the country appears – as of this writing– to have minimized COVID-19’s spread. This
result is unexpected, particularly because
Japan’s aging, population density and otherimportant variables exceed those of heavily
impacted Italy. Figure 5 shows that after the
10th recorded death from the coronavirus,
Japan seems to have nearly flattened the
upward curve of infection. The figure suggeststhat South Korea is leading in flattening the
curve, with Japan, Hong Kong and Singapore
not far behind. Japan may be in a much better
position than most of Europe and North

But requisite reforms go beyond Japan’s
domestic protocols, platforms and paradigms.
We have argued elsewhere46 that the pandemic
response could be bolstered by greater use of
the WHO framework on health-emergency
disaster-risk management (Health-EDRM). The
WHO describes Health-EDRM as the“systematic analysis and management of healthrisks, posed by emergencies and disasters,
through a combination of (1) hazard andvulnerability reduction to prevent and mitigate
risks, (2) preparedness, (3) response and (4)recovery measures.”47 WHO’s current technicalguidance has not incorporated the HealthEDRM.
10

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substantive response, particularly in such animportant year for further institutionalizing andintegrating the 2030 Agenda.

Also, one would have expected the pandemic tohave galvanized the international disaster-risk
reduction (DRR) community. Certainly the UN
Office for Disaster Risk Reduction (UNDRR)
issued a March 12 press release exhorting
disaster management agencies to “prioritize
biological hazards.” The UNDRR duly observes
that natural hazards are the focus for national
disaster management agencies. It encourages
them to include health emergencies as a toppriority, because they clearly lead to cascading
systemic breakdown in such criticalinfrastructure as health care and financial
services. Yet we are now 5 years out from 2015
adoption of the Sendai Framework on Disaster
Risk Reduction, in tandem with the Paris
Agreement and the SDGs. Sendai explicitly
incorporates climate change, health risks, andthe urgency of acting in advance rather than
waiting and then responding. Surely thepresent crisis should produce a more

We argued that TMG’s example, and its TMG
2050, suggests that robust and integrated
governance can help cities maximize mitigation
and adaptation. TMG 2050 deserves close
attention because it is a very democratic,collaborative benchmark built on impressive
results, smart industrial policy, aggressive
fiscal policy, and an emphasis on equity andinclusivity. We also pointed out that TMG 2050
is not acting on its own, but rather in an “all ofgovernment” array of platforms and throughinternational engagement. Japanese silobreaking is leading to substantial progress in
integrating the three key elements - Paris,
SDGs, and Sendai – of the 2030 Agenda. We
can only hope Japan contributes to keeping the2030 Agenda on track in this potentiallydistracting, disruptive and divisive year.

Andrew Dewit, Professor in the School of Economic Policy Studies, Rikkyo University, Japan.
dewit@rikkyo.ac.jp (https://apjjf.org/mailto:dewit@rikkyo.ac.jp)
Riyanti Djalante, Academic Programme Officer, United Nations University- Institute for the
Advanced Study of sustainability (UNU-IAS), Japan.
djalante@unu.edu (https://apjjf.org/mailto:djalante@unu.edu)
Rajib Shaw, Professor, Graduate School of Media and Governance, Keio University.
http://www.rajibshaw.org Science Committee Member, Integrated Research on Disaster Risk (IRDR)

Notes
1

Tokyo’s Zero Emission Strategy is available at the following URL:
https://www.kankyo.metro.tokyo.lg.jp/en/about_us/zero_emission_tokyo/strategy.html
2Silo-breakers are individuals and institutions that break down the walls – or “silos”- that
separate public-sector governance, business management, and other areas. For their role indisaster risk reduction and climate adaptation, see “Silo-breakers: Asia and the Pacific calls
for integrating climate adaptation and disaster risk reduction,” United Nations Office ofDisaster Risk Reduction, September 6, 2019:https://www.undrr.org/news/silo-breakers-asia-and-pacific-calls-integrating-climate-adaptation11

18 | 7 | 3

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-and-disaster-risk
3
On this lack of monitoring, see “US Cities Boost Clean Energy Efforts, but Few on Track to
Meet climate Goals,” American Council for an Energy-Efficient Economy, July 24, 2019:https://www.aceee.org/press/2019/07/us-cities-boost-clean-energy-efforts-0
4
See the US city database and assessments at “State and Local Policy Database,” American
Council for an Energy-Efficient Economy, March, 2020:
https://database.aceee.org/city-scorecard-rank
5
The Berlin City data are available (in German) at “Berlin (B),” German Federal Renewable
Energies Agency:
https://www.foederal-erneuerbar.de/landesinfo/bundesland/B/kategorie/top%2010/auswahl/28
9-anteil_erneuerbarer_/#goto_289
6Tokyo’s 2017 level of 14.1% renewable energy is displayed (in Japanese) on p. 124 of theTokyo Environmental White Paper, 2019:https://www.kankyo.metro.tokyo.lg.jp/basic/plan/white_paper/100200a20191031132600879.files/2019zenbun.pdf
7
Tokyo’s GHG emissions data can be referenced (in Japanese) on p. 125 of the Tokyo
Environmental White Paper, 2019:https://www.kankyo.metro.tokyo.lg.jp/basic/plan/white_paper/100200a20191031132600879.files/2019zenbun.pdf
8
On this point, note that “Project Drawdown” has assessed refrigerant
management/alternative refrigerants and reduced food waste as among the top actions ineffective GHG emissions reduction potential. See their comparative table on the scale ofpotential cuts: https://drawdown.org/solutions/table-of-solutions
9
On green infrastructure in Japan, see Andrew DeWit “Is Japan a Climate Leader? Synergistic
Integration of the 2030 Agenda,” Japan Focus, February 1, 2020:
https://apjjf.org/2020/3/DeWit.html
10These results were reported by what appears to be the first ever comparison of energy andother resource flows in megacities. See Kennedy, C. et al “Energy and material flows ofmegacities,” Proc Natl Acad Sci U S A. 2015 May 12:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4434724/
11
See “Creating a Sustainable City: Tokyo’s Environmental Policy,” Tokyo Metropolitan
Government, September 2018:
http://www.kankyo.metro.tokyo.jp/en/about_us/videos_documents/documents_1.files/creating_a_sustainable_city_2018_e.pdf
12
See p. 109 “The Weight of Cities: Resource Requirements of Future Urbanization,”International Resource Panel, 2018, available at the following URL:
http://www.resourcepanel.org/reports/weight-cities
13
The data are compiled by the International Association of Public Transport, and publishedas “World Metro Figures 2018”:
https://www.uitp.org/sites/default/files/cck-focus-papers-files/Statistics%20Brief%20-%20Worl
d%20metro%20figures%202018V4_WEB.pdf
14
For example, Project Drawdown assess “water distribution efficiency” as representing an
opportunity to halve water loss (currently 30.3 billion cubic liters/yr), reduce GHG emissions
by, and save between USD 250-350 billion:12

18 | 7 | 3

APJ | JFhttps://drawdown.org/solutions/water-distribution-efficiency
15
On these items, see the OECD’s work on Water and Cities: Ensuring Sustainable Futures:
http://www.oecd.org/water/water-and-cities.htm
16
See p. 109 “The Weight of Cities: Resource Requirements of Future Urbanization,”International Resource Panel, 2018, available at the following URL:
http://www.resourcepanel.org/reports/weight-cities
17
These kinds of funds (kikin) are not peculiar to TMG, and are financed via such measures asaccumulated savings from cost-cutting, unanticipated tax and related revenue increases, debt
finance, and other items. Japanese subnational governments use these funds to smooth out
annual budgeting as well as target special purposes (notably building municipal structures,supporting primary industries, and coping with aging). On these funds, and their striking
increase in recent years, see (in Japanese) Tatsuoka Kenjiro, “Why Have Local Government
Funds Increased?” JRI Review, 5(66), 2019:https://www.jri.co.jp/MediaLibrary/file/report/jrireview/pdf/11084.pdf
18
On Japanese Society 5.0’s integration of cyberspace and physical space, see “Society 5.0,”
Japanese Cabinet Office, nd: https://www8.cao.go.jp/cstp/english/society5_0/index.html
19
See (in Japanese) p. 20-21 of “Tokyo Metropolitan Government Budget Summary, FY 2020,”
Tokyo Metropolitan Government, February:https://www.zaimu.metro.tokyo.lg.jp/syukei1/zaisei/20200124_reiwa2nendo_tokyotoyosanang
aiyou/2yosanangaiyou.pdf
20
Concerning TMG’s FY 2019 and FY 2020 budgets, see (in Japanese) summaries at Tokyo
Metropolitan Government finance website: https://www.zaimu.metro.tokyo.lg.jp/zaisei/
21
Within an already voluminous literature on these matters, see “Christina Kwauk et al.,“Girls’ education in climate strategies,” Brookings Working Paper, December 10, 2019:https://www.brookings.edu/research/girls-education-in-climate-strategies/
22
The supplementary budgets are outlined (in Japanese) in detail “Concerning additions to the
FY 2019 and FY 2020 supplementary budgets,” Tokyo Metropolitan Government News,
February 18, 2020:
https://www.zaimu.metro.tokyo.lg.jp/yosan/20200218_hoseiyosanan_tsuika.pdf
23
See “G-20 Nations Pledge $5 Trillion to Spur Global Economic Recovery From
Coronavirus,” Wall Street Journal, March 26, 2020.
24
One recent assessment of the pandemic’s implications for the smart city is seen in “Taking
Stock of COVID-19: The Short- and Long-Term Ramifications on Technology and End
Markets,” ABI Research White Paper, March 18, 2020:
https://www.abiresearch.com/press/covid-19-pandemic-will-force-companies-around-world-rad
ically-rethink-how-they-operate-and-embrace-technological-investment/
25
The Ministry of Environment “Zero Carbon Cities in Japan” mapping is available in English
and regularly updated:
http://www.env.go.jp/en/earth/cc/2050_zero_carbon_cities_in_japan.html
26
The details of Gunma Prefecture’s programme are available (in Japanese) at “Gunma
Prefecture announces a 5-zeros by 2050 plan,” Gunma Prefecture, December 25, 2019:https://www.pref.gunma.jp/04/e01g_00147.html
27
The use of the term “2030 Agenda” derives from the fact that the UN’s three landmark
agreements – the SDGs, the Paris Agreement and the Sendai Framework on Disaster Risk
13

18 | 7 | 3

APJ | JF

Reduction - all cover the 2015-2030 period. On the effort to enhance synergies among thethree agreements, see Handmer, et al. “Achieving risk reduction across Sendai, Paris and theSDGs: International Science Council Policy Brief, May, 2019:https://council.science/wp-content/uploads/2019/05/ISC_Achieving-Risk-Reduction-Across-Sen
dai-Paris-and-the-SDGs_May-2019.pdf
28
On the Japanese Cabinet Office’s strategic approach to using the SDGs, see (in Japanese)
Seki Sachiko “Concerning the Promotion of Japanese-Style SDGs,” Governance, October,
2019.
29
The platform is described (in Japanese) at: http://future-city.jp/sdgs/
30
The categories are described in detail (in Japanese) at “SDGs Action Plan 2020,” Cabinet
Office, Government of Japan, December 2019:https://www.kantei.go.jp/jp/singi/sdgs/dai8/actionplan2020.pdf
31
The Smart City platform’s website (in Japanese) is here:
https://www.mlit.go.jp/scpf/index.html
32
The central government’s National Resilience plans for 2014-2019 are available (inJapanese) here: https://www.cas.go.jp/jp/seisaku/kokudo_kyoujinka/kihon.html
33
The National Resilience Plan and related materials are available (in Japanese) at thefollowing internet URL: http://www.cas.go.jp/jp/seisaku/kokudo_kyoujinka/
34
The list of plans is available (in Japanese) at “Concerning other national plans in regard tonational resilience,” Cabinet Office, March 25, 2019:https://www.cas.go.jp/jp/seisaku/resilience/dai47/siryo3-3.pdf
35
The membership, minutes and materials studied by the National Resilience (Disaster
Prevention and Reduction) Deliberation Committee are available (in Japanese) at thefollowing internet URL: http://www.cas.go.jp/jp/seisaku/resilience/
36
Links to Japan’s subnational National Resilience plans are available (in Japanese) here:
https://www.cas.go.jp/jp/seisaku/kokudo_kyoujinka/tiiki.html
37
The plans, budgets, committee data, and other relevant information are available via the
Cabinet Secretariat’s dedicated website: https://www.cas.go.jp/jp/seisaku/kokudo_kyoujinka/
38
On this, see “Lifelines: The Resilient Infrastructure Opportunity,” World Bank, June 17,2019:https://www.worldbank.org/en/news/infographic/2019/06/17/lifelines-the-resilient-infrastructu
re-opportunity39
One example is Center for Strategic and International Studies Senior Vice-President
Matthew P. Goodman in his “Parsing the Osaka G20 Communique,” Center for Strategic andInternational Studies, July 3, 2019:https://www.csis.org/analysis/parsing-osaka-g20-communiqué
40
The report can be accessed at the following URL:
https://www.itrc.org.uk/infrastructure-underpinning-sustainable-development/
41
On this, see Fermin Koop, “Coronavirus hits crucial year for nature and climate,” China
Dialogue, March 19, 2020:
https://www.chinadialogue.net/article/show/single/en/11915-Coronavirus-hits-crucial-year-fornature-and-climate
42
See the first-ever “Global Health Security Index,” developed by the Economist, the Nuclear
Threat Initiative, and the Johns Hopkins Center for Health Security. The Index is the world’s
14

18 | 7 | 3

APJ | JF

first, and in addition to getting the US wrong, lists Japan as 21st and Singapore as 24th. The
Index is a very important initiative, but clearly needs silo-breaking revision of underlying
assumptions and other factors. The Index is available at:https://www.ghsindex.org/wp-content/uploads/2019/10/2019-Global-Health-Security-Index.pdf
43
The working group’s membership and other details are (in Japanese) here:
http://www.resilience-jp.biz/wg/wg24/
44
The handbook (in Japanese) was updated on March 15 and is here:
http://www.hosp.tohoku-mpu.ac.jp/info/information/2326/
45
These are detailed (in Japanese) in “2020 Committee proposes 7 commitments,” Nikkei
Medical, February 12, 2010:https://medical.nikkeibp.co.jp/leaf/mem/pub/report/t344/202002/564278.html
46
See Riyanti, Djalante, Rajib Shaw, and Andrew DeWit, “Building resilience against
biological hazards and pandemics: COVID-19 and its implications for the Sendai Framework,”
Progress in Disaster Science, Vol. 6 April, 2020:
https://www.sciencedirect.com/science/article/pii/S259006172030017X
47
See “Emergency Risk Management for Health: Overview,” World Health Organization, May
2013:
https://www.who.int/hac/techguidance/preparedness/risk_management_overview_17may2013.
pdf

15

International Journal of Disaster Risk Reduction 51 (2020) 101808

Contents lists available at ScienceDirect

International Journal of Disaster Risk Reduction
journal homepage: http://www.elsevier.com/locate/ijdrr

Review Article

An integrated approach to sustainable development, National Resilience,and COVID-19 responses: The case of Japan
Andrew DeWit a, Rajib Shaw b, Riyanti Djalante c, *aRikkyo University, Japan
Keio University, Japanc
United Nations University - Institute for the Advanced Study of Sustainability (UNU-IAS), Japanb

A R T I C L E I N F O

A B S T R A C T

Keywords:
COVID-19
Japan
Fiscal stimulus
Resilience
Sustainability
Society 5.0
Sustainable development goals (SDGs)

The COVID-19 pandemic has led to historic economic fallout. To protect public health and stabilize incomes,
governments have implemented massive fiscal stimulus packages. These fiscal supports are crucial, though there
is concern that sustainable and resilient development will be sacrificed in the rush to preserve incomes andindustries. The aim of the paper is to review whether the Japanese governments’ responses in terms of financial
stimulus considers longer term resilience and sustainability. This paper reviews pertinent academic literature andpublicly available data from governments and organisations. The research is a rapid analysis of emerging in­formation provided by the government of Japan and other international organisations. Using the case of Japan,
this paper suggests that it is possible both to protect public health and essential services, while also promoting
resilience and sustainability. Japan’s integrated solutions show that pandemic response can include accelerated
decarbonization and resilient, sustainable development. The paper also warns also that failure to act on longterm sustainability risks increased inequality, higher opportunity costs, cascading hazards, and further retreat
from planetary thinking and globalism.

1. Introduction
This paper begins by reviewing the global developments, then turns
to the specifics of the Japanese case. We conclude with a section on
strategies towards further bolstering long-term sustainability and resil­
ience building. As to global developments, the World Health Organiza­tion (WHO) officially declared COVID-19 a pandemic on March 11, 2020[1], and by May 15 was reporting over 3.4 million confirmed cases [2]. It
soon became clear that the pandemic’s social and economic impacts
were accelerating with no modern precedent. Economic impacts that
unfolded over a few years during the Great Depression now erupt withina few weeks. By April 18, the International Monetary Fund (IMF) had
already projected the pandemic’s total 2020–2021 costs to be USD 9
trillion, equivalent to the combined size of the German and Japanese
economies [3]. A month later, on June 24, the IMF raised that figure to
USD 12 trillion [4]. On April 7, the International Labour Organization(ILO) estimated global job losses in the second quarter (April–June) of
2020 to equate to 195 million full-time positions [5]. By June 30, theILO had more than doubled that estimate, to 400 million [6]. These newdata are almost certain to become under-estimates.

Amidst the chaos, astute global leaders have sought to articulate acollective response. On March 19 UN Secretary General Antonio
Guterres warned that "[w]e are facing a global health crisis unlike any inthe 75-year history of the United Nations” [7]. Guterres emphasized theimperative of solidarity, hope and a coordinated global response tocounter a “human crisis” [8]. The March 26 G20 Leaders’ Statement on
COVID-19 from their Extraordinary Summit echoed this sentiment,
declaring that "[c]ombatting this pandemic calls for a transparent,robust, coordinated, large-scale and science-based global response in thespirit of solidarity [9].
Spending programmes to cope with the pandemic’s impacts haveincreased in scale and frequency, both multilaterally and domestically.
As to the former, on March 25 the UN launched a USD 2 billion global
humanitarian response plan (GHRP) to fund the fight against COVID-19
in the world’s poorest countries [10]. March 26 saw the G20 pledge USD
5 trillion of stimulus (both multilateral and country-level) into theglobal economy, as part of targeted fiscal policy, economic measures,and guarantee schemes to counteract the pandemic’s social, economic
and financial impacts. On March 31, the EU Solidarity Fund’s scope wasbroadened to include major public health emergencies. The FY 2020

* Corresponding author.
E-mail address: djalante@unu.edu (R. Djalante).
https://doi.org/10.1016/j.ijdrr.2020.101808
Received 26 May 2020; Received in revised form 10 July 2020; Accepted 4 August 2020
Available online 13 August 2020
2212-4209/© 2020 Elsevier Ltd. All rights reserved.

A. DeWit et al.

International Journal of Disaster Risk Reduction 51 (2020) 101808

financing of roughly EUR 800 million is aimed at supporting member
countries’ action to protect their populations and prevent viral spread[11].
Country-level fiscal stimulus packages have been far more numerous
and aggressive. Table 1 summarizes the cumulative fiscal stimulus, incurrency amounts and share of GDP, for several major countries as ofApril 20. For example, April 7 saw the Japanese Cabinet approve thecountry’s largest ever stimulus of JPY 108 trillion (approximately USD 1
trillion), subsequently increased to JPY 117.1 trillion on April 20. On
May 26, that amount was doubled, with the total reaching JPY 234.2.
Most observers expect several more stimulus packages in Japan andelsewhere as the public-health crisis worsens.
Measures to recover from the present crisis are virtually certain to
include long-term investments in health, energy, water, transport, andother critical infrastructure [15]. Climate-aware individuals and in­stitutions recognize the present crisis as an opportunity - indeed animperative - for resilient, decarbonizing and equitable structural change.
Certainly COVID-19 has dramatically reshaped the policymaking debate
by: 1) bolstering public authority over private agency, 2) elevating
collaborative planning over reliance on price signals, 3) expanding thescope of all-hazard resilience to emphasize pandemic risks, and 4) vastly
increasing public awareness of the need for holistic resilience. Thus,
back on March 31, UN Secretary General Guterres was able to insist that"[t]he recovery from the COVID-19 crisis must lead to a different
economy” without attracting a flurry of criticism [16].
Yet many questions whether this ideational change will become
institutionalized and lead to inclusive resilience. There is no guaranteethat national-level countermeasures will come to embody the 2030
Agenda, let alone serve as a basis for productive global cooperation.
There is also no consensus on precisely what constitutes best practice indecarbonizing and disaster-resilient infrastructure, and hence no simple
guide for selecting and implementing such urban systems.
Many voices equate sustainability with green energy – notable solar
and wind - within a context wherein “green recovery” has become thebyword for transcending fossil fuels. But simply investing in more solar
and wind does not seem sufficient. Data on global renewable investment
between 2010-19 show that China is the leader, followed by the US andJapan [17]. But those prodigious investments alone did not reduce
emissions, increase equity, and otherwise achieve the 2030 Agenda
goals. Equally, if not more important, is the resource-efficiency of urban
and semi-urban communities, the inclusivity of governance, and the
myriad other factors that are key to the 2030 Agenda.
The scope of the challenge is underscored by International Energy
Agency estimates that the COVID-19 shock - though unprecedented will only lead to an 8% reduction in CO2 emissions in 2020, relative to2019 [18]. To be sure, that decline in emissions accords with the call forannual CO2 reductions of 7.6% to limit warming to 1.5◦ [19]. But the
IEA warns that 2020’s decline in emissions could be followed by amassive increase unless stimulus plans emphasize low-carbon anddecarbonizing recovery. Just as unprecedented economic chaos alone
does not eliminate emissions, fiscal stimulus does not necessarily lead to“build back better."Hence the urgency of examining the evidence on what countries are
doing. Observers note that some countries - notably China, Germany andSouth Korea - are thinking of including sustainability goals in upcoming

fiscal stimulus [20]. But the evidence suggests Japan is already battling
COVID-19 and building climate resilience at the same time. This paper
shows that Japan embeds holistic resilience and sustainability in its
fiscal stimulus packages. Past and present performance indicate Japan’semphasis on integrated solutions can help accelerate decarbonizationand foster resilient, sustainable development while countering COV­
ID-19’s myriad impacts. Japan is one example of how COVID-19 coun­
termeasures are being used to bridge national and international
imperatives.
The next section turns to the fiscal and institutional details of theJapanese case.
2. Japan’s fiscal stimulus in context
As noted earlier, Japan’s COVID-19 fiscal countermeasures total JPY
234.2 trillion as of July 1, 2020. Much expert commentary on Japan’s
first round of fiscal stimulus pointed to the fact that it was not all new
finance, but rather built on Japan’s December 2019 fiscal stimulus [21].
In other words, the criticism largely suggested that JPY 108 trillion sizeof Japan’s April 7 fiscal stimulus was exaggerated. But this appraisal of
the scale of Japan’s April 2020 fiscal stimulus deflected attention fromthe important resilience-oriented content of the December 2019 stim­
ulus. The December stimulus had nothing to do with COVID, and instead
responded to Japan’s need to further bolster holistic disaster resiliencein the wake of floods, seismic events, power outages, and other shocks
during 2018 and 2019. We present the main elements of the December
2019 package in Table 2.
Table 2 shows that there were three key pillars in the December 2019stimulus: National Resilience Plans (NRP) and disaster reconstruction;
economic risk countermeasures; and “Post 2020 Olympic Games” legacy
investment in Society 5.0, SDGs-inclusive society. Of course, the 2020
Olympic Games are postponed to 2021, and in the end may not even be
held. But that does not mean the investment in critical infrastructures is,
ipso facto, wasteful.
The table also separates the JPY 13.2 trillion public spending fromthe JPY 26 trillion total of public and private spending. The latter figure
is achieved via national government support for local government
spending (through direct and indirect subsidies), low-interest loans tofoster business investment, and similar mechanisms.
In terms of precise content among the three categories, the NRP shareis JPY 2.8 trillion, investments in Society 5.0 and SDGs (both investment
in infrastructure and training human resources) JPY 781.6 billion. The
NRP projects are underpinned by the idea that “coping with climatechange is also conducive to disaster prevention,” and the Society 5.0/
SDG initiatives explicitly target zero-emissions technology (such as
natural refrigerants), energy efficiency, and related decarbonization[22].
The subsequent fiscal stimulus (cumulative to April 20) built on thislegacy by doubling down on the NRP, SDGs and Society 5.0 roles. The
package also included JPY 15 trillion for restructuring supply chains to
re-shore or at least further diversify (eg, among ASEAN countries) the
production of critical medical and related materials (pharmaceuticals,
masks, ventilators, sanitizers, and other items). Moreover, consistent
with the December 2019 approach, the measures undertaken in April
ramp up the efforts on Society 5.0, digital transformation, decarbon­
ization, and other measures specifically to reduce the risks of future
pandemics. The package also emphasizes SDGs-style multilateral

Table 1COVID-19 fiscal stimulus, % GDP (as of July 1, 2020) [12,14].
Country

Fiscal Stimulus (Amount)

Fiscal Stimulus (% GDP)

Japan
US
Germany
FranceChina

JPY 234.2 trillion (USD 2 trillion)
USD 2.9 trillion
EUR 913 billion
EUR 425 billion
RMB 4.2 trillion

42.2
14
26.9
19
4.1

Table 2
December 2019 Fiscal Stimulus (JPY trillion) (Source [12].

Source: Japanese Cabinet Secretariat [12,13]; IMF [3,4,14].
2

MeasurePublic Spending

NRP and Disaster Reconstruction
Economic Risk
Post 2020 Olympic Games
Total

5.8
3.1
4.3
13.2

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International Journal of Disaster Risk Reduction 51 (2020) 101808

engagement on water systems, public health and other critical infra­
structure via JETRO, JBIC, JICA and through UNICEF, IMF, WBG, ADB,
and other agencies where Japan has a track record of close
collaboration.
The above is not to insist that Japan is a leader in fighting COVID-19.
In the May 7 Financial Times former UN Executive Secretary of the UN
Framework Convention on Climate Change, Christiana Figueres,
included Japan among the countries that “acted in line with the risks.”
But it is also the case that, like almost all other countries, Japan’s preCOVID all-hazard disaster resilience grossly under-estimated the risksof a pandemic. And again, like most other countries, Japan’s pandemic
response was delayed and remains inadequate. Yet it is also true thatJapan’s 20,261 confirmed cases and 982 fatalities as of July 9, are much
lower than most of its peer countries in the G20 and OECD [23]. But inany event, this paper is not the venue to compare the relative merits ofdifferentiated epidemiological responses to COVID-19 per se, particu­
larly because much remains unclear about the pandemic’s trajectory andwhat is effective in the face of it.

Table 4
Japan’s local SDGs communities and model cases (as of April 2020) Source:
https://sdgs-support.or.jp/journal/sdgs-future-city/.

3.1. Society 5.0 and national SDGs initiatives
Far more important for our purposes here is that Japan’s actions are
evolving in a holistic paradigm. For one thing, they are part of an in­tegrated, resilience-oriented “Society 5.0′′ industrial policy regime that
predated COVID-19 [24,25]. We saw earlier that this policy regime wasalready heavily funded in Japan’s pre-COVID, December 2019 stimulus.
And that pre-COVID stimulus comprises a core element of the larger
April 20 stimulus noted earlier. Society 5.0’s policy arms include such
critical cyber-physical linkages as “post 5G” next-generation commu­
nications, remote-sensing for disaster risk reduction, digitalization insmart cities, 3-D mapping for compact cities, monitoring and controls for
integrating variable renewable energy, and other means to bolster
evidence-based collaborative governance [25]. Japan’s Society 5.0 is
also directly tied to the 2030 Agenda’s Sustainable Development Goals(SDGs). Indeed, Japan’s SDGs initiative appears to be unique among thedeveloped countries: its multi-level SDGs collaboration deliberately uses
the SDGs’ 17 goals and 169 targets to focus local government initiatives
on myriad domestic challenges in combination with overseas engage­
ment and contributions. In short, Japan does not see SDGs as external
aid but rather as a platform for integrating sustainable domestic andoverseas development [26].
As is shown in Table 3, Japan has organized a broadly inclusive Local
SDGs Public-Private Collaborative Platform. By the end of June, theplatform included 631 local governments in addition to most of thenational government’s central agencies. It also includes 1318 business
firms, research institutions, NPOs and other members, bringing the total
to 1962 members. Table 4 also shows the ongoing results of the JapaneseCabinet Office’s efforts to disseminate best practice. Since 2018, theCabinet Office has opened a competition for subnational governments to
be designated as SDG Future Cities and for particularly well-integrated
initiative to be designated as Model Cases. As of April of 2020, there
are 60 SDG Future Cities and 20 Model Cases.
A further important platform context for shaping Japanese action is

Subnational Governments
Central Agencies
Private Firms and others
Total Membership as of end June 2020

631
13
1318
1962

29
10
31
10
Cities: 60, Model Cases: 20

3.2. National Resilience Plans (NRP)
One of Japan’s key governance platforms for designing, imple­
menting and revising integrated policy is National Resilience [27]. Na­
tional Resilience predates the 2030 Agenda’s Sendai Framework on
Disaster Risk Reduction (SFDRR), formally adopted in 2015, but closely
parallels its content by emphasizing all-hazard disaster preparation inadvance, building back better, and “whole of government” inclusive
governance. National Resilience also encompasses smart communica­
tions, sustainable energy systems, resilient water networks, and theother critical infrastructures that compose holistic resilience.
Japan’s national and subnational governments are closely linked in a
rapidly expanding portfolio of national and subnational National
Resilience Plans (NRPs) that have legal precedence over other plans.
NRPs are aimed at bolstering the country’s resilience to natural disasters
and other hazards, as well as fostering the capacity to recover from suchdisasters when they occur. Since 2014, there have been 2 iterations(2014, 2018) of the NRP Basic Plan as well as 6 annual action plans that
decide and then monitor the planning cycle and the achievement of Key
Performance Indicators (KPI). These KPIs include hard measures, such as
monitoring hazards via smart sensors, strengthening back-up power for
hospitals and other facilities, reinforcing flood-control systems, andhardening critical communications infrastructure. The KPIs also include
soft measures, such as skill-building, risk communication, and measures
to break down governance silos. In the 2019 revision of the original 5year NRP basic plan, the number of KPIs had increased to 179. More­over, Japanese National Resilience has been funded at roughly JPY 5
trillion per year since FY 2018. The investments finance soft and hardmeasures in addition to training and international engagement.

Table 5
Japan’s smart city public-private collaborative platform (as of June 2020)(Source: https://www.mlit.go.jp/scpf/about/index.html).

Table 3
Japan’s local SDGs public-private collaborative platform (as of April2020), Source: http://future-city.go.jp/platform/.
NumberNumber2018 SDG Future Cities
2018 SDG Model Cases
2019 SDG Future Cities
2019 SDG Model Cases
Total Cities and Cases

its Smart City Public-Private Collaborative Platform, whose membershipis itemized in Table 5. Of particular note is the growing number of local
governments, at present 115. The platform also includes 120 observers,
and is yet another venue in which decarbonizing and inclusive Society
5.0, SDGs, and DRR best practice are shared among a multiplicity of
stakeholders.
A more recent platform is Japan’s Green Infrastructure PublicPrivate Collaborative Platform. The local government membership in­cludes Sendai City (the host city for the SFDRR), Tokyo, and otherinfluential cases. Moreover, the important role of central agencies iscoupled with the participation of business, academe, NPOs and otherstakeholders whose collective expertise encompasses water, energy,
construction, and other areas crucial to designing and implementing
comprehensive green-infrastructure solutions (Table 6).

3. Japan’s integrated paradigm: society 5.0, SDGs and National
Resilience

Member Class

Category and Year

3

Platform Member Class

NumberSubnational Governments
Central Agencies
Businesses, Research Centres, and others
Business Associations
Total Membership

115
11
359
2
487

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International Journal of Disaster Risk Reduction 51 (2020) 101808

Table 6
Japan’s green infrastructure public-private collaborative platform (as ofMarch 19, 2020) (Source: http://www.mlit.go.jp/report/press/sogo10_hh_000216.html).
Member Class

NumberSubnational Governments
Central Agencies
Businesses, Research Centres, and others
Individual Memberships
Total Membership

23
4
150
232
409

Table 8
Sapporo City’s 2020 Economic Stimulus-Related Spending (unit: JPY billion)(Source: p 14 http://www.city.sapporo.jp/zaisei/kohyo/yosan-kessan/r2/documents/r2gaiyouzentai.pdf).
Disaster-Recovery and Resilience: 20.9
Future-Oriented Investment: 11.1

Resilient Schools
Emergency Power
Flood and OtherICT in Schools

9.36
0.24
11.32
9.54

planet, and ensure that all people enjoy peace and prosperity by 2030.
The 17 SDGs are integrated—that is, they recognize that action in one
area will affect outcomes in others, and that development must balancesocial, economic and environmental sustainability. Through the pledge
to Leave No One Behind, countries have committed to fast-track andprioritize progress for the most disadvantaged. That is why the SDGs aredesigned to achieve several ‘zeros’, including zero poverty, hunger,
AIDS, and discrimination against women and girls. Broad stakeholder
participation is needed to reach these ambitious targets. The creativity,
knowhow, technology and financial resources from all elements of so­ciety are necessary to achieve the SDGs in every context. Moreover,through Nationally Determined Contribution (NDCs), countries show
how they plan to meet the Paris Agreement on Climate Change [28]. In
addition, the Sendai Framework for DRR calls for a comprehensive,
multi-hazard and coherent approach (SFDRR, 2015).
Objectively speaking, integrating the 2030 Agenda is even more
important in the midst of COVID-19. As IRENA (2020) puts it, “the goals
set out in the United Nations 2030 Agenda and the Paris Agreement canserve as a compass to stay on course during this disorienting period.
They can help to ensure that the short-term solutions adopted in the faceof COVID-19 are in line with medium- and long-term development andclimate objectives.” The UN has also emphasized that the recovery fromthe COVID-19 crisis “must lead to a different economy” [10,16]. The
International Resource Panel (IRP) has also pointed out that
resource-efficient green stimulus packages can lead to cost savings, newindustries, and equitable economic growth [29].
Evn so, public policy is clearly distracted by political polarization,
geopolitical tensions, and other factors. In this section, we outline key
implications if the fiscal response does not conform with the 2030
Agenda, both at the national level in Japan, and also globally.

3.3. Prefectural and cities resilience initiatives
A key test of any such ostensibly collaborative initiative is how well it
diffuses and how purposefully engaged the actors are. By May 1 of 2020,
all of Japan’s 47 prefectures had adopted their own regional versions of
the NRP. Moreover, as a Table 7 shows, 1472 of Japan’s 1741 cities,
special wards, and towns had either adopted their own local versions of
the NRP or were formulating plans. This number of local governments
doing NRPs was more than seven times the 190 total from just over a
year earlier, April 1 of 2019 [12,13]. That startling 775% rate of increasein a little over a year is testament to the rapid spread of risk-awareness inJapan. Recent years of unprecedentedly destructive typhoons, floods
and other disasters have led to a consensus on the need for compre­
hensive planning and integrated countermeasures. Japan’s subnational
governments now routinely request increased regular budget and special
fiscal stimulus spending on NRP, SDGs, Society 5.0 projects and theirintegration. These fiscal and related requests are articulated collectively
through such subnational representative organisations as the National
Governors’ Association, The National Mayors’ Association and others.
An example of how the December 2019 fiscal stimulus was used at
the subnational level is seen in Table 8 in Sapporo City. The table shows
Sapporo’s 2020 initial spend on economic stimulus, responding to thenational government’s December package, focused on close to JPY 19
billion for resilient and smart schools. Other spending included JPY
11.32 billion on bolstering the city’s waterways, transport networks andother critical infrastructure. This emphasis on resilience is no surprise.
Like many of Japan’s subnational governments, Sapporo is aggressive inbuilding on national policy to pursue integrated solutions to disaster,
demographic, fiscal, and myriad other hazards. Sapporo was selected as
one of the SDGs projects in June of 2018 and followed that up in
December 2019 by revising the NRP it had adopted in January of 2016.
Sapporo had already undertaken a Compact City Plan from March of2016 and had also implemented a Smart City initiative from March of2017. Sapporo is only one example of productive use of the fiscal
stimulus within Japan’s larger context of 2030-Agenda oriented plat­form institutions.

4.1. Increased inequality
Emergency spending only to perpetuate the patently vulnerable
status quo risks forfeiting opportunity to reduce a range of negative
externalities that erode human health and welfare and have been
implicated in the retreat of democracy (EIU, 2020). Concerning the US,
Philip Alston, the UN Special Rapporteur on extreme poverty and humanrights, pointed out that “[l]ow-income and poor people face far higher
risks from the COVID-19 due to chronic neglect and discrimination, anda muddled, corporate-driven, federal response [that] has failed them”(OHCHR, 2020). The UN has also warned that coronavirus-driven debt
crises threaten poor countries already at risk. It recommends acceler­ating investment in resilient infrastructure, strengthening social pro­tections, enhancing regulatory frameworks, and strengthening theinternational financial safety net and framework for debt sustainability.
And it strongly advises that this action be coordinated lest the larger
opportunity be lost in the gaps among governance and other silos [30].

4. Towards resilience building and long-term sustainability
globally
Having analysed Japan’s financial stimulus in responding to COVID19 response from section 2 to 3, we turn to examine how integrated
financial and economic stimulus can foster a rights-based, low carbon,
resilient and sustainable recovery. The year 2020 was slated to be the“super year” of global action toward sustainability. The SDGs - also
known as the Global Goals - were adopted by all United Nations Member
States in 2015 as a universal call to action to end poverty, protect the4.2. Higher opportunity costs
Table 7
Increase in Japan’s local national resilience plans (NRPs) (Source: https://www.
cas.go.jp/jp/seisaku/kokudo_kyoujinka/pdf/200401_keikakumap.pdf).
Administrative Level

April 1, 2019

May 1, 2020

Local Government

190

1472

Opportunity costs are the pecuniary and other potential benefits
forgone when one alternative is chosen over another. Specifically con­cerning fiscal countermeasures to COVID-19 and its economic fallout,
failure to include climate action risks accelerated global warming. We
have seen that the scale of COVID-19 counter-measures is already4

A. DeWit et al.

International Journal of Disaster Risk Reduction 51 (2020) 101808

enormous, unprecedented in peacetime. Most countries lack the fiscal
capacity and political will to continue such spending beyond one or two
years, let alone for decades. Focused investment in public health systems- particularly in least developed countries - could reduce economic costs
from future outbreaks as well as contribute to containing the present one[31]. For example, analyses suggest that in the US alone social
distancing measures lead to net benefits of $5.2 trillion [32]. These kindsof benefits could be multiplied by making the health investments
climate-smart as well.

large-scale crises from COVID-19. Its financial stimulus is characterized
by long-term consideration for national and local resilience, along with avision of Society 5.0. Japan has a powerful track record of managing
large scale crises and complex recovery from natural and man-madedisasters. It offers a pertinent example of how to do integrated plan­ning, implementation, and revision through multi-stakeholder andincreasingly all-hazard platforms. Japan integration of COVID-19
countermeasures and resilience merits closer study for lessons onleast-cost and synergistic mitigation and adaptation. We would also urgethat Japan use it stimulus packages even more productively, as a win­
dow of opportunity for implementing long-term sustainability andresilience.
In conclusion, it is a tall order to draft and implement a coherent
strategy of COVID-19 countermeasures coupled with the 2030 Agenda.
Global partnerships are critical to formulating and disseminating a
global response. That is why goal 17 of the SDGs centres on strength­
ening global partnerships among national governments, the interna­
tional community, civil society, the private sector and otherstakeholders. The 2030 Agenda thus embodies the shared responsibility
and global solidarity essential to making COVID-19 recovery a major
step in the long journey back from planetary boundaries and towards
sustainable and resilient communities.

4.3. Greater complexity and systemic risk
Global connectedness has led to increased complexity. Thatcomplexity carries with it benefits for some but at the same time ahidden cost for all: fragility (Jensen, April 9, 2020). In finance, forexample, interconnected institutions benefit from complex networks
and reduced transaction costs, but have produced a fragile structure
through which illiquidity and insolvency can become almost virulent
during periods of financial distress (Billion et al., 2012). Similarly,
COVID-19’s unprecedented impact is rooted in complexity and fragility.
Human ecosystem encroachment has led to a per-decade tripling ofoutbreaks since the 1980s, including ebola, HIV, swine flu, avian flu, andother viruses. Global interconnectedness has provided more humanhosts, and inequality an abundance of compromised immune systems.
This systemic reality risks accelerated evolution of mutations, and un­
derscores the imperative of leaving no one behind. Emerging infectious
diseases in humans are frequently caused by pathogens originating fromanimal hosts, and zoonotic disease outbreaks present a major challenge
to global health [33].The overlap of human security and national se­
curity clearly transcends national borders.
Climate change and disaster risk offer additional examples of sys­
temic risks that are embedded in the complex networks of an increas­
ingly interconnected world. The Paris Agreement on Climate Change
calls for limiting warming to 2 ◦ C and pursuing efforts for 1.5◦ [34]. The
IPCC [35] states that delaying actions for mitigating climate change
leads to worsened climate risk and even greater efforts to cope with theimpacts [36]. Indeed, the global community stands at the precipice ofthe soft and hard limits of adaptation increases, which may increase theloss and damages from climate change [37]. The interaction between
natural and human-induced disasters is increasingly evident. Natural
hazards can trigger technical and societal disasters, and hence naturaland non-natural risks have multiplied (UNDRR, 2019). The systemic
nature of disaster risk is exacerbated by the fact that that the events canbe sudden and unexpected, the impacts are interlinked, and the dyna­
mism may change over time. Disaster risk can also be compounded, suchthat one even triggers subsequent events. And multiple events – orcascading catastrophes - can unfold almost simultaneously. The global
community must therefore increase its capacity to build resiliencethrough risk-informed sustainable development (UNDRR, 2019). It is
crucial that the SFDRR’s lessons be used to strengthening the resilienceof nations and communities for dealing with the health, disasters, andclimate challenges [38].

Declaration of competing interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
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4.4. Increased risk of retreat from planetary thinking and globalism
The ongoing fiscal stimulus packages have raised deep concerns
among fiscal conservatives, market liberals and others concerning overreach of tax/debt states. The nearly inevitable increases in taxation andoutrage over the contents of ongoing fiscal relief (eg, for airlines) could
further weaken political coalitions supporting climate action and global
engagement. In order to achieve a virtuous cycle of mitigation andadaptation, stakeholder inclusion and co-benefits must be maximized inleast-cost solutions. Fiscal and other resources are not infinite, and 2030
Agenda solutions have to be robust against emergent political hazards.
In this regard, we have shown that Japan’s National Resilience
Program has built a strong foundation for equipping Japan to respond to5

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6

Commentary

Reflection of Challenges and Opportunities within the
COVID-19 Pandemic to Include Biological Hazards
into DRR Planning
Emily Ying Yang Chan 1,2,3,4,5,*, Caroline Dubois 3,4, Ada Ho Yin Fong 4, Rajib Shaw 6,7, Ranit Chatterjee 7,8,
Ambika Dabral 7, Antonia Loyzaga 9, Yong-kyun Kim 10, Kevin Kei Ching Hung 1,3,5 and Chi Shing Wong 1,3
Collaborating Centre for Oxford University and CUHK for Disaster and Medical Humanitarian Response(CCOUC), The Chinese University of Hong Kong, Hong Kong, China;
kevin.hung@cuhk.edu.hk (K.K.C.H.); cswong@cuhk.edu.hk (C.S.W.)
2 Nuffield Department of Medicine, University of Oxford, Oxford OX37BN, UK
3 JC School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong,
Hong Kong, China; caroline.dubois@gxfoundation.hk
4 GX Foundation, Hong Kong, China; fong.adahy@gmail.com
5 Accident & Emergency Medicine Academic Unit, The Chinese University of Hong Kong, Prince of Wales
Hospital, Hong Kong, China
6 Graduate School of Media and Governance, Keio University, Fujisawa 252-0882, Japan; shaw@sfc.keio.ac.jp
7 Resilience Innovation Knowledge Academy (RIKA), New Delhi 110059, India;
ranit@rikaindia.com or chatterjee.ranit.8a@kyoto-u.ac.jp (R.C.); ambika@rikaindia.com (A.D.)
8 Graduate School of Informatics, Kyoto University, Kyoto 606-8501, Japan
9 National Resilience Council, Pasay City 1300, Philippines; aloyzaga@observatory.ph
10 Ministry of Interior and Safety, Sejong 30128, Korea; unkim68@gmail.com* Correspondence: emily.chan@cuhk.edu.hk; Tel.: +852-2252-8850
1

Citation: Chan, E.Y.Y.; Dubois, C.;
Fong, A.H.Y.; Shaw, R.; Chatterjee,
R.; Dabral, A.; Loyzaga, A.;
Kim, Y.-k.; Hung, K.K.C.; Wong, C.S.
Reflection of Challenges andOpportunities within the COVID-19
Pandemic to Include Biological
Hazards into DRR Planning. Int. J.
Environ. Res. Public Health 2021, 18,
1614. https://doi.org/
10.3390/ijerph18041614
Academic Editor: Paul B.
Tchounwou
Received: 30 December 2020
Accepted: 5 February 2021
Published: 8 February 2021
Publisher’s Note: MDPI stays
neutral with regard to jurisdictional
claims in published maps andinstitutional affiliations.

Abstract: COVID-19 has reinforced the need to revisit the integration of health within disaster risk
reduction (DRR) strategies for biological hazards in a system-wide approach. In November 2020,
DRR experts attended the Asia-Pacific Partnership for Disaster Risk Reduction (APP-DRR) Forumto share progress and learnings in the areas of health system resilience, data management, residual
risk management, risk communication, digital literacy, and knowledge product marketing. Advancements for health in DRR included the importance of multi-sectoral, multi-hazard action plans;
adaptation to technological advancements in data collection, dissemination and protection; promoting the health and wellbeing of essential and nonprofessional workers; and improving inclusivity
in digital literacy. COVID-19 has affected progress towards the Sustainable Development Goals(SDG) and created a unique opportunity within DRR to re-evaluate the adequacy of response mechanisms against concurrent, cascading or interacting risks of future biological hazards. Health emergency disaster risk management (Health-EDRM) is a new World Health Organization paradigm
that includes DRR at intra-, inter- and multidisciplinary levels. Scientific advancement under
Health-EDRM is necessary for health and non-health actors in DRR education and research. Continuous education on the multifaceted risk governance is a key to building awareness, capacity andaccelerating towards achieving the international DRR and the SDG targets.
Keywords: health-EDRM; disaster risk reduction; biological hazards; Sendai Framework; COVID19, pandemic

Copyright: © 2021 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms andconditions of the Creative Commons
Attribution

(CC

BY)

license(http://creativecommons.org/licenses/by/4.0/).

1. Introduction
The intersection between health, resilience capacity building and disaster risk reduction (DRR) planning and strategies has emerged as an interdisciplinary field of great importance for the protection of human health and wellbeing [1] since the publication ofInt. J. Environ. Res. Public Health 2021, 18, 1614. https://doi.org/10.3390/ijerph18041614

www.mdpi.com/journal/ijerph

Int. J. Environ. Res. Public Health 2021, 18, 1614

2 of 13several international frameworks, including the Sendai Framework for disaster risk reduction 2015–2030 [2], and more recently in World Health Organization (WHO) Framework for Health-Emergency Disaster Risk Management Framework (Health-EDRM) [3].
The ongoing COVID-19 pandemic has amplified the need to bring the health sector frontand-center in disaster risk management at national and international levels. A hazard isdefined by the United Nations Office for Disaster Risk Reduction (UNDRR) within the
Hyogo Framework for Action as “a potentially damaging physical event, phenomenon or
human activity that may cause the loss of life or injury, property damage, social and economic disruption or environmental degradation. Hazards can include latent conditions
that may represent future threats and can have different origins: natural (geological, hydrometeorological and biological) or induced by human processes (environmental degradation and technological hazards)” [4]. A pandemic is an example of a biological hazard,
which are hazards that may be either “of organic origin or conveyed by biological vectors”, would be further defined by characteristics such as “infectiousness or toxicity, dose–
response, incubation period, case fatality rate and estimation of the pathogen for transmission” [5], and may have amplified impacts in the age of globalization.
Globally, hazard management planning and response strategies have yet to reflect
the non-linear transition of biological hazards, particularly pandemics, which can emergein overlapping waves with different impacts, and the community must enter a response
phase before the initial recovery phase is completed [6]. As a result, the non-linear attributes of biological hazards have rendered the human community vulnerable to protracted
crises that persist and increase the community’s vulnerability to the cascading risks ofmulti-hazard that generate complex secondary events and interactions [7]. Many global
at-risk communities face cumulative impacts of concurrent geological and hydrometeorological hazard events like earthquakes and cyclones during the COVID-19 pandemic,
exacerbating existing issues of food insecurity and social security. Examples of multi-hazards with cascading risks include the cyclone Amphan landfall in India and Bangladesh,which disrupted clean water and sanitation systems, leading to barriers in adequate handwashing and hygiene, which has, in turn, exacerbated not only the spread of COVID-19
but other waterborne diseases [8]. The Philippines experiences an average of twenty tropical typhoons annually, which has added burden to the emergency situation of the country, leaving many communities to rely on their own resources for protection as local government resources are spent responding to COVID-19 [9]. In addition, many vulnerable
communities are affected by syndemics—the concurrent, cascading or interacting risks ofbiological hazards within the same individuals and groups, thereby aggravating disease
burdens such as COVID-19 and an array of noncommunicable diseases [10]. The inadequacy of available risk strategies catered for the nuances of biological hazards will undoubtedly challenge the resilience of community health and health systems.

2. Materials and Methods
This paper delineates the key issues as highlighted at the Asia-Pacific Partnership for
Disaster Risk Reduction (APP-DRR) Forum (December 2020) convened by the United Nations Office for Disaster Risk Reduction (UNDRR) Regional office for Asia and the Pacific.
This is a multi-stakeholder forum that includes governments, regional inter-governmentalorganizations, civil society organizations, international organizations and donor organizations. The purpose of the discussions is to monitor the implementation of the Sendai
Framework across the region and for stakeholders to share community-relevant insights
and identify key priority action areas towards DRR in the region [11].
The way forward for health system resilience building, data management, residual
risk management, risk communications, digital literacy, and knowledge product marketing were priority areas identified in this forum and are discussed in this paper.

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3. Results
3.1. Health System Resilience
When responding to a biological hazard, the health sector is expected to lead the immediate frontline response. In response to the multifaceted impacts of COVID-19, many
jurisdictions mobilized resources outside of the health sector to impose control measuresagainst the spread of the virus, which brought in travel, tourism, education, and othersectors. The most common measures included personal behavioral regulations such as
mandatory face masks in public places [12]; social distancing like city lockdowns, quarantine, and school closures [13–15]. Other measures include emergency international travel
guidelines, such as self-declaration of health status, and mandatory COVID-19 testing [16–18]. Although the Sendai Framework calls for the broader health system vigilance andresilience and to integrate disaster risk management across primary, secondary, and tertiary healthcare, there is a discord in how national responses are organized to respond to
COVID-19. Japan, for example, has a dedicated National Action Plan for Pandemic Influenza and New Infectious Diseases (2013) [19], which provides multi-sectoral, holistic andcomprehensive recommendations from the pre-outbreak to the recovery phase. The national action plan proactively monitors outbreaks in other areas of the world, and recommends international joint simulation exercises in the pre-outbreak phase. The plan contains recommendations to ensure continuity of medical care, of education, welfare-services, and business recovery mechanisms. The plan, however, does not consider concurrent, cascading or interacting hazards [6]. In contrast, Singapore’s national Pandemic
Readiness and Response Plan for Influenza and Other Acute Respiratory Diseases (2014)[20] aims to mitigate the mortality and morbidity consequences after the onset of the firstwave through rigid surveillance. The plan mobilizes essential services, case monitoringand isolation mechanisms, and infection control in hospitals so as to maintain healthcare
provision. However, the plan is developed by the Ministry of Health and heavily emphasizes the healthcare and public health approach, but is limited in considering the role andresponsibility of other sectors [6]. While these plans include guidance on post-epidemic
surveillance and the lifting of social and economic restrictions to return to normalcy, neither of these plans takes into consideration the mitigation or treatment of long-term physical, social and psychological impacts of a pandemic, which can include symptoms of anxiety, depression and even posttraumatic stress among healthcare workers or the wider
population [21]. In the case of COVID-19, there is evidence of post-viral syndrome, which
can include fatigue, myalgia, headaches and shortness of breath [22].
Most of these communities have a primary focus on building resilient health systems
and building capacity within health workers to apply DRR approaches in service delivery[2]. Nevertheless, there are broader aspects to consider:The capacity of the relevant health and non-health workers across the entire pathwayof care should be strengthened, from screening, testing, diagnosis, treatment, recovery and rehabilitation [6];Surveillance and information systems must be strengthened to ensure that data collected includes all populations and will enable the system to identify and protectgroups facing vulnerability [6];Public–private partnership models for health service provision should be exploredand promoted to maximize functionality and service provision, especially when government systems are constrained [6].

3.2. Data Management
Biological hazards affect population groups differently, depending on their exposure. Vulnerability will vary according to the nature of the hazard, existing mitigation andprotection systems, and any existing and inherent risks faced. Traditional groups facing
vulnerability include, but are not limited to, older people, groups living in rural areas,

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migrant groups, indigenous groups, and those with comorbidities, physical or mental disabilities. In order to assess impact inclusively, baseline pre-disaster data for health andsocioeconomic indicators should be made available to identify and minimize the impact
of determinants that may exacerbate biological risks [6]. To achieve DRR that is inclusiveof the vulnerable and the forgotten, risk assessments during emergency settings must
therefore include disaggregated data and analysis for groups facing vulnerabilities suchthat policies may holistically address the risks of the entire community.
Meanwhile, efforts will be needed to address the challenges in data storage, monetization of data, ethics related to secondary use of data, and implications on personal protection. While sharing timely and accurate data is necessary to the response and containment to a global pandemic, stringent protocols for the secure storage and distribution ofdata must be implemented, which consider access rights, encryption and continuous review of security, which take into account the evolving benchmark for security and technological advancements [23]. Global data platforms such as Google, Facebook, Uber andcell phone companies have in the past monetized data, for example, in making geolocation
data available to scientists for disease spread modeling or similar research. In the case of
COVID-19, such information has been utilized for contact tracing or controlling population access to public spaces. In addition, a clear protocol for the management of secondary
data is necessary to guarantee a balance between privacy and the usefulness of data [24].
Personal protection is important, and includes mechanisms for identity protection, protection against discrimination, understanding how personal data are used, and informed
consent prior to data collection, particularly if the information collected can reveal information related to the health of the individual or their family [25].
3.3. Residual Risk Management
The global response to COVID-19 has highlighted essential workers as a highly exposed group with unique needs. The categorization of essential services varies between
jurisdictions, across workforces from healthcare, social work, government services, agriculture, transport, waste management and others. However, despite society’s reliance on
essential workers, many have been unprotected, working under inadequate health andsafety conditions, and putting themselves and their families at risk [26,27]. In many communities, duties of care and protection have been undertaken by nonprofessionals suchas informal home care providers [28]. There is a gendered impact of increasing relianceon informal care, which is provided by women in many communities. School closures in
Asia, for example, are impacting professional women differently, who provide informalcare within families. Travel restrictions have caused challenges and uncertainties to foreign domestic workers, many of whom are women [29]. Informal care providers are often
not directly protected by legal measures for health protection or adequate infectious disease control training [30]. In Muslim communities, evidence has shown that women are
more likely to wear face coverings in public for religious reasons, but not in their houses
while caring for others, while men wear masks for hygiene both inside and outdoors [31].
In identifying and monitoring groups facing vulnerabilities, protection mechanisms can
support informal care providers through alternative means like the provision of material
resources such as personal protective equipment, medicines; information resources suchas home care guidelines; and appropriate training so that they may be able to care forother sick or at-risk groups while minimizing their risk and exposure [6,28].
Under COVID-19, health sectors across countries have resorted to the basic means ofservice and functionality. The International Labor Organization has published a policy
framework on protecting the workforce during the pandemic, which encompasses areasof employment stimulation, supporting enterprises, worker protection and social dialog
for solutions [32]. The International Monetary Fund has conducted research on the implication of fiscal policy measures on income inequality within and between vulnerable
groups, including essential workers [33]. However, there is little discussion, experiencesharing, and evidence-based lessons learned on the health impact this protract crisis has

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on essential or nonprofessional workers. With all the new challenges posed by megacities,
migration, rural urbanization and technological advancement, what constitutes “essential” workers in a community must be revisited and defined for relevant DRR planningand capacity building.
3.4. Risk Communication
Risk communication can only be made effective when taking the “whole of government, whole of society” approach [3]. The global impact of biological hazards highlights
the importance of effective communication between stakeholders at all levels, from theinternational level, among experts and policymakers, to the community level, within thegeneral public, within households, and among individuals. As the fundamental component to enhancing community cooperation, mobilization and resilience, risk communication should include a top-down approach from government or authorities that participate
in cross-country dialog to enable early and effective warning systems. These warning systems should trigger national or international standard operating procedures to mitigate
the impact as early as possible [3,6]. Communication also requires the bottom-up input of
the whole society to ensure that the information disseminated is tailored and relevant toall members of society and their protection. Efforts should be taken to extend this dialog
to groups facing vulnerability, such as indigenous communities, migrants and refugees,
for whom information transfer tends to be complex and indirect. The participation andengagement of local government, faith-based groups and religious leaders, as well as civilsociety groups, are essential in this process [6]. Moreover, it should be recognized that
resource information channels vary with user demographics, acceptability, and access.
Studies have shown that health literacy and risk perception are negatively correlated withincome, education and social status. The European Health Literacy Survey conducted ineight countries demonstrated that 50% of adults have problematic or inadequate levels ofaccess, understanding, appraisal and application of health or risk information [34,35]. A
study in Australia showed that people with low health literacy and people whose native
language is not English demonstrated poorer understanding of COVID-19 symptoms andprevention measures, more difficulty accessing government information, difficulty accessing prescription medication, and experienced greater anxiousness and financial difficulties [36]. Studies conducted in Australia and the United States showed that factors increasing vulnerability to COVID-19, such as age, underlying chronic diseases, and income
are also factors associated with the ability to access and understand health informationand decision-making [36,37]. During the COVID-19 pandemic and widespread lockdown,
digital media has become a convenient and rapid tool for people to gain information. It is
important that risk communication ensure equitable access and understanding by allgroups and mitigate against misinformation.
3.5. Digital Literacy
There is growing discussion on the use and functionality of digital tools for information-sharing, contact tracing, and communication. The rapid development of innovative information and communications technology (ICT) has enabled and enhanced the capacity for large-scale data collection, analysis and dissemination. As exemplified during
COVID-19, such systems have allowed individuals to remotely conduct normative dailytasks and maintain social cohesion despite extreme physical distancing measures [38]. ICT
allows sectors to continue their basic functions, such as the health sector using telemedicine for non-essential patients, the education sector using remote learning, and the business sector to promote teleworking. Furthermore, technology has enabled sectors to conduct extraordinary functions in the context of a pandemic beyond national jurisdiction.
For example, governments and private entities have implemented efficient surveillance,
reporting, or contact tracing through artificial intelligence other technologies that aggregate and share large-scale data; mapping disease spread for community protection [24].

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However, in adopting ICT measures, careful considerations must be made to ensure digital tools are inclusive to all members of the community. For example, barriers of accessand adaptability must be considered within ICT infrastructure to guarantee access to information and services among the elderly, disabled groups, lower-income households, or
those living in remote areas [6].
3.6. Knowledge Product Marketing
Updating and generating new recommendations and tools for DRR is a continuous
process. Outside of science, these tools can be used to develop effective public communication strategies and raising awareness for community preparedness [6]. The DRR community requires more tools and knowledge-sharing platforms to facilitate planning andstrategy development [2], and there is as yet limited availability of updated and relevant
DRR knowledge product specialization for biological hazards at a global scale such as the
COVID-19 hazards. This has hindered knowledge sharing, scenario planning, and crosssectoral learning. Although the WHO Thematic Platform for Health-EDRM was formed
in September 2016 to “coordinate activities, promote information-sharing, develop partnerships, and provide technical advice to strengthen the Health-EDRM research field”, asof 2020, there remains an urgent need to strengthen multidisciplinary learning and collaborative efforts to maximize the impact of such knowledge development. Active engagement in shared knowledge and building understanding of the complex nature of biological hazards will enable the DRR community to develop and facilitate scientific risk assessment mechanisms so as to build resilient systems in the future [3].
4. Discussion
The COVID-19 pandemic has had devastating human and socioeconomic impacts
worldwide. The global attention received for COVID-19 provides an opportunity for thehealth and DRR communities to reconceptualize knowledge and tools for disaster risk
mitigation, response and recovery. In November 2020, DRR experts from the Asia-Pacificregion attended the Asia-Pacific Partnership for Disaster Risk Reduction (APP-DRR) Forum to share progress, policy priorities and opportunities thus far for DRR in the region
with respect to the COVID-19 pandemic [11]. Experts shared learnings for risk governance, including health system resilience; data management; residual risk management,risk communication, digital literacy, and knowledge product marketing. Special academic
attention has been paid regarding the integration of biological hazards into DRR planning[6]. Although the Health-EDRM Framework was established to ensure that health will beconsidered within the DRR dialog at intra, inter and multidisciplinary levels, further efforts are required to ensure that both health and non-health actors in education and continuous education are included within DRR frameworks. Notably, and urgently, to include students and young professionals who will become key stakeholders in the next
decade in promoting awareness, scientific development, policy, and capacity at the intersection of health and DRR. Successful implementation of the Sendai Framework will require updated Health-EDRM and DRR tools that consider concurrent, cascading and interacting hazards. Cascading risks have a serious impact on national action plans, and theimpacts faced are becoming increasingly complex and interdependent. However, national
plans still tend to focus on the most probable impacts rather than on those that will bringthe most complex consequences that require heavily coherent and coordinated response[7]. Adaptive governance mechanisms are necessary for building interdependent resilience cutting across social, institutional, economic and ecological levels. Reinforcing continuous learning and innovation across the governance of different sectors will strengthen
DRR outcomes [39], systematic risks analysis and related action planning. Table 1 summarizes how the above discussion may expand into and impact DRR, related challenges
and suggested solutions.
The COVID-19 pandemic has demonstrated the ability for a biological hazard totravel across national borders and the need for governance structures mitigating against

Int. J. Environ. Res. Public Health 2021, 18, 1614

7 of 13transnational risks. There is a role for North-South, and South-South collaboration in
jointly developing technological, medical and social innovations, which can accommodate
local variation, that lead to creating incentivization for long-term multi-generational resilience [40]. Inter-sectoral coordination such as public–private partnership models forhealth service provision should be explored to maximize the functionality of service provision and the range of services available [6].
There is a large number of activities, priorities and stakeholders that must be mobilized, facilitated, and coordinated, not only in response to the pandemic and in the recovery phase but also in developing DRR plans against the next hazard that emphasizes acoordinated response across linked sectors rather than over-burdening one sector [6]. In
order to operationalize lessons learned in impactful, cost-effective and sustainable ways,
methods in cross-program planning, monitoring and evaluation can be taken from thearea of project management. This will involve viewing international development as atransformative public sector project when evaluating delivery constraints such as time,
cost and quality. International development and private sector projects are at risk of facing
similar challenges in poor stakeholder management, cost overruns, inadequate monitoring, and lack of understanding of local context. However, international development projects often have less tangible goals and certainly face higher socio-political complexities
that induce further transaction costs [41].

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Table 1. Opportunities for different areas to expand into and impact disaster risk reduction (DRR), related challenges and suggested solutions.

IssuesOpportunities to Expand into DRR

Challenges
 Weaknesses in current action plans that do Strengthen health considerations

not consider the entire disaster cycle or prewithin multi-sectoral national or inpare for concurrent, cascading or interacting
ternational DRR action plansrisks• Weaknesses in current action plans that do Improve hazard-related health out- not consider multi-sectoral impact or recomes by revaluating the resilience sponse
Health systems resilienceand vigilance of the health system as• Weaknesses in current action plans that doa wholenot consider post-epidemic long-term physiological or psychological effects National bodies are creating unique, siloednational action plans that lack complementarity

Suggested Solution
Develop multi-hazard, multi-sectoral and adaptive action plans for
DRR

Consider health systems-wide paradigm to care, beyond clinical care

Reinforce awareness-building andcontinuing professional education asa key component in policy development• Identify areas of improvement in ex Consider inclusivity and representa Security considerations in terms of data storisting data platforms (collection,
tion of vulnerable groups in building
age and management
storage, analysis, sharing) in terms
data management toolsof:- Inclusivity of vulnerable groups Incorporate the latest technological- Compatibility with other DRR infor- Ethical considerations for data use, monetiza- advancement and adaptive capacition of data, and personal data protection
ties for piloting secure data collection
Data management
mation platforms
and data management tools- Compatibility with technologicaladvancement
 Unique opportunity to collect robust
post-pandemic data across all popu Continuous education regarding syslations, to be used in recovery assesstems development and updates
ment research or for future hazards
 Define or redefine “essential”
 Develop policy and guidelines to There is no standard definition of “essential”
Residual risk management
groups, including part-time workers,
protect essential workers and nonworkers or nonprofessional workers
nonprofessionals (e.g., home care
professional workers

Int. J. Environ. Res. Public Health 2021, 18, 1614

9 of 13givers), and non-health sector workers
 Data and research in health impact
and needs of essential workers andnonprofessional groups including
needs in material resources, information gaps, or training opportunities Continuous education of stakeholders involved in policy update and development
Review or strengthen top-down gov- Limited evidence of barriers to inclusivity of Develop inclusive platforms for inernment approaches to early warn- populations or inclusivity of communication formation dissemination (e.g., used
ing systems
channelsby the elderly, disabled individuals)
Consider health literacy in disaster Limited but growing political will in manag- Community dialog to review and rerisk communication and decision- ing misinformation or in determining the re- search barriers of information accessmaking frameworks
liability of the information
and understanding Building awareness and appropriate
Consider demographic and healthpolicies for communities facing vulfactors (e.g., old age, physical disabilnerabilities and improving patterns
ities) in ability access to informationof communication under complex
circumstances
Use of novel technology to develop Complex access to digital tools for certain Build community dialog to promotetools for DRR data management (e.g.,groups (e.g., elderly, remote/rural groups, the use of digital tools and underinformation sharing, data collection,
low-income groups)
stand barriers to usage
tracking)
 Pilot novel and innovative tools for
Use novel technology to improve
telemedicine, robotic temperature
health DRR (e.g., diagnostics, telemonitoring, or automated dispenmedicine)sary Building awareness and appropriate
policies for communities facing vulnerabilities and improving patterns

 Research into health impact andhealth needs of a pandemic on essential workers and nonprofessional
workers, in order to build evidencebased policy and guidelines
Risk communication

Digital literacyLacking recognition or political will to protect the health and wellbeing of these groups(e.g., material provision, information dissemination)

Int. J. Environ. Res. Public Health 2021, 18, 1614

10 of 13of communication under complex
circumstances Update Health-EDRM and DRR
tools, in particular, to consider the Lack of political or institutional will for
multifaceted and adaptive nature ofmulti-sectoral planningconcurrent, cascading and interacting hazards
 Multi-sectoral participation in theKnowledge product mardevelopment of updated tools andketingguidelinesCollect evidence and lessons learned
for needs in addressing novel biological hazards
Developadaptiveknowledge products

tools

and

Begin a multi-sectoral dialog for DRR
Building awareness and identifying
knowledge gaps within communities
to encourage active research and policy development

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5. Conclusions
COVID-19 has impacted progress across the Sustainable Development Goals (SDG).
The economic impact has resulted in an estimated 71 million people pushed into extreme
poverty (SDG 1—no poverty); 80 million children under the age of 1 are estimated to missroutine vaccinations (SDG 3—good health and wellbeing); school closures will affect 90%
of students (SDG 4—quality education); cases of domestic violence will increase in 30% ofcountries (SDG 5—gender equality); and 60% of countries will experience prison overcrowding and further risk of spreading COVID-19 (SDG 16—peace, justice and strong institutions) [40].
However, the pandemic also creates opportunities to strengthen SDG, such as
strengthening partnerships under SDG 17 in developing shared warning mechanisms,
data sharing, multi-stakeholder partnerships in science to build evidence-based policy
recommendations. These partnerships can be built between sectors of a country, but alsoin North–South or South–South cooperation [6].
Opportunities and resources available during the response and recovery of the
COVID-19 pandemic may allow DRR stakeholders to examine and evaluate systemic
weaknesses in a holistic and comprehensive manner. To ensure that the global population
would be more sufficiently protected against future concurrent, cascading, or even interacting hazards, revisiting current DRR plans and strategies within the current frameworkof biological hazards will be instrumental. The COVID-19 pandemic has created a chance
to strengthen partnerships; build mechanisms for a coordinated response between DRR
experts and counterparts in health; and build health as a core component across disasterprevention, mitigation, response and recovery. Building understanding of the multifaceted and adaptive components of risk governance within people in their formative years
will allow the next-generation to accelerate towards achieving the targets under the Sendai Framework as well as the SDGs. Continuous education, notably of students and young
professionals, may be a key component when building awareness about DRR.
Author Contributions: Conceptualization, E.Y.Y.C.; methodology, E.Y.Y.C., C.D., A.H.Y.F.; writing—original draft preparation, C.D., A.H.Y.F.; writing—review and editing, E.Y.Y.C., R.S., R.C.,
A.D., A.L., Y.-k.K., K.K.C.H., C.S.W. All authors have read and agreed to the published version of
the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Acknowledgments: This article is a follow-up to the Integrating Biological Hazards (Including Pandemics) into DRR Planning Technical Advisory Document developed by RIKA and authored by
Rajib Shaw, Ranit Chatterjee and Ambika Dabral.
Conflicts of Interest: The authors declare no conflict of interest.

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Progress in Disaster Science 7 (2020) 100117

Contents lists available at ScienceDirect

Progress in Disaster Sciencejournal homepage: www.elsevier.com/locate/pdisas

Invited ViewPoint

Ecosystem-centric business continuity planning (eco-centric BCP): A post
COVID19 new normal⁎

Mahua Mukherjee a, Ranit Chatterjee b,d, , Bhagat Kumar Khanna c, Preet Pal Singh Dhillon a, Atul Kumar a,
Sukhreet Bajwa b, Amit Prakash b, Rajib Shaw b,eaCentre of Excellence in Disaster Mitigation and Management, Indian Institute of Technology Roorkee, India
RIKA India, New Delhi, India
ARISE India, FICCI, IndiadKyoto University, Japane
Keio University, Japanbc

A R T I C L E

I N F O

Article history:
Received 5 May 2020
Received in revised form 18 June 2020
Accepted 28 June 2020
Available online 02 July 2020
Keywords:
ECO-centric-business continuity plan (BCP)
MSME (micro small medium enterprises)
COVID-19 recovery
New normal

A B S T R A C T

This article views the COVID-19 pandemic as an opportunity leading to a signiﬁcant reduction in pollution levels, cleanwaters in rivers, improved visibility, and other tangible beneﬁt to humanity and the environment. In Post-COVID scenario, to restore the margins and regain the lost production, industries are likely to increase their production leading toa quantum jump in the pollution levels. Having precedence of such a scenario in 2008–09, this article looks at what are
the possible avenues to engage the city government and business houses through an a new normal ECO-BCP concept
for long term sustainability. All economic stimulus needs to be tied down with the stringent reduction in the emission
norms. The Ten Principles for the Eco-centric BCP guide the reopening of MSMEs after lockdown period called to checkthe spread of the COVID-19 pandemic. The Eco-centric BCP model will help the MSMEs to adopt the new-normal business strategies to align with the country-speciﬁc commitments to SDGs, SFDRR and Paris declaration.

1. Introduction
The COVID-19 pandemic's impact on lives and livelihoods globally arebeyond measure as the war against the Virus is continuing. Involving
more than 210 countries, more than 428,652 deaths, and about 7.7 million
people infected and are still continuing [20 www.Worldometers.org on
13th June 2020], the pandemic is looming large on us. This is the ﬁrst
global crisis, threatening human existence, after World War II. A statedmortality rate of 3.4% [21] is much more than seasonal ﬂu's mortality
rate. The world was unprepared for this pandemic crisis, and global cooperation at initial stages was negligible. In the absence of any readily available
medication and vaccine for the Virus, shortage in preventive gears in theface of a highly contagious virus, all combined to make this public healthemergency into a worldwide epidemic. The Governments world over had
to take the hard decision to save the lives of the citizens by enforcing lockdown or mass testing ﬁrst to identify the affected persons [22]. Keeping
economic growth was common second priority.
Cities, Industries and businesses are in turmoil [3]. The Micro, Smalland Medium Enterprises (MSMEs) are always at risk, and as a result, they

will bear the maximum brunt of the pandemic [1,5]. This has resulted in
migration, loss of livelihood mainly for the contract and daily wagers andan uncertain future. The MSMEs had not catered to the fall out of such ahighly contagious health emergency.
Past experience of pandemic recovery has shown an increase in production, reclaiming more land for production among other measures tomake up for the losses. While making even with the economic losses isimportant but at the same time, balancing the burden on the environmentis important. Recovery from this grim scenario needs to have balanced
approaches to reach targets set by entities differently. This article considers the present pandemic as an opportunity to drive economic growthand support livelihood while at the same time, protect the ecosystem andpromote wellbeing in the society through an Ecosystem-centric BusinessContinuity Plan (Eco-centric BCP) model. Analysis of secondary literature
has led to the development of the conceptual framework and principles
for ‘Eco-centric BCP’. The following section delves into relevant literature.
Based on this, Sections 3, 4, and 5 presents the conceptual framework,
ten principles and strategies for adopting Eco-centric BCP. The penultimate section discusses the possible approaches and integration of the⁎ Corresponding author at: RIKA India, New Delhi, India.
E-mail address: ranit@rikaindia.com. (R. Chatterjee).

http://dx.doi.org/10.1016/j.pdisas.2020.100117
2590-0617/©2020 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

M. Mukherjee et al.

Progress in Disaster Science 7 (2020) 100117

customisable and ﬂexible. It focuses on four aspects, namely- decent work
supporting Sustainable Development Goal (SDG) 8, promoting positive approach supporting SDG 16, prevention from a crisis, and ﬁnally generating
investment through private sectors. In these anthropocentric guidelines, theecosystem discussion is silent.
Media Information conﬁrms [2] that there is a signiﬁcant decrease in air
pollution level due to lockdown China has recorded a 25% reduction in CO2emission, which can save about 77,000 lives. In Venice, the water in the canals cleared and experienced more water ﬂow and visibility of ﬁsh reportedby the government [2]. The social media is ﬂooded with photographs showing clean skies and wild animals roaming around in urban centres. The pandemic provides a unique opportunity to transit our business models
towards the ecosystem-centric new-normal sustainable approach.

ECO-centric BCP concept leading to a series of recommendations for the
future.
2. Literature review
A ‘Business Continuity Planning’ (BCP) aims to prepare for, provide to
and maintain control and capabilities for managing organisations' overall
ability to continue to operate during disruptions. It establishes strategic objectives and guiding principles for the organisation, and is expected to integrate safe industrial standards for afﬂuent and emission for resilience. A
report of the International Labour Organisation [8] discussed the four pillars (4Ps) model to develop a BCP: People (safety and security), Process (internal organisational processes like supply chain, logistical planning), Proﬁt(management of risks to products/services) and Partnerships. With thehuge loss of life and capital, the COVID-19 pandemic demonstrates the incredible capacity of societies to stand together to ﬁght against unprecedented, insurmountable challenges and adapt [12].
In the high-level meeting on climate and sustainable during the 73rd
session of UN General Assembly, the General Assembly President statedthat people have a decade left to combat the worse impact of the climate crisis and recent improvement of the environment set an example that change
in approach can show the tangible result [18]. Many businesses that have“in-person transactions” and “foot trafﬁc” model are struggling the mostdue to nation-wide lockdown, even though the demand remained strong[17]. Countries throughout the world are announcing special economic
packages as India announced to spend about 10%, and Japan 20% of theGDP [4,16] globally around $7 trillion in total committed as a relief package until now [13]. In the post-COVID scenario, to restore the margins
and regain the lost production, the industry is likely to increase its production rapidly leading to a quantum jump in pollution levels. Signiﬁcant reduction in emissions and working towards sustainability may be a wiseidea even from a ﬁnancial point of view [14,15]. Present health crisis andeconomic consequences of COVID-19 and climate crisis need to be reﬂectedonce the business entities conceptualise their BCP [19].
The COVID-19 has redeﬁned the use and design of the public space, utility services in the urban centres. These factors directly or indirectly have abearing on the business continuity. The real estates and the construction industry will need to come up with a design and legal solutions on building
interface with public health. The planning of green spaces, mass transits, industrial units and ofﬁce space design needs a to revisited and coming up
with a set of guidelines to integrate the health component into urban planning and design would be necessary [6].
The countries are focusing on reviving the economy and experts are suggesting that protecting nature can prevent future pandemics; so a parallel
approach should be more effective to address COVID-19 pandemic and climate crisis [12]. Learning from the recovery plan and policies of the ﬁnancial crisis of the year 2008–09, governments are adopting approaches intheir guidelines, many of the effective solutions have a concern regarding
environmental protection [13]. The German government chose to continue
climate protection through helping companies in recovery with setting incentives for reducing carbon emission, promoting modern technologies
and renewable energies while announcing economic packages for various
sectors [10].
Palahi et al. [11] recommend that any new model framework needs toinclude transformative policies, purposeful innovations, risk-taking capability, as well as the sustainable business market. Further, they suggest replacing the current economic indicators such as GDP to sustainable
wellbeing as an index for a sustainable society. Recently-developed
UNDRR and ADPC toolkit [17] to support MSMEs focus on the protectionof employees, protection of the business and utilisation of resources available. Similarly, ILO has advocated developing an effective risk and contingency system for any business after a due diligent review of the 4Ps, risk
and vulnerability proﬁle and opportunities [8]. ILO proposed toolkit platform in a report about a ‘Network of Networks’ facility that can help sustainable & resilient enterprises (SRE) to keep on working in conﬂicts anddisaster-prone areas [9]. The tool enables the MSMEs to be adaptive,

3. Conceptual framework for ECO-centric BCPThe Sendai Framework, Sustainable Development Goals and the Paris
agreement all aim for a sustainable society. Carrying forward the discussion
from Section 2, the ECO-centric BCP concept rests on four parametersnamely; Parameter-1 Reduction in emission from the industry; Parameter2 sustainable use and reuse of ecosystem services; Parameter-3 Legislationand implementation, and Parameter-4 Sustainable energy usage and consumption (Fig. 1). While the industry is the centre for providing goods
and services, /driving economic growth by providing livelihood opportunities, a sustainable model of business operation will reduce the chances offailure in the supply chain by ensuring available resource in the market
and stabilising the cost of procurement. These can be achieved by investingin science and technology and promoting innovation.
Further, comprehensive risk assessment to factor in issues arising due toenvironmental impact might be beyond the individual business's capability
to manage. The recovery planning needs to envision the possible impact ofaction taken in the post-pandemic phase. This would have a signiﬁcant impact on the secondary sphere of inﬂuence which will help in having accessto clean water due to reduced afﬂuent, better health and wellbeing due toreduced emission rates and stable livelihood. In the long-term, this willlead to gender equality, support quality education and address issues ofpoverty and hunger. It is important to note a scale of inﬂuence, where alocal action can inﬂuence the tertiary sphere at a subnational or national
scale.
4. Ten principles of the ECO-centric BCP model
The participatory and reconciliatory attitude, as mentioned by [13] and[11] is the core concept of the new Eco-Centric BCP model. To address the
gap areas identiﬁed in Section 2, the Eco-centric BCP model proposes
reorganised 4Ps to boost economic and ecosystem functions both; they
are People, Process, Facility (infrastructure, machinery, ﬁnance and partnership) and Technology (including improvisation and innovations). To infuse MSMEs' business continuity, ten strategic guiding principles for 4Ps areproposed (Fig. 2).
5. Adopting ECO-BCP
This section identiﬁes various ways of adopting the Eco-centric-BCP
model for ground application.
5.1. Cluster concept
Business continuity for the private sector is directly linked with the essential services provided by the city. Local government is a service provider
for its citizens and a custodian of the ecosystem services in its jurisdiction.
ECO-BCP concept applies to both city services and business sector. At thecity level, the Eco-BCP will aim at maintaining low energy consumption
and sustainable use of its various natural resources. A possible approachfor doing that is by integrating the Eco-BCP as an integral component of
the ongoing urban-centric mission being undertaken by the Indian2

M. Mukherjee et al.

Progress in Disaster Science 7 (2020) 100117

Fig. 1. Conceptual Framework for the ‘Eco-centric BCP’ connecting SFDRR and SDGs.

Fig. 2. The Ten Principles of the Eco-centric BCP Model.
3

Progress in Disaster Science 7 (2020) 100117

Low

Severity of Pollung Industry

government. In normal times the reduction of CO2 emission, sustainable
use of ecosystem services, providing undisruptive basic services and lowering energy consumption is the onus of the city governance. A combinationof Business Continuity Planning (BCP) and Life Continuity Planning (LCP)
is needed to continue these dimensions in case of an emergency situation
for safeguarding life and critical assets while ensuring energy independence(Fig. 3). While dealing with the private sector, especially the MSMEs, twoapproaches of Individual and Cluster Eco-BCP [7] may be adopted depending on the size and capacity of the MSMEs to boost Economic and Ecosystem Functions. The Cluster BCP will ensure continuity of MSMEs,
Community and immediate environment in a group for small scale
MSMEs, who as an individual organisation, may not be able to prepare or
adopt a BCP. Such clusters can be at ward level in cities or can also happen
within further smaller clusters who mutually share the vision for a greener
future.

High

M. Mukherjee et al.

5.2. Graduated adoption

Low

The natural ecosystems, even when severely constrained in urban areas,
continuously provide our ecosystem- and resilience services through theirecosystem functions. Graduated Standard Operating Protocol (SOP) adoption to control the ﬂow of emissions and throw of efﬂuents to the ambient
ecospheres of air, water, and soil shall be in place. The industries shalladopt the moderate to stringent targets, based on the potential level of industrial wastes' harmful impact and waste treatment standards practisedby the said Industries. Fig. 4 explains the concept of target selection.

High

Industrial Emission/ Eﬄuent Standard
Fig. 4. Graduated SOP target adoption based on the level of polluting industry tocontrol emissions and efﬂuents throw in the ambient ecosphere.

Government
National to
Local

5.3. Scalability

Large scale
Industries

The inclusive approach within the industry community, starting from
top to the last post in the chain need to take responsibilities and initiatives
to allow this change to happen. Major handholding needs to come from relevant government ministries at national to local levels, through theirorganisational arms for policy and planning backup, ﬁscal policies like access to easy-term loan, subsidies and incentives in terms of a tax rebate. Industrial and business associations, large and medium industries can extend
technical support for retroﬁtting, skilling, training, advanced gears andtechnology sharing and graduated SOP for the new-normal Eco-centric
BCP including reporting protocol, 3rd party inspection. Corporate Social
Responsibilities (CSR) components can incentivise the paradigm shift.
Networked initiatives among multi-actors will be required to bring thechange in Industrial environment (Fig. 5).

Community

Cluster
SMEs

SMEs• Supply-chain• CSR Funding

National
Business
Associations

Fig. 5. Networked Chain of Activities and Actors for the scalability of MSMEs' Ecocentric BCP.

6. Discussion
the economy has focused on increasing liquidity in global markets without
any environment strings attached [13]. An eco-centric approach, an opportunity to produce differently and to help other ecosystems to survive, canserve as a paradigm shift in the investment plan (economic packages) for
the 21st-century public services. The authorities need to create incentives
for public and public privates industries to direct their investment in the
Eco-centric BCP model.
Apart from liquidity measures, industrial bodies need to go for policy
formation with major climate beneﬁts such as clean energy and infrastructure, disaster preparedness, zero-carbon transportation etc. All economic
stimulus needs to be tied down with the stringent reduction in the emission
norms. It is important to ensure funds from the public sources to the objectives of the SDGs and Climate change mitigation while creating jobs andkick-starting economic activity. The rejoined sense of common good for humanity and the environment to be utilised to build a more resilient and sustainable economy by adopting the Eco-centric BCP approach for MSMEs.
The Eco-centric BCP model shall not aim to come back to Business as
Usual (BaU) level but to recover better. Cities need to identify clusters
with possible high emission rates post lockdown and urge sustainable useof ecosystem services, especially water in drought and water scare areas. Integrating the climate-sensitive city planning, restoration of a heritage built
forms and ecosystems, etc.

Accelerated economic activity without any string of environmental concerns will worsen pollution condition. Most of the money inﬂow to revive

Fig. 3. Level of Services and Plan Activators during Covid 19 Pandemic.
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[15] Teske, et al. Achieving the Paris Climate Agreement Goals, Institute for Sustainable Futures 2018. www.oneearth.uts.edu.au; 2018.
[16] Times of India (TOI). In Comparison: India's Stimulus Package vs Rest of the World;
2020 accessed at https://timesoﬁndia.indiatimes.com/world/in-comparison-indiasstimulus-package-vs-rest-of-the-world/articleshow/75710393.cms on 15th June 2020.
[17] UNDRR, ADPC. Small Business Continuity and Recovery Planning Toolkit. United Nations Ofﬁce for Disaster Risk Reduction for Aisia and Paciﬁc and ADPC; 2020 http://
www.adpc.net/igo/category/ID1583/doc/2020-r74Yp1-ADPC-COVID19_Small_Business_Continuity_and_Recovery_Planning_Toolkit.pdf.
[18] UN Press. https://www.un.org/press/en/2019/ga12131.doc.htm; 2019.
[19] Vis P. Planting the seeds of a Green Economic Recovery After Covid-19. Euractive article
https://www.euractiv.com/section/energy-environment/opinion/planting-the-seedsof-a-green-economic-recovery-after-covid-19; 2020.
[20] Worldometer. www.Worldometers.info. Accessed on June 13, 2020.
[21] World Health Organisation. WHO Director-General's Opening Remarks at the Media
Brieﬁng on COVID-19. 3 March 2020 https://www.who.int/dg/speeches/detail/whodirector-general-s-opening-remarks-atthe-media-brieﬁng-on-covid-19—3-march-2020;
2020. Accessed on April 15 2020.
[22] Djalante R, Shaw R, Dewit A. Building resilience against biological hazards and pandemics: COVID-19 and its implications for the Sendai Framework. Prog Disaster Sci.
2020.

A strong political will and sense of urgency are required towards thiscritical aspect of integrating scientiﬁc advice on sustainability and climatechange into policies and guidelines to protect the environment along withrejuvenating the economy. The Eco-centric BCP model will help the
MSMEs to adopt the new-normal business strategies to align with thecountry-speciﬁc commitments to SDGs, SFDRR and Paris declaration. The
adaptation to new norms and swift change shown by the global community
in behaviour and functioning has no precedence in history. This encouraging spirit of collective action towards common goals must be unlisted bysensitising every stakeholder about commitment towards climate change.
The Ten Principles for the Eco-centric BCP guide reopening of MSMEs
after lockdown period called to check the spread of the COVID-19
pandemic.
Circular economy, alternate green jobs like ecotourism, afforestation,
integrated water management shall be Post-Covid MSME sectors getting
prime attention from investors. Developing a new normal in the MSME sector will require staggered lifting of the lockdown period with conditional
written commitment from the individual industrial units to follow safety
practices guidelines. A strong penal and monitoring regime is needed formaking these norms non-negotiable. Replacing the BaU recovery planwith robust Eco-centric BCP model will require strong support from service
providers who can provide support in terms of ﬁnancial, technical, managerial, policy and planning. The ecosystem centric BCP planning will be the
new normal to boost the economy and the ecosystem functions in thedays to come.
Declaration of Competing Interest
The authors declare that they have no known competing ﬁnancial interests or personal relationships that could have appeared to inﬂuence thework reported in this paper.
References[1] Chatterjee R, Okazaki K. In: Pal I, Meding J, Shrestha S, Ahmed I, Gajendran T, editors.
Risk Governance and the Role of Informal Sector in Disaster Recovery: The Case of 2015
Nepal Earthquake Chapter: Chapter 4. Springer; 2020.
[2] CNN Travel Blog. https://edition.cnn.com/travel/article/jellyﬁsh-venice/index.html;
2020.
[3] Boissay F, Rungcharoenkitkul P. Macroeconomic Effects of Covid-19: An Early Review
BIS Bulletins. accessed online at https://www.bis.org/publ/bisbull07.pdf; 2020.
[4] FICCI. http://www.ﬁcci.in/ﬁcci-in-news-page.asp?nid=20956; 2020. March 26, 2020,
Accessed on 20 April 2020.

5

International Journal ofEnvironmental Researchand Public Health
ArticleIdentifying Research Trends and Gaps in the Context
of COVID-19
Hongyue Zhang 1 and Rajib Shaw 2, *1
2*

Ocean College, Minjiang University, Fujian 350108, China; 2589@mju.edu.cn
Graduate School of Media and Governance, Keio University, Fujisawa 252-088, Japan
Correspondence: shaw@sfc.keio.ac.jp

Received: 6 April 2020; Accepted: 7 May 2020; Published: 12 May 2020


Abstract: The COVID-19 pandemic has affected the world in different ways. Not only are people’s
lives and livelihoods affected, but the virus has also affected people’s lifestyles. In the research sector,
there have been significant changes, and new research is coming very strongly in the related fields ofvirology and epidemiology. Similar trends were observed after the Severe Acute Respiratory SyndromeCoronavirus (SARS-CoV) and Middle East Respiratory Syndrome Coronavirus (MERS-CoV) episodesof 2003 and 2012, respectively. Analyzing 20 years of published scientific papers, this article points out
the highlights of coronavirus-related research. Significant progress is observed in the past research
related to virology, epidemiology, infectious diseases among others. However, in research linked
to public health, its governance, technology, and risk communication there seem to be gap areas.
Although the World Health Organization (WHO) global research road map has identified social
science-related research as a priority area, more focus needs to be given in the upcoming days for
multi, cross and trans-disciplinary research related to public health and disaster risk reduction.
Keywords: coronavirus research trends; COVID-19; public health and disaster risk reduction;social science research; public health preparedness; mitigation; response and recover; World HealthOrganization research roadmap

1. Introduction
The coronavirus disease COVID-19 was declared a pandemic by the World Health Organization(WHO) on the 11th of March 2020, within less than three months after its first report in Wuhan, China inlate December 2019 [1]. The numbers (infected people, death, number of new cases, among others) are
increasing on a daily basis. From China, the hotspots shifted first to Europe and then to the USA. Many
countries have declared indefinite to time-bound lock downs, with severe restrictions on in-country as
well as international travel. Tremendous pressure is mounting on countries’ health care systems andhealth care professionals are also becoming direct victim of the virus in many cases, with reported
deaths in several countries.
Three major characteristics of COVID-19 are: (1) high rate of spread, (2) aged and low immunity
people are more vulnerable to be infected, and (3) differential recovery rates in different countries [2].
While the urgent need is to develop the appropriate curative medicines and vaccines, there are different
types of ongoing research on this topic. Pandemic risk is not just a medical issue, but has strongsocio-economic, behavioral, psycho-social, governance and technological implications. Of course,
virology, medical science, epidemiology are the core for addressing the key issue. However, these
also need to be linked to other issues. Governance and decision-making related to pandemic risk areimportant points, which need to be discussed more.
Incorporation of pandemic/biological hazard risk in the Sendai Framework of disaster risk
reduction is important [3], and it is mentioned that the global framework can be well linked with
Int. J. Environ. Res. Public Health 2020, 17, 3370; doi:10.3390/ijerph17103370

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the health emergency and disaster risk management (H-EDRM) concept. We also see different
governance-related decisions in East Asia which were effective in different stages of the pandemic [2].
Similarly, different innovative technologies have been used for pandemic response in different countries.
A comprehensive review of the technology and its innovative use for serving different types of services
during lock-down is yet to be done. People’s behavior is one of the key aspects of pandemic response.
Risk perception, understanding and communication are also linked to behavior change. New researchwould come out on the behavior as well as social changes during pandemics. There are also tremendous
economic implications of the pandemic, which can be observed at global, regional, national and local
levels. Some of the economic issues are also linked to the local social issues, especially for micro-,small- and medium-enterprises (MSMEs).
Keeping this in mind, this paper makes a modest attempt to analyze past and current research
trends related to coronavirus over a period of 20 years. Detailed analysis and discussions are provided
from the papers published in last three months. The analysis shows some gaps and issues, which needs
to be linked to the global research road map of WHO [4].
2. WHO Research Road Map
On 30 January 2020, following the recommendations of the Emergency Committee, the WHO
Director General declared that the COVID-19 outbreak constituted a Public Health Emergency ofInternational Concern (PHEIC). World experts on COVID-19 met at the WHO headquarters in Geneva
from the 11 to 12 February 2020, to assess the current level of knowledge about the new virus,
agree on critical research questions that needed to be answered urgently and ways to work together
to accelerate and fund priority research that can contribute to curtail this outbreak and prepare for
future outbreaks [4]. The global imperative for the research community is to maintain a high-level
discussion platform which enables consensus on strategic directions, nurtures scientific collaborations
and, supports optimal and rapid research to address crucial gaps, without duplication of efforts.
Experts identified key knowledge gaps, and research priorities and shared scientific data on ongoing
research, thereby accelerating the generation of critical scientific information to contribute to the control
the COVID-19 emergency. Eight immediate research actions were proposed as follows:--

Mobilize research on rapid point of care diagnostics for use at the community level
Immediately assess available data to learn what standard of care approaches from China andelsewhere are the most effective.
Evaluate as fast as possible the effect of adjunctive and supportive therapies.
Optimize use of protective equipment and other infection prevention and control measures inhealth care and community settings.
Review all evidence available to identify animal host(s), to prevent continued spillover and tobetter understand the virus transmissibility in different contexts over time, the severity of disease
and who is more susceptible to infection.
Accelerate the evaluation of investigational therapeutics and vaccine using “Master Protocols”.
Maintain a high degree of communication and interaction among funders so that critical research
is implemented.
Broadly and rapidly share virus materials, clinical samples and data for immediate publichealth purposes.

The target of the WHO Research Road Map was: (1) to ensure that the affected people gets proper
diagnosis and optimum care, and (2) to support research priorities that lead to development of global
research platform. A cross-cutting, inter-disciplinary approach was suggested which looks at the
ethical aspects, as well as practical implications with international solidarity.
Nine specific thematic areas were suggested as follows:-

Virus: natural history, transmission and diagnostics.

Int. J. Environ. Res. Public Health 2020, 17, 3370-

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Animal and environmental research on the virus origin, and management measures at thehuman-animal interface.
Epidemiological studies.
Clinical characterization and management.
Infection prevention and control, including health care workers’ protection.
Candidate therapeutics research and development
Candidate vaccines research development
Ethical considerations for research.
Social sciences in the outbreak response.

Thus, broadly speaking there are three categories of research areas: (1) Science and technology(related to the virus, animals, the environment and epidemiology); (2) Governance and management(clinical management, health care worker’s protection, ethical issues); (3) Social and behavior issues(people and citizen’s response behavior).
In their recent book, [5] has argued the challenges and gaps in H-EDRM. The WHO pointed out
in 2019 that H-EDRM remains as a fragmented nascent field, and needs to be developed as a coherent
enterprise. Key challenges include non-alignment of research tools, lack of a strategic overarchingresearch agenda, sub-optimal development of multisectoral and interdisciplinary approaches, absenceof the science-policy-practice nexus, deficiency in standardized terminology, and meagre coordination
among stakeholders [6]. It is interesting to note that the road map of WHO for COVID-19 makes nomention of H-EDRM. This issue will be discussed later.
3. Methodology
To understand the research trends, the Web of Science core collection database was used to search
for SCIE and SSCI papers related to coronavirus published in 2000–2019. The search formula wasdefined as “TS = Coronavirus”, and the language was set to English. In November 2002 Severe AcuteRespiratory Syndrome Coronavirus (SARS-CoV) broke out in Guangdong, China, and became an acuteepidemic in 2003. Middle East Respiratory Syndrome Coronavirus (MERS-CoV) is reported in Saudi
Arabia in 2012 and has since spread to different countries.
In this analysis, twenty years (2000 to 2019) have been broken into five time slices: 2000–2003,
2004–2007, 2008–2011, 2012–2015, and 2016–2019. See Table 1 for the main information about the
publication situation in each time period.
Table 1. Main information of the relevant coronavirus publications between the year of 2000 and 2019.
Time Period

2000–2003

2004–2007

2008–20112012–2015

2016–2019

Number of Publications
Source journals
Author keywords
Average citations per documents
Authors of single-authored documents
Authors of multi-authored documents
Collaboration Index

848
226
881
57.32
56
2624
3.36

2706
599
2911
39.96
131
8944
3.51

1824
511
2881
31.24
69
6940
3.97

2446
585
3278
26.41
133
9617
4.22

2786
645
4610
7.19
91
11,886
4.43

In order to analyze the evolution characteristics of coronavirus research topics over time, a word
cloud was used to reflect the dominant topics during each period. A ‘word cloud’ is a visual
representation of word frequency. The more commonly a term appears within the text being analyzed,
the larger the word appears in the generated image. Word clouds are increasingly being employed asa simple tool to identify the focus of written material [7]. Also, co-word analysis [8–10] was used toconstruct a co-occurrence map to reveal the research hotspots and evolution of each time slice. Co-wordanalysis is used in a longitudinal framework which allows us to analyze and track the evolution of a

Int. J. Environ. Res. Public Health 2020, 17, 3370
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4 of 16

researchfieldkeywords
along consecutive
periods[8].authors
Additionally,
develops
a performance
analysisofAuthorare a listtimeof terms
thatbelieveitbest
represent
the content
of theirspecific
themesusing
different
basic
bibliometricindicators.
papers. In the following study, the hot topics of each time slice are visualized by building the word
keywords
are a listof terms
believe
represent
contentofofpaper
their papers.
cloudAuthorof author
keywords.
Since
titlesthat
andauthors
abstracts
can best
interpretthe thecontents
more
In the following study,
the hot topics
of eachtime fromslice arevisualizedby building
thecloudtheofcomprehensively
than keywords,
terms
extracted
titlesand abstracts
are used
towordconstructauthor
keywords.
Since
titlesandabstracts
caninterpretthecontents
of
paper
more
comprehensively
co-word map by VOSviewer
the topic clusters of each time slice are analyzed based on the cothan keywords,
terms extracted from titles and abstracts are used to construct the co-word map by
word
map.
VOSviewer and the topic clusters of each time slice are analyzed based on the co-word map.
4. Research Trends Until 2019
4. Research Trends Until 2019

4.1. Time Period: 2000–2003
4.1. Time Period: 2000–2003
From 2000 to 2003, the frequency of SARS occurrences was 141, and the total cited frequency
From 2000 to 2003, the frequency of SARS occurrences was 141, and the total cited frequency
was 11,723. That is to say, the SARS research in 2003 has received widespread attention worldwide
was 11,723. That is to say, the SARS research in 2003 has received widespread attention worldwide(Figure 1). In addition, the research frequency of HEPATITIS (a type of disease) during this period is(Figure 1). In addition, the research frequency of HEPATITIS (a type of disease) during this period is
also very high, 65 times, and the total cited frequency is 2544. The research on HEPATITIS is basicallyalso very high, 65 times, and the total cited frequency is 2544. The research on HEPATITIS is basically
based on Mouse. From the statistical results, the hot topics in 2000–2003 shown in Table 2.
based on Mouse. From the statistical results, the hot topics in 2000–2003 shown in Table 2.

Figure 1.
1. Keywords
Keywords Cloud
Cloud Map
Map ofof 2000–2003.
2000–2003.
FigureTable 2. Items and frequency of hot keywords between 2000–2003.
Table 2. Items and frequency of hot keywords between 2000–2003.
Item

Frequency
Item
Frequency
CORONAVIRUS
168
CORONAVIRUS
168
MOUSE HEPATITIS-VIRUS
137
MOUSE HEPATITIS-VIRUS
137
IDENTIFICATION
90
IDENTIFICATION
90
MURINE CORONAVIRUS
82
MURINE CORONAVIRUS
82
ACUTE
RESPIRATORYSYNDROME69
ACUTE RESPIRATORY SYNDROME
69
VIRUS
67
VIRUS
67
INFECTION
62
INFECTION
62
MONOCLONAL-ANTIBODIES
59
MONOCLONAL-ANTIBODIES59
SEQUENCE
58
SEQUENCE
58
HONG-KONG
55
HONG-KONG
55
EXPRESSION
49
EXPRESSION49
OUTBREAK46
OUTBREAK46
CENTRAL-NERVOUS-SYSTEM
45
CENTRAL-NERVOUS-SYSTEM
45
GLYCOPROTEIN40
GLYCOPROTEIN
40
PROTEIN
35
PROTEIN SYNCYTIAL VIRUS
35
RESPIRATORY10RESPIRATORY SYNCYTIAL
VIRUS
10MESSENGER-RNAS
10MESSENGER-RNAS
107
PACKAGING SIGNAL
PACKAGING
SIGNAL77
RECOMBINANT
VACCINIA VIRUS
RECOMBINANT
VACCINIA
VIRUS
76
BROME
MOSAIC-VIRUS
BROME MURINE
MOSAIC-VIRUS
66
CORONAVIRUSES
MURINE CORONAVIRUSES
66
MAMMALIAN-CELLSMAMMALIAN-CELLS

6

Year
2003
2001
2003
2001
2003
2002
2001
2001
2002
2003
2002
2003
2001
2002
2002
2000
2000
2000
2000
2000
2000
2000

Year
2003
2001
2003
2001
2003
2002
2001
2001
2002
2003
2002
2003
2001
2002
2002
2000
2000
2000
2000
2000
2000
2000

There are two papers cited over 150 times during 2000–2003, one is written by Luo et al. (2000)
published in Journal of Virology, titled “Retargeting of coronavirus by substitution of the spikeInt. J. Environ. Res. Public Health 2020, 17, 3370
Int. J. Environ. Res. Public Health 2020, 17, x

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5 of 16Int. J. Environ. Res. Public Health 2020, 17, x

5 of 16

glycoprotein
the 150
hosttimes
cell species
The oneotherisiswritten
writtenby
by LuoLaneetetal.
al.
There areectodomain:
two paperscrossing
cited overduringbarrier”.
2000–2003,(2000)publishedalso publishedin Journalof theVirology,
titled“A central
roleTheforotherCD4(+)T
cells andin
(2000)
in Journalof Virology,
titledof coronavirus
by substitution
the spikeglycoprotein
ectodomain:crossing
host “Retargetingcellspeciesbarrier”.
is written
byofRANTES
Laneet al.
virus-induced
centralnervoussysteminflammation
anddemyelination.”
glycoprotein
ectodomain:crossing
the host cell
speciesbarrier”.
other is written
byRANTES
Lane et al.
(2000) also publishedin Journalof Virology,
titled“A central
roleThefor CD4(+)T
cells andin
VOSViewerisadoptedtoconstructtheterms
cooccurrence
map.
Terms
are
extracted
fromthe(2000)
also
publishedin
Journalof
Virology,
titled“Acentralrole
for
CD4(+)Tcells
and
RANTESinvirus-induced central nervous system inflammation and demyelination.”
title VOSViewer
and abstract
Theto
minimum
numberof occurrences
ofmap.
a termis setareas extracted
10, and a relevancevirus-induced
centralnervoussysteminflammationand demyelination”.
isfields,
adoptedconstruct
the terms
cooccurrence
Termsfrom thescore
iscalculated
for
each
term.
Based
on
the
score,
the60%
most
relevantterms
areselected
to build
VOSViewer
adoptedconstruct thetermsofcooccurrence
Terms
from
the
title
title and
abstractisfields,
Thetominimum
numberoccurrencesmap.
of a term
is areset extracted
as 10, anda relevancethecooccurrencemap(Figure2).
Blueclusters
arestudiesof
SARS
cases,
andtheredclusters
areandabstract
fields,theminimum
numberofoccurrences
of
a
term
is
set
as
10,
and
a
relevancescore
isscore is calculated for each term. Based on the score, the 60% most relevant terms are selected to build
studiesofproteins
andgenes.
The
yellowclusters
arestudiesofmousehepatitis;
and
the
green
calculated
for eachmap
term.
Based2).
onBluethe score,
theare60%
most ofrelevantbuild thethe cooccurrence(Figureclusters
studies
SARS terms
cases, areandselected
the red toclusters
areclustersofare
studiesof antibody
chain
reactions.
The areanalysisshows
aandstrongpresenceof areredclusters
cooccurrencemap (Figure2). Blueclusters
arestudiesof SARScases,
thehepatitis;redclusters
studies
proteins
andgenes.
The
yellowclusters
studiesof mouse
andthestudies
green(proteinandgene).
inter-disciplinary
natureof analysis
the
which
isand
required,may
notclusters
be arethatofproteins
andgenes.
The
yellowclusters
arestudiesof research,mouse
hepatitis;the greenclusters
arestudiesofTheantibody
chain
reactions.
The
shows
a strong
presenceof clusters
red
strong.
studies
antibody
reactions. The analysis
strong presence
red clusters(proteinofandgene). chain
The inter-disciplinary
natureshowsof thearesearch,which isofrequired,may(protein
not be andthatgene).
strong.The inter-disciplinary nature of the research, which is required, may not be that strong.

Figure 2. 2000–2003 term co-occurrence map.
Figure 2. 2000–2003 term co-occurrence map.
Figure 2. 2000–2003 term co-occurrence map.

4.2.Time
TimePeriod:
Period:2004–2007
4.2.
2004–2007
4.2. Time
Period:From
2004toto2004–2007
2007,SARSSARShashasbecomebecomeaaresearchresearchfocus
focusandandfocus,
focus,with
with977977occurrences
occurrencesandand29,584
29,584
From
2004
2007,
totalcitations
citations(Figure3).
total(Figure
3).
From
2004
to 2007,
SARS has become a research focus and focus, with 977 occurrences and 29,584
total citations (Figure 3).

Figure3.3.Keywords
Keywordscloud
cloudmap
mapofof2004–2007.
2004–2007.
FigureFigure 3. Keywords cloud map of 2004–2007.

“Protein”“Protein”occurredoccurred490
490times
timeswith
with14,994
14,994citations,citations,ofofwhich
which“spike“spikeprotein”
protein”appeared
appeared184
184times
times
and
cited
7155
times.490
In addition,“patients”
appear 137
times,“spikewithcitations,“nucleocapsid”
andwas
was
cited
7155
times.
Inwithaddition,“patients”
appear137 5108
times,
with
5108 184
citations,“Protein”
occurred
times
14,994 citations,of whichprotein”
appearedtimes
appears
120
times,
andits
frequencyofcitationsreached3622
times.
The
hot
topicsin
2004–2007“nucleocapsid”
appears
120
times,
andits
frequencyofcitationsreached3622
times.
The
hot
topicsand was cited 7155 times. In addition, “patients” appear 137 times, with 5108 citations,
extracted
fromthestatisticalresults
are
shown
in
Table
3.
It
is
noted
that
there
are
seven
articlesthatin 2004–2007 extracted
the statisticalare shownin Table
3. It is3622
notedthat The
therehotaretopics
seven“nucleocapsid”
appearsfrom
120 times,
and its results
frequencyof citations
reachedtimes.
were
cited
more
than
500
times
between
2004
andare2007.
Theandinformation
shown
in theTablearticles
that
were
cited
more
than
500 times
between
2004
2007.3.The
is shown
in thein
2004–2007
extracted
fromthestatisticalresults
shown
in
Table
It is
isinformation
noted that
there
are4.sevenTable
4.
articles that were cited more than 500 times between 2004 and 2007. The information is shown in the

Table 4.

Int. J. Environ. Res. Public Health 2020, 17, 3370

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Table 3. Items and frequency of hot keywords during 2004–2007.
Item

Frequency

Year

INFECTION CONTROLTREATMENTCHEMOKINESCORTICOSTEROIDZOONOSIS
TURKEY CORONAVIRUS
MULTIPLE SCLEROSISS GLYCOPROTEIN
MOUSE
QUARANTINECORONAVIRUS
SARS
SEVERE ACUTE RESPIRATORY SYNDROMESARS CORONAVIRUS
SEVERE ACUTE RESPIRATORY SYNDROME (SARS)SARS-COVSPIKE PROTEIN
NUCLEOCAPSID PROTEIN
VIRUS
EPIDEMIOLOGYINFECTIOUS BRONCHITIS VIRUS
RESPIRATORY VIRUS
ADENOVIRUS
PORCINE EPIDEMIC DIARRHEA VIRUS
HUMAN BOCAVIRUS
PCR
TGEV
GLYCOSYLATION

12
8
8
7
6
6
6
6
6
6
242
212
171
64
47
150
47
38
27
23
23
9
9
8
7
7
7
7

2004
2004
2004
2004
2004
2004
2004
2004
2004
2004
2005
2005
2005
2005
2005
2006
2006
2006
2006
2006
2006
2007
2007
2007
2007
2007
2007
2007

Table 4. Top cited papers during 2004–2007.
Author Name

Year

Publication Journal

Title

GCS

Allander T. et al.

2005

Proc. Nat. Acad. Sci. USA

Cloning of a human parvovirus
by molecular screening of
respiratory tract samples

1034

Li WD et al

2005

Science

Bats are natural reservoirs of
SARS-like coronaviruses

861

van der Hoek L

2004

Nat. Med.

Identification of a new humancoronavirus

756

Calisher CH

2006

Clin. Microbiol. Rev.

Bats: Important reservoir hostsof emerging viruses

671

Lau SKP et al.

2005

Proc. Nat. Acad. Sci. USA

Severe acute respiratory
syndrome coronavirus-like virus
in Chinese horseshoe bats

654

653

634

Woo PCY et al.

2005

J. Virol.

Characterization and complete
genome sequence of a novel
coronavirus, coronavirus
HKU1,from patients withpneumonia

Chou KC et al.

2004

Curr. Med. Chem.

Structural bioinformatics and its
impact to biomedical science

The term cooccurrence map are shown in Figure 4. Red clusters are researches on hospital casedetection. The green cluster is the study of virus structure and replication and interaction after invadingInt. J. Environ. Res. Public Health 2020, 17, 3370

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the human body. Yellow clusters are for phylogenetic analysis; and blue clusters are the first-bodybinding domains and immunodeficiency studies in mice. There is a definite high concentration of red
Int. J. Environ.
Res. Public
Health 2020, 17,x
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Int. J. Environ.
Res. Public
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FigureMap.
Figure4.4.2004–2007
2004–2007Term
TermCooccurrence
Cooccurrence
Map.
Figure 4. 2004–2007 Term Cooccurrence Map.

4.3.
Period:2008–2011
4.3.Time
Time
Period:2008–20114.3.
TimePeriod:2008–2011
From
From2008
2008toto2011,
2011,researchresearchon
onSARS
SARSdid
didnotnotdecrease,decrease,withwith332
332occurrences
occurrencesand
andaaatotal
totalofof6961
6961
From
2008
to
2011,
research
on
SARS
did
not
decrease,with
332
occurrences
and
total
of
6961
citations.
In
addition,“severeacute
respiratory
syndrome”
appeared
more
than
200
times,
withatotal
citations.
In
addition,“severeacute
respiratory
syndrome”
appeared
more
than
200
times,
withcitations.
In addition,“severeappeared
acute respiratory
syndrome”
appearedmore than
200 times,
with aaof
5000
citations;“bronchitis”
98
times,
with
a
total
of
2933
citations;“children”
appeared
total ofof 5000 citations;citations; “bronchitis”“bronchitis” appeared
appeared 98
98 times,
times, with
with aa total
total ofof 2933
2933 citations;citations; “children”“children”
total
69
times, 5000
andatimes,total of2933
citations(Figure5). Thetopic5).trendsof 2008–2011
areillustrated
inTable 5.
appeared
69
and
a
total
of
2933
citations(FigureThe
topic
trendsof
2008–2011
areillustrated
appeared
69 times,there
and aweretotalfourof 2933
citations(Figure5).
The
topic trendsof 2008–2011
areillustrated
During
2008–2011,
hot
papers
with
over
400
citations,andtheinformation
is
shown
in
inTableTable5.5.During
During2008–2011,2008–2011,there
therewere
werefourfourhot
hotpapers
paperswith
withoverover400
400citations,citations,andandthetheinformation
information
in
Table
6.
shownininTableTable6.6.
isisshown

FigureFigure5.5.Keywords
Keywordscloud
cloudmap
mapofof2008–2011.
2008–2011.
Figure 5. Keywords cloud map of 2008–2011.
Table 5. Items and frequency of hot keywords during 2008–2011.
Table 5. Items and frequency of hot keywords during 2008–2011.
Table 5. Items and frequency of hot keywords during 2008–2011.
Item Item
Frequency
Year
Frequency Year
Item

PATHOGENESISPATHOGENESISPATHOGENESISNUCLEOCAPSIDNUCLEOCAPSIDNUCLEOCAPSIDAPOPTOSISAPOPTOSISAPOPTOSISHUMAN
METAPNEUMOVIRUS
HUMAN
METAPNEUMOVIRUS
HUMAN
METAPNEUMOVIRUS
REPLICATIONREPLICATIONREPLICATIONSARS-COV
SARS-COV
SARS-COV
VIRUS
VIRUSVIRUS
CORONAVIRUS
CORONAVIRUS
CORONAVIRUS
INFECTIOUS BRONCHITIS VIRUS
INFECTIOUS
BRONCHITIS
VIRUS
INFECTIOUS
BRONCHITIS
VIRUS
PHYLOGENETIC ANALYSISPHYLOGENETICANALYSISPHYLOGENETICANALYSIS
INFLUENZA
INFLUENZA
INFLUENZA
RT-PCR
RT-PCR
RT-PCR
MOUSE HEPATITIS VIRUS
MOUSE
HEPATITIS
VIRUS
MOUSE
HEPATITIS
VIRUS
PIGS
PIGS
PIGS
PHYLOGENETIC TREEPHYLOGENETICPHYLOGENETICTREETREE

Frequency
101010101010
999
999
999
878787292929
159
159
159
37
3737
26
26
26
18
1818
17
1717
9
995
555
55

Year
2008
20082008
2008
20082008
2008
20082008
2008
20082008
2008
20082008
2009
20092009
2009
20092009
2010
20102010
2010
20102010
2010
20102010
2010
20102010
2010
20102010
2011
20112011
2011
20112011
2011
20112011

Table 6. Top cited papers with over 400 citations during 2008–2011.
Table 6. Top cited papers with over 400 citations during 2008–2011.
Author Name
Author Name

Year
Year

Publication Journal
Publication Journal

Reyes-Turcu
Reyes-Turcu
FE. et al.
FE. et al.

2009
2009

Ann. Rev. Biochem.
Ann. Rev. Biochem.

Ernst B, et al.
Ernst B, et al.

2009
2009

Nat. Rev. Drug Discov.
Nat. Rev. Drug Discov.

Title
Title
Regulation and Cellular Roles ofRegulation and Cellular Roles of
Ubiquitin Specific Deubiquitinating
Ubiquitin Specific Deubiquitinating
Enzymes
Enzymes
From carbohydrate leads to
From carbohydrate leads toglycomimetic drugs
glycomimetic drugs

GCS
GCS
782
782
480
480

Int. J. Environ. Res. Public Health 2020, 17, 3370

8 of 17

Table 6. Top cited papers with over 400 citations during 2008–2011.
Author Name

Year

Publication
Journal

Title

GCS

Reyes-Turcu, F.E.
et al.

2009

Ann. Rev. Biochem.

Regulation and Cellular Roles of
Ubiquitin Specific Deubiquitinating
Enzymes782

Int. J. Environ. Res. Public Health 2020, 17, x

8 of 16Nat. Rev. Drug
From carbohydrate leads to480
Ernst, B. et al.
2009
Int. J.Ruuskanen
Environ. Res.OPublic
8 of 16
Discov.
glycomimetic drugs
et Health 2020, 17, x
2011
LancetViral pneumonia
453
al.
Ruuskanen, O.
2011
LancetViral pneumonia
453
RuuskanenetOal.
etStructures
andmechanisms of viral
2011
LancetViralpneumonia
453
Crit.
Rev.
Biochem.
Mol.
al.JM et al.
White
2008
membraneproteins:
Multiple
445
Structures
andfusionmechanismsof viral
Biol.
Crit. Rev. Biochem.
Structuresandon
mechanismsofviral 445
variations
a commontheme
White, J.M. et al.
2008
membranefusionproteins:
Multiple
Crit. Rev. Biochem.
Mol. Biol. Mol.
White JM et al.
2008
membranefusionproteins:
Multiple
445
variations on
a common
theme
Biol.
The term cooccurrence map of 2008–2011 publications
is generated
in Figure6. The red cluster
variations
on a common
themeis the study of protein structure and mechanism, and blue clusters are used to study the immune
The termcooccurrence
2008–2011
publications
generated
Figure 6.andThe treatment
red clusterof
response
to virusesin micemap
andofanchors.
Greencluster is isthestudy ofindiagnosis
mechanism,
iscasesthe studyof protein
structureand cluster
mechanism,and blue clusters
areof
used
to study
the immune
and children,andthe yellow
is a phylogenetic
analysis
epidemicdysenteryusing
responsetovirusesinmice
andanchors.
Green
cluster
is
the
study
of
diagnosis
andtreatment
ofof
responsetovirusesinmice
andanchors.
Green
cluster
is
the
study
of
diagnosis
andtreatmentof cases
chickens and dogs. Here, a strong concentration is found in green cluster (diagnosis and treatment
cases
and
children,andtheyellowclusterisaphylogenetic
analysisofepidemicdysenteryusing
andchildren,and the followed
yellow clustera phylogenetic
epidemicdysentery using chickens
cases
and children),by rediscluster(protein analysis
structureofandmechanism).
chickens
dogs.
Here,concentration
a strong concentration
is greenfoundclusterin greencluster (diagnosis
and treatmentofanddogs.andHere,a strong
is found in(diagnosis
and treatmentof cases andcases and followed
children),by
followedby redcluster(proteinandstructureand mechanism).
children),
red cluster(proteinstructuremechanism).

Figure 6. 2008–2011 term co-occurrence map.

4.4. Time Period: 2012–2015 Figure 6. 2008–2011 term co-occurrence map.
4.4. Time
Period:From
20122012–2015
to2015, MERS-COV is the most prevalent topic, with 320 occurrences and cited 13,882
4.4. Time
Period:2012–2015
times.
“SARS”
occurred
161 times and
was
cited
3359 times.
“Infectious
bronchitis virus”
occurredFrom 2012 to 2015, MERS-COV
is themostprevalent
topic,
with 320 occurrences
and cited
13,882in
From
2012
to
2015,
MERS-COV
is
the
most
prevalent
topic,
with320
occurrences
and
cited
13,882113 papers
with1815 citations(Figure7). cited
Duringthisperiod,keywords
including“epidemiology”,
times.
“SARS”
occurred
161 times
and was3359
times.
“Infectious
bronchitis
virus”
occurred intimes.
“SARS” occurred161
times protein”,
and was cited
3359 times.“phylogenetic“Infectious bronchitis
virus”
occurredandin“respiratory
viruses”,“spike“influenza”,
analysis”,“vaccine”
113 papers with 1815 citations (Figure 7). During this period, keywords including “epidemiology”,
113
paperswith
1815
citations(Figure7).
Duringthisperiod,keywords
including“epidemiology”,“children” arealso hottopics,with over
30 occurrences.
The trending
topics“vaccine”
of each year
2012–
“respiratory
viruses”,“spikeprotein”,“influenza”,“phylogenetic
analysis”,
andduring“children”“respiratory
viruses”,“spikeprotein”,“influenza”,“phylogenetic
analysis”,“vaccine”
and
2015
are
shown
inwithTableover
7. During
2012–2015,The
there
are fourpaperswhich
werecited 2012–2015
over 400 times,
are
also
hot
topics,30 occurrences.
trending
topicsof eachyear
duringare“children”
are
also
hot
topics,
with
over
30
occurrences.
The
trending
topicsof
eachyear
during2012–(Tablein8).Table 7. During 2012–2015, there are four papers which were cited over 400 times, (Table 8).
shown2015 are shown in Table 7. During 2012–2015, there are four papers which were cited over 400 times,(Table 8).

Figure 7. Keywords cloud map of 2012–2015.
Figure 7. Keywords cloud map of 2012–2015.

7. Keywordsof 2012–2015.
Table 7. Figure
Items andfrequencycloudof hotmap
keywords
during 2012–2018.
Item
CHINA

Frequency
10

Year
2012

Table 7. Items and frequency of hot keywords during 2012–2018.

Int. J. Environ. Res. Public Health 2020, 17, 3370

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Table 7. Items and frequency of hot keywords during 2012–2018.
Item

Frequency

Year

CHINA
RESPIRATORY
MOLECULAR EPIDEMIOLOGYEPITOPE
MOUSE HEPATITIS VIRUS
ENCEPHALOMYELITISSPIKE GLYCOPROTEINPATHOGENICITYSARSSPIKE PROTEINPHYLOGENETIC ANALYSISFELINE CORONAVIRUS
RESPIRATORY VIRUS
CORONAVIRUS
MERS-COV
INFECTIOUS BRONCHITIS VIRUS
EPIDEMIOLOGYMERSANTIVIRAL
RECOMBINATIONRSVBETACORONAVIRUS

10
8
8
7
6
6
6
6
60
36
34
29
26
252
96
65
44
33
12
9
8
8

2012
2012
2012
2012
2012
2012
2012
2012
2013
2013
2013
2013
2013
2014
2014
2014
2014
2015
2015
2015
2015
2015

Table 8. Top cited papers with over 400 citations during 2012–2015.
Author Name

Year

Publication
Journal

Title

GCS

Zaki AM et al.

2012

New Engl. J. Med.

Isolation of a Novel Coronavirus
from a Man with Pneumonia in
Saudi Arabia

1308

Assiri A et al.

2013

New Engl. J. Med.

Hospital Outbreak of Middle
East Respiratory SyndromeCoronavirus

551

LancetHuman infections with the
emerging avian influenza A
H7N9 virus from wet market
poultry: clinical analysis andcharacterisation of viral genome

546

NatureDipeptidyl peptidase 4 is afunctional receptor for the
emerging humancoronavirus-EMC

470

Chen Y et al.

Raj VS et al.

2013

2013

The terms extracted from title and abstracts of 2012–2015 publications on coronavirus are used tobuild the cooccurrence map shown in Figure 8. Red clusters are experiments on mouse proteins andRNA synthesis in mice and blue clusters are phylogenetic analysis of infectious bronchial virus (IBV),
porcine epidemic virus (PEDV), cats, dogs, and bats. Green clusters are case studies. It was interesting
to note that the green clusters have more concentration, which are on case studies.

coronavirus-EMC

The terms extracted from title and abstracts of 2012–2015 publications on coronavirus are used
to build the cooccurrence map shown in Figure 8. Red clusters are experiments on mouse proteins
and RNA synthesis in mice and blue clusters are phylogenetic analysis of infectious bronchial virus
Int. J. Environ. Res. Public Health 2020, 17, 3370
10 of 17
(IBV), porcine epidemic virus (PEDV), cats, dogs, and bats. Green clusters are case studies. It wasinteresting to note that the green clusters have more concentration, which are on case studies.

Figure 8.
8. 2012–2015
term co-occurrenceco-occurrence map.
map.
Figure2012–2015 term

4.5. TimeTime Period:
Period:2016–2019
2016–2019
During 2016–2019,2016–2019,it itcan
canFigurethat MERS-COV
is hotstillissue,
the hot
issue,
be beseenseen
fromfrom
Figure9 that9MERS-COV
is still theoccurringoccurring4065
times according
to the statistical“Infectious
bronchitis
493 times,493
andtimes,
citedand
4065cited
times
accordingto the statisticalresults.results.
“Infectious
bronchitis
virus”
virus”
occurred
151withtimes856with
856 citations.
“Porcine
epidemicdiarrhea
virus”
alsotopic
a hotintopic
occurred
151 times
citations.
“Porcine
epidemicdiarrhea
virus” isalso ais hot
thisinthis period,
74 citations.
The
most frequent
topics2016–2019
during 2016–2019also included“Saudiperiod,with 74withcitations.
The most
frequent
topics during
also included“Saudi Arabia”,
Arabia”,“epidemiology”,“SARSCov”,“vaccine”,
protein”
and “phylogenetic
analysis”,“epidemiology”,“pedv”, “pedv”,“SARSCov”,“vaccine”,“spike “spike
protein”
and “phylogenetic
analysis”,
with
with
35 occurrences,respectively.
trending
topicseachyear
yearduring
during2016–2019
2016–2019areare shownshown inover over
35 occurrences,respectively.
TheThetrending
topics
of of
each
Table
9.
five
papersTable
9. There
There
are
five
paperscited
over 110
110 times
timesduring
during2016–2019
2016–2019(refer(referto
toTableTable10).
10).
Int. J. Environ.
Res.arePublicHealth2020,cited17, x over
10 of 16

FigureFigure 9.
9. Keywords
Keywords cloud
cloud map
map ofof 2016–2019.
2016–2019.
Table 9. Items and frequency of hot keywords during 2012–2018.
Table 9. Items and frequency of hot keywords during 2012–2018.
Item

Frequency
Item
Frequency
SWINE
SWINE
14 14
DOG
DOG
11 11
DIAGNOSTICSDIAGNOSTICS
8 8
RESPIRATORYRESPIRATORYDISEASE DISEASE
8 8
DIVERSITY
DIVERSITY
6 6
HUMAN CORONAVIRUSESHUMAN CORONAVIRUSES
6 6
IMMUNOGENICITY
6
IMMUNOGENICITY
6
INFECTIOUS BRONCHITIS VIRUS (IBV)6
INFECTIOUS BRONCHITIS VIRUS (IBV)6
MIDDLE EAST RESPIRATORY SYNDROME
78
MIDDLE EAST RESPIRATORY SYNDROME
78
PORCINE EPIDEMIC DIARRHEA VIRUS
74
PORCINE EPIDEMIC DIARRHEA VIRUS
74
SARS-COV47
SARS-COVVACCINE
47 47
VACCINE BATS
47 32
BATS
32 87
INFECTIOUS
BRONCHITIS VIRUS
INFECTIOUS BRONCHITIS
VIRUS
87 84
MERS
MERSSAUDI ARABIA
84 61
SAUDI ARABIA
61 60
VIRUS
VIRUS
60 50
PEDV
PEDV
50 22
FELINE
INFECTIOUS PERITONITISFELINE INFECTIOUS PERITONITIS
22 21
ZOONOSIS
MOLECULAR EPIDEMIOLOGY
12
RSV
10
3C-LIKE PROTEASE
9MONOCLONAL ANTIBODY
9

Year
2016
2016
2016
2016
2016
2016
2016
2016
2017
2017
2017
2017
2017
2018
2018
2018
2018
2018
2019
2019
2019
2019
2019
2019

Year
2016
2016
2016
2016
2016
2016
2016
2016
2017
2017
2017
2017
2017
2018
2018
2018
2018
2018
2019

Int. J. Environ. Res. Public Health 2020, 17, 3370

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Table 9. Cont.
Item

Frequency

Year

ZOONOSIS
MOLECULAR EPIDEMIOLOGYRSV
3C-LIKE PROTEASE
MONOCLONAL ANTIBODY

21
12
10
9
9

2019
2019
2019
2019
2019

Table 10. Top cited papers with over 100 citations during 2016–2019.
Author Name

Year

Publication Journal

Title

GCS

Thompson BT et al.

2017

New Engl. J. Med.

Acute Respiratory Distress Syndrome

168

Warren TK et al.

2016

NatureTherapeutic efficacy of the small
molecule GS-5734 against Ebola virus
in rhesus monkeys

144

de Wit E et al.

2016

Nat. Rev. Microbiol.

SARS and MERS: recent insights into
emerging coronaviruses

131

Chan JFW et al.

2016

J. Infect.

Zika fever and congenital Zika
syndrome: An unexpected emerging
arboviral disease

115

ScienceCo-circulation of three camelcoronavirus species andrecombination of MERS-CoVs in
Saudi Arabia

113

Sabir JSM et al.

2016

Int. J. Environ. Res. Public Health 2020, 17, x

11 of 16

The term cooccurrence map of 2016–2019 is shown in Figure 10. The red clusters are studies on
The term cooccurrence map of 2016–2019 is shown in Figure 10. The red clusters are studies ontheexpression
and replication
replication ofof viralviral enzymes
enzymes inin recipient
recipient cells,
cells, human
human immunodeficiency
immunodeficiency virus,
virus,
the expression andamong others.
others. Green
Green clusters
clusters areare researchresearch on
on patients,
patients, hospitals,
hospitals, children
children andand health.
health. Blue
Blue clusters
clustersamongarestudiesofvaccines,virus
strains,andtheyellowclusters
areresearches
usingpolymerase
chain
are studies of vaccines, virus strains, and the yellow clusters are researches using polymerase chain
reactionbyanimals.
Here
also,
important
issue
is
the
increaseofgreen
clusters
which
are
on
patients,
reaction by animals. Here also, important issue is the increase of green clusters which are on patients,
hospitals, children
children andand health.
health.
hospitals,

Figure 10. 2016–2019 term co-occurrence map.
Figure 10. 2016–2019 term co-occurrence map.

4.6. Summary of Research Trends: 2000–2019
4.6. Summary of Research Trends: 2000–2019
From 2000 to 2019, there are two main research hotspots: one is about the structure, expression
From 2000 tothere are two
main
research
is about
the structure,
expression
and interactionof 2019,the coronavirus
afterentering
thehotspots:
human onebody;
the otheris about thecase ofandinteractionofthecoronavirus
afterentering
the
human
body;
the
other
is
about
the
case ofpatients, including children (Figure 11). Studies on gene expression, interactions and structural changes
patients,
includingchildren(Figure11).areStudiesgene expression,interactions
and structuralafter
the virus
invadesthe human
body
mainlyonfocusedon the developmentof antibodies
andchanges
after
the
virus
invades
the
human
body
are
mainlyfocusedonthedevelopmentof
antibodies
vaccines, animal experiments, virus mutations and activity changes; Medical research on patients withand vaccines, animal
experiments,
mutationsactivitydiagnosischanges; Medical
research on patientscoronaviruses
is mainly
focused onvirus
patient
immuneandresponse,
and treatment.
with coronaviruses is mainly focused on patient immune response, diagnosis and treatment.
From the time series analysis, it is observed that: public safety incidents affected scientific output
and research topics, as observed after SARS and MERS. This may be an obvious increase in terms offocus on research topics. In addition to SARS and MERS, there are a few other types of coronavirus
research. Whether these viruses will have a profound impact on humans needs further study. Table
11 shows that in the five time periods, research on patients with coronavirus has been a hot spot, andmany scholars have conducted research on patients’ symptoms and diagnostic methods, as well asfocus on the interaction with cells and virus replication after the virus enters the organism. Spikeprotein and structural changes of virus, immune reaction, T-cell study as well as antibody
development are hot topics after SARS outbreak after 2003. It is worth noting that the study ofphylogenetic analysis based on spike protein sequences has become a hot spot in 2012–2019. In theInt.
J. Environ.
Res. Public Health2020,
17, 3370
12 of 17study
of coronavirus
from
2003
to 2019, in addition to SARS and MERS, IBV, PEDV and mouse
hepatitis have also been studied by many scholars.

Figure 11.
11. 2000–2019
density map.
map.
Figure2000–2019 term
term co-occurrenceco-occurrence density

From the time series analysis, it is observed that: public safety incidents affected scientific output
and research topics, as observed after SARS and MERS. This may be an obvious increase in terms offocus on research topics. In addition to SARS and MERS, there are a few other types of coronavirus
research. Whether these viruses will have a profound impact on humans needs further study. Table 11shows that in the five time periods, research on patients with coronavirus has been a hot spot, and manyscholars have conducted research on patients’ symptoms and diagnostic methods, as well as cases ofdifferent ages, especially children; In the field of biomedicine, mice are used as test objects, focus on
the interaction with cells and virus replication after the virus enters the organism. Spike protein andstructural changes of virus, immune reaction, T-cell study as well as antibody development are hot
topics after SARS outbreak after 2003. It is worth noting that the study of phylogenetic analysis basedon spike protein sequences has become a hot spot in 2012–2019. In the study of coronavirus from 2003
to 2019, in addition to SARS and MERS, IBV, PEDV and mouse hepatitis have also been studied bymany scholars.
Table 11. Summary of word cloud and co-occurrence maps for five time series.
Time Period

Top 5 Author Keywords

Top 3 Cluster in Cooccurrence Map

2000–2003-

Coronavirus (168)
Mouse hepatitis virus (137)
Identification (90)
Murine coronavirus (82)
Acute respiratory syndrome (71)

2004–2007-

Acute respiratory syndrome (718)Coronavirus (518)
Identification (477)
SAR Scoronavirus (335)
Virus (322)-Coronavirus (159)
SARS Cov (88)
SARS (74)Severe acute respiratory syndrome (39)
Infectious bronchitis virus (37)--Coronavirus (252)
MERS Cov (96)
Infectious bronchitis virus (65)
SARS (60)Epidemiology (44)-

2008–20112012–2015-

Red cluster (protein and gene)
Yellow cluster (mouse hepatitis)
Blue cluster (SARS and patient
cases study)-

Red cluster (Pneumonia andhospital patient)Green cluster (virus structure,interaction and replication)
Blue cluster (s protein andmouse study)

-

-

-

Red cluster (protein structure andinteract mechanism)Green cluster (patient diagnosis
and sample)
Blue cluster (immune response and tcell study on mouse)
Red cluster (Cell, protein study test
on mouse)
Green cluster (respiratory virus
patient study)
Blue cluster (IBV and Phylogenetic
analysis of bat, cat and pig)

Int. J. Environ. Res. Public Health 2020, 17, 3370

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Table 11. Cont.
Time Period

2016–2019

Top 5 Author Keywords-

Coronavirus (384)
MERSCov (245)
Infectious bronchitis virus (87)
Porcine epidemic diarrhea virus (74)Influenza (64)

Top 3 Cluster in Cooccurrence Map-

Red cluster (Cell replication andneutralizing antibody)Green cluster (Respiratory virus
and patient)Blue cluster (IBV, PEDV andphylogenetic analysis)

5. Research Trend in 2020
The same methodology was used for 2020 analysis as well. The Web of Science core collection
database was used to search SCIE and SSCI papers related to coronavirus published since 2020.
The search formula was defined as “TS = Coronavirus” and the language was set to English. The main
information of the publication is shown in Table 12.
Table 12. Key information of the 2020 literature search.
Period2020 January to March

Number of publications
Source journals
Author keywords
Average citations per documents
Authors of single-authored documents
Authors of multi-authored documents
Collaboration Index

384
155
630
1.81
57
1955
6.5

Since the outbreak of the COVID-19 in late 2019, a total of 384 papers have been published.
Epidemiological knowledge is adopted to study infection of the virus. Thus, epidemiology andemerging infection diseases become two prominent key words after the names of the virus like 2019ncov,
covid19, SARScov2 among others. It is to be emphasized here that in several virology/epidemiology
papers, SARS-COV2 refers to the virus which caused the disease, and the disease itself is referred as
COVID-19 or 2019cov. In order to analyze the trend of COVID-19 research, Keyword Plus (provided
by Web of Science) and author keywords are both adopted to build the trend map (Figure 12) based on
the logarithm of keyword occurrences. It should be noted that as keyword plus illustrated, besides
acute respiratory syndrome, MERS, replication and expression, a small cluster including pathogenicity,
influenza, diarrhea, respiratory syndrome, RIG-I, syncytial virus and crystal-structure shows anaggregate status. Author keywords reveal that studies on virus, pathogenesis, outbreak, travel andporcine delta coronavirus are linked together, and shows a continuing trend. Five papers cited over 40
Int. J. Environ. Res. Public Health 2020, 17, x
13 of 16
times are shown in Table 13.

Figure 12. Keywords cloud map of 2020.
Figure 12. Keywords cloud map of 2020.

Table 13. Top cited papers with over 40 citations of 2020.
Author Name
Huang CL et al.

Year

Publication Journal

Title
Clinical features of patients infected

GCS

Figure 12. Keywords cloud map of 2020.
Int. J. Environ. Res. Public Health
2020,
3370
Table
13.17,
Top
cited papers with over 40 citations of 2020.

Author Name

Year

Publication Journal
Title
Clinicalfeatures of 2020.
patients infected
Table 13. Top cited papers with over
40 citations
Huang CL et al.
2020
Lancetwith 2019 novel coronavirus in Wuhan,
Author Name
Year
Publication Journal
Title
China
A NovelCoronavirus
fromPatients
Clinicalfeaturesof patients
infectedwith
Huang
CL et al.2020 2020
LancetZhu
N et al.
New Engl.
J. Med.
2019 novel
coronavirusininChina,
Wuhan,
China
with Pneumonia
2019
A familial
clusterfromof pneumonia
A NovelCoronavirus
Patients with
Zhu N et al.
2020
New Engl. J. Med.
associatedwith
20192019
novel
Pneumonia
in theChina,
Chan JFW et al.
2020
Lancetcoronavirus indicating person-toA familial cluster of pneumonia
persontransmission:a studyof a family
associatedwith the2019 novel
Chan JFW et al.
2020
Lancetclustercoronavirus indicating person-to-person
Epidemiologicalclinicaltransmission:a study ofanda familyclustercharacteristics
of
99
cases
of
2019
Epidemiological and clinical novel
Chen NS et al.
2020
Lancetcoronavirus
pneumonia
Wuhan,
characteristics of
99 cases ofin2019
novel
Chen NS et al.
2020
LancetChina:a descriptive
study China:
coronavirus
pneumonia
in Wuhan,A pneumonia
outbreakstudy
associated witha descriptive
Zhou P et al.
2020
Natureanewcoronavirusofprobable with
bat a
A pneumonia outbreak associatedZhou P et al.
2020
Naturenew coronavirus originof probable bat origin

14 of 17

GCS
97
GCS
97
68
68

54
54

42
42

41
41

Figure 13 shows the term cooccurrence map. Red clusters represent research on proteins andcellularFigure
genes.13Green
research
COVID-19
case outbreaks.
clusters
showsclusters
the termrepresent
cooccurrence
map.onRed
clusters represent
researchYellow
on proteins
andrepresent
studiesof infection
history andsymptoms,
whilecaseblueoutbreaks.
clusters represent
researchoncellular genes.
Greenclusters represent
research
on COVID-19
Yellow clusters
represent
respiratory
viruses. history and symptoms, while blue clusters represent research on respiratory viruses.
studies of infection

Figure2020
term
co-occurrencemap.
Figure13.13.
2020
term
co-occurrencemap.

canbebeseen
seenfrom
fromthethegreengreencluster,cluster,thetheresearchresearchononCOVID-19
COVID-19has
hasattracted
attractedinternational
international
AsAscanattention.
Theauthor
keywords
revealthat
besides
China,
othercountries
includethe
UnitedStates,attention. The author keywords reveal that besides China, other countries include the United States,
CanadaandThailand.
Fever
and
cough
main
symptoms
COVID-19,“fever”
and“cough”
CanadaandThailand.
Fever
and
cough
arearethethemain
symptoms
of of
COVID-19,
soso“fever”
and“cough”
appearmore
frequently
intheauthor
keywords.
In
addition,
population
migrationhasplayeda hugeappear more frequently in the author keywords. In addition, population migration has played a hugeroleinspreadingthevirus,
so
isolationisaneffective
means
to
limit
the
spreadofthevirus.
The
terms
role in spreading the virus, so isolation is an effective means to limit the spread of the virus. The
mouse and pig in the red cluster are receptors of coronavirus and seem to be used for medical tests.
Other keywords also include “cell”, “protein”, “gene” and “pathogen”.
From the currently published papers, it is observed that the research on COVID-19 mainly includes
epidemiological characteristics, virus traceability studies, early transmission, mode and modeling
analysis of COVID-19 predicting the spread and trend of the epidemic, clinical characteristics of
COVID-19, diagnosis and treatment also attracted wide attention. The development of antibodies
and vaccines will be of great concern. As of 6 May 2020, the number of people infected with
COVID-19 has exceeded 3.8 million globally. The global and local economies are highly affected, andsocio-economically vulnerable people like daily wedger are at high risk.
6. Discussion and Way Forward
As per [11], experts recognized that an important amount of information is available just threemonths into the outbreak, there are still concerns about knowledge gaps and lack of clear evidence
to support some interventions. The importance of strengthening capacity was highlighted in the
research roadmap meeting in February 2020. Integration of research activities in the response toInt. J. Environ. Res. Public Health 2020, 17, 3370

15 of 17

outbreaks and the lessons learnt on SARS, Ebola, Lassa fever, and Nipah have led to a prompt research
response now. Participants emphasized that as we mobilize the research community for COVID-19,
concerted efforts should be made to facilitate the sustainment of this capacity to support other ongoingor future outbreaks across the world. On the 26th of March, WHO issued six prioritized strategies, tobe undertaken by governments to cope with the pandemic. The strategies were as follow: (1) Expand,train and deploy health-care workers; (2) Implement systems to find suspected cases; (3) Ramp
up production of tests and increase availability; (4) Identify facilities that can be transformed into
coronavirus health centers; (5) Develop plans to quarantine cases; and (6) Refocus governments on
suppressing the virus [11]. The document also identified eight knowledge gaps as follows: (1) humananimal interface, (2) clinical consideration, (3) vaccine, (4) behavior and education, (5) transmission,(6) therapeutics, (7) healthcare workers, and (8) ethical considerations.
In its analysis, [3] calls for an international protocol of pandemic response, where similar standards
are processes are maintained. That needs more research and continued international dialogue.
Governance become a key challenge in many countries, and not that much research is conducted on
pandemic governance and needs to be considered as a core research gap. In the context of governancethe H-EDRM [12], which was described earlier can provide a basic framework. Incorporation ofpandemic risk and biological hazards need to be incorporated in the Sendai Framework national
implementation in respective countries, which seems to be a gap area. India is one exception, where the
National Disaster Management Act (Law) was enacted country wise to respond to COVID-19 forthe first time since the promulgation of the law in 2005. Thus, there seems to be a strong gap ofincorporation of biological hazards in disaster response, recovery and long-term preparedness. New
research is required in the areas of supply chain management, business continuity planning (BCP)and short to medium term response and recovery planning. We also did not notice much researchon the risk assessment methodologies, which is an integral part of the disaster response and risk
reduction. Multi-disciplinary research incorporating public health, disaster risk reduction, economics
of pandemics, social psychology, anthropology, sociology, psychology and ecology are required.
Social innovation in long term care can be seen as the potential option for addressing COVID-10
from the analysis of the Italy case [13]. Social innovation key factors in Italian Long Term Care are listed
as follows: (1) coordination/integration in public health care, (2) design to meet target group needs, (3)framework/structural conditions, (4) funding, (5) leadership and governance, (6) local community focus,(7) specificity of LTC, (8) network, (9) sustainability, and (10) workforce. These elements need to be
integrated properly to develop new social innovation in long term care. This area needs a strong focus
along with development of other innovative and emerging technologies, linked to social innovation.
The International Network of Government Science Advice (INGSA) in its COVID-19 theme
has identified sixteen different topics: data visualization/tracking tool, research/education tools,
risk communication/preparedness, economics, social resilience/social cohesion, international
cooperation/science diplomacy, science communication/trust, national governance, ethics/social science,
policy development, role of digital technologies, sub-national governance, global south COVID
response, emergencies and mental health, regulation and emergency response, and human rights
issues [14].
The key issue emerging from this literature analysis is that over a period of 20 years, different
types of epidemic diseases have prompted innovative research on epidemiology, virology, disease
infection, vaccine, impacts on different age groups among others. However, an epidemic or pandemic
response is not just a health issue, it is very much a disaster response. Thus, basic disaster response
framework needs to be adopted and followed. More research is required for new research on biologicalhazard response, role of different types of technology, governance mechanisms, risk communication,
people’s behavior and citizen participation. On the public health side, public health preparedness,
implementation of H-EDRM frameworks, experience sharing through open access data sharing andpublication is required to reduce the north south divide of knowledge management [15]. Researchcommunication, and role of media is another important issue, which is often not properly researched.

Int. J. Environ. Res. Public Health 2020, 17, 3370

16 of 17

As argued in [1], the COVID-19 response as “infodemic”, the role of right information through reliable
sources and at right time is very important. Infodemic was the term used by WHO to highlight theimportance of right and timely information during pandemic. This is the core of risk communication
for invisible disasters, where trust on information becomes a core issue. Research on early recovery
planning is also urgently required.
As it is said that earthquake problem cannot be solved by seismologist or earthquake engineers,
it needs a wider expertise of planner, social scientist, economists among others. Similarly, the pandemic
risk reduction and response needs expertise beyond health professionals. In future we hope to see
more inter-, trans- and multi-disciplinary approaches in health risk management, pandemic response,
disaster risk reduction.
7. Conclusions
Analysis of research papers with keywords “Coronavirus” over last 20 years shows that there
has been an increase in the COVID related research after major Coronavirus spread like SARS, MERS
etc. Most of the research focus on virology, immunology epidemiology etc., however there is little
research on linking biological hazards (including pandemic) to disaster response, covering holistic
approach of response. While H-EDRM framework provides an opportunity to the integration of publichealth and disaster risk reduction, response and recovery, new research needs to focus on different
aspects of pandemic response, recovery and long-term development. COVID-19, being an infodemic,
information, risk communication, citizen behavior are areas which needs additional research.
Author Contributions: Conceptualization: R.S.; methodology: H.Z., R.S.; analysis: H.Z.; writing—original draft
preparation: R.S. and H.Z.; writing—review and editing: R.S. All authors have read and agreed to the publishedversion of the manuscript.
Funding: The first author acknowledges support from: (1). Fujian Education Department Education and Scientific
Research Project (JAT190600), (2) National Natural Science Foundation of China (41801393) and (3) Research
Foundation for Advanced Talents of Minjiang University (MJY19023).
Conflicts of Interest: The authors declare no conflict of interest.

References
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Hua, J.; Shaw, R. Corona Virus (COVID-19) “Infodemic” and Emerging Issues through a Data Lens: The Caseof China. Int. J. Environ. Res. Public Health 2020, 17, 2309. [CrossRef] [PubMed]
Shaw, R.; Kim, Y.K.; Hua, J. Governance, technology and citizen behavior in pandemic: Lessons fromCOVID-19 in East Asia. Prog. Disaster Sci. 2020. [CrossRef]
Djlante, R.; Shaw, R.; DeWit, A. Building resilience against biological hazards and pandemics: COVID-19
and its implications for the Sendai Framework. Prog. Disaster Sci. 2020. [CrossRef]
WHO. COVID 10 Public Health Emergency of International Concern: Global Research and Innovation Forum; WHO:
Geneva, Switzerland, 2020; p. 7.
Chan, E.; Shaw, R. Overview of health-EDRM and health issues in DRR: Practices and challenges. In Public
Health and Disasters; Chan, E., Shaw, R., Eds.; Springer: Singapore, 2020; pp. 1–6.
Lo, S.T.T.; Chan, E.Y.Y.; Chan, G.K.W.; Murray, V.; Abrahams, J.; Ardalan, A.; Kayano, R.; Yau, J.C.W. Health
Emergency and Disaster Risk Management (Health-EDRM): Developing the Research Field within the Sendai
Framework Paradigm. Int. J. Disaster Risk Sci. 2017, 8, 145–149. [CrossRef]
Atenstaedt, R. Word cloud analysis of the BJGP. Br. J. Gen. Pract. 2012. [CrossRef] [PubMed]
Garfield, E. Scientography: Mapping the tracks of science. Current Contents Soc. Behav. Sci. 1994, 7, 5–10.
Munoz-Leiva, F.; Viedma-del-Jesusu, M.; Sanchez-Fernandez, J.; Lopez-Herrera, A. An application of co-wordanalysis and bibliometric maps for detecting the most highlighting themes in the consumer behaviour
research from a longitudinal perspective. Qual. Quant. 2011. [CrossRef]
Chen, X.; Chen, J.; Wu, D.; Xie, Y.; Li, J. Mapping the research trends by co-word analysis based on keywords
from funded project. Procedia Comput. Sci. 2016, 91, 547–555. [CrossRef]
WHO. A Coordinated Global Research Roadmap: 2019 Novel Coronavirus; WHO: Geneva, Switzerland, 2020;
p. 36.

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17 of 17WHO. Health Emergency and Disaster Risk Management Framework; WHO: Geneva, Switzerland, 2019.
Casanova, G.; Principi, A.; Lamura, G. Social innovation in long-term care: Lessons from the Italian case. Int.
J. Environ. Res. Public Health 2020, 17, 2367. [CrossRef] [PubMed]
INGSA. INGSA COVID-19 Resources. 2020. Available online: https://www.ingsa.org/covid/resources/(accessed on 1 April 2020).
CODATA. Data Together COVID-19 Appeal and Action. 2020. Available online: https://codata.org/wpcontent/uploads/2020/03/Data-Together-COVID-19-Statement-FINAL.pdf (accessed on 5 April 2020).
© 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open accessarticle distributed under the terms and conditions of the Creative Commons Attribution(CC BY) license (http://creativecommons.org/licenses/by/4.0/).

British Medical Bulletin, 2020, 1–42
doi: 10.1093/bmb/ldaa030

Narrative review of non-pharmaceuticalbehavioural measures for the prevention of
COVID-19 (SARS-CoV-2) based on the
Health-EDRM framework
Emily Ying Yang Chan1,2,3,4,*, Tayyab Salim Shahzada3,4 ,Tiffany Sze Tung Sham3,4 , Caroline Dubois1,4 , Zhe Huang1,3 , Sida Liu1,4 ,Janice Ying-en Ho1 , Kevin KC Hung1,3,5 , Kin On Kwok3 , and Rajib Shaw6
1 Collaborating Centre for Oxford University and CUHK for Disaster and Medical Humanitarian Response(CCOUC), The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong,
Shatin, Hong Kong SAR, China, 2 Nuffield Department of Medicine, University of Oxford, Oxford OX37BN, UK,
3 JC School of Public Health and Primary Care, Prince of Wales Hospital, The Chinese University of Hong
Kong, Shatin, Hong Kong SAR, China, 4 GX Foundation, Quarry Bay, Hong Kong SAR, China, 5 Accident &Emergency Medicine Academic Unit, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong
Kong SAR, China, and 6 Graduate School of Media and Governance, Keio University, Fujisawa 252-0882,
Japan*Correspondence address. Rm 308, 3/F, JC School of Public Health and Primary Care, Prince of Wales Hospital, Shatin, Hong
Kong SAR, China. E-mail: emily.chan@cuhk.edu.hk
Editorial Decision 30 July 2020; Accepted 7 August 2020

Abstract
Introduction: Non-pharmaceutical measures to facilitate a response to the
COVID-19 pandemic, a disease caused by novel coronavirus SARS-CoV-2, areurgently needed. Using the World Health Organization (WHO) health emergency and disaster risk management (health-EDRM) framework, behavioural
measures for droplet-borne communicable diseases and their enabling andlimiting factors at various implementation levels were evaluated.
Sources of data: Keyword search was conducted in PubMed, Google
Scholar, Embase, Medline, Science Direct, WHO and CDC online publication
databases. Using the Oxford Centre for Evidence-Based Medicine review
criteria, 10 bottom-up, non-pharmaceutical prevention measures from 104© The Author(s) 2020. Published by Oxford University Press on behalf of Duke University School of Law, Harvard Law School, Oxford University Press, and Stanford Law School. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This is an Open
Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/
by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
For commercial re-use, please contact journals.permissions@oup.com

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Invited Review

2

E. Y. Y. Chan et al., 2020

English-language articles, which published between January 2000 and May
2020, were identified and examined.

Areas of concern: Strong evidence-based systematic behavioural studies for
COVID-19 prevention are lacking.
Growing points: Very limited research publications are available for nonpharmaceutical measures to facilitate pandemic response.
Areas timely for research: Research with strong implementation feasibility
that targets resource-poor settings with low baseline health-EDRM capacity
is urgently needed.
Key words: health-EDRM, behavioural measures, non-pharmaceutical, primary prevention, droplet-borne, biologicalhazards, COVID-19, SARS-CoV-2, coronavirus, pandemic

Introduction
Uncertainties in disease epidemiology, treatment
and management in biological hazards have often
urged policy makers and community health protection agencies to revisit prevention approaches
to maximize infection control and protection. The
COVID-19 pandemic, a disease caused by novel
coronavirus SARS-CoV-2, has pushed global governments and communities to revisit the appropriate
non-pharmaceutical health prevention measuresin response to this unexpected virus outbreak.1
The World Health Organization (WHO) healthemergency and disaster risk management (healthEDRM) framework refers to the structured analysis
and management of health risks brought uponby emergencies and disasters and was developed
based on the Sendai Framework for Disaster Risk
Reduction 2015–2030. The framework focuseson prevention and risk mitigation through hazard
and vulnerability reduction, preparedness, response
and recovery measures2 and further calls attention
to the significance of community involvement
to counteract the potential negative impacts ofhazardous events such as infectious disease outbreaks.2 While the framework does not provide

details on event-specific prevention, it is welljustified for primary prevention measures against
COVID-19, which is defined as a biological hazard
under the health-EDRM disaster classification.3
While there is evidence for potential COVID-19
droplet transmission,4 the WHO has suggested
that airborne transmission may only be possible
in certain circumstances4 and further evidence isneeded to categorize it as an airborne disease
specifically.
Health-EDRM prevention measures can beclassified into primary, secondary or tertiary levels.5
Primary prevention mitigates the occurrence of
illness through an emphasis on health promotionand education aimed at behavioural modification6 ; secondary prevention involves screening
and infection identification; tertiary prevention
focuses on treatment. In the context of COVID-19,
both secondary and tertiary preventive measures
are complicated due to the high incidence ofasymptomatic patients,7 the lack of consensus andavailability of specific treatment or vaccine8 and theadded stress on the health system during a pandemic.
Primary prevention that focuses on protecting

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Areas of agreement: Evidence-guided behavioural measures against transmission of COVID-19 in global at-risk communities were identified, including regular handwashing, wearing face masks and avoiding crowds andgatherings.

Non-pharmaceutical H-EDRM measures for COVID-19, 2020

Methodology
A literature search was conducted in May 2020.
English language-based literature published between
January 2000 and May 2020 were identified andincluded. Further literature was identified using
the references of those already reviewed. Typesof literature include international peer-reviewed
articles, online reports, commentaries, editorials,

electronic books and press releases from universities
and research institutions, which include expert
opinions. Grey literature published by the WHO,the US Centers for Disease Control and Prevention(CDC) and other local government publications andinformation outlets were also included. Literaturethat did not fulfil the criteria was excluded, for example peer-reviewed studies without English-language
abstracts.
Research databases examined in this study
included PubMed, Google Scholar, Embase, Medline
and Science Direct. The keywords and phrases
included in the initial search can be broadly categorized into three groups: those relating to the virus,
including variations of COVID-19 nomenclature,or relevant to broader respiratory viruses (suchas ‘COVID-19’, ‘SARS’, ‘enveloped viruses’); thoserelating to general disease prevention and management (such as ‘transmission’, ‘risk management’)and those relating to primary prevention measures(such as ‘handwashing’, ‘coughing and sneezing’,‘face masks’). The full list can be found in Appendix
1. Behavioural measures as well as risk factors for
infectious disease transmission were reviewed inorder to generate 10 common preventive measuresfor discussion. The avoidance of cutlery sharing,for example, was generated after determining it
as a highly preventable risk for infectious diseasetransmission. Each primary prevention measure
was summarized narratively according to the risk
factors, co-benefits, enabling and limiting factors
and strength of evidence. Three reviewers assessed
the studies independently and agreed on the final
research used.
The literature was categorized according to the
Oxford Centre for Evidence-Based Medicine Levelsof Evidence (Fig. 1),18 which systemizes strengthof evidence into levels, based on the process ofstudy design and methodology. Three reviewers
collectively engaged in and agreed on the final
categorization.
No new data were generated or analysed in support of this review.

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an individual from contracting an infection9 istherefore the most practical option. A comprehensive
disaster management cycle (prevention, mitigation,
preparedness, response and recovery) encompasses
both top-down and bottom-up measures.10,11 Topdown measures require well-driven bottom-up
initiatives to successfully achieve primary prevention
and effectively modify community behaviours.12
During and since the writing of this review, several
landmark publications have studied and addressed
the effect of non-pharmaceutical behavioural
measures in preventing the transmission of COVID19, generally concluding that while effectiveness anduptake of measures varied, behavioural change at
personal and population levels is key to effectively
control the spread of COVID-19.13 –17 The purposeof this narrative review is to highlight the feasibilityof implementing non-pharmaceutical preventive
measures within a population facing an emergency,
building on the health-EDRM framework, andtheoretical aspects of behavioural change presented
in other publications.
Based on the health-EDRM framework, whichemphasizes the impact of context on efficacy ofmeasure practices,3 this article examines available
published evidence on behavioural measures thatmight be adopted at the personal, household andcommunity levels for droplet-borne transmitted
diseases and enabling and limiting factors foreach measure. Additionally, this article reviews thestrength of available scientific evidence for each of
the behavioural changes, which may reduce healthrisks.

3

4

E. Y. Y. Chan et al., 2020

Results
The search identified 104 relevant publications, all ofwhich were reviewed and included in the results analysis. The search identified and grouped 10 common
bottom-up, non-pharmaceutical, primary prevention
behavioural measures, based on the health-EDRM
framework. The review of evidence is disaggregatedinto the 10 prevention measures.
Six ‘personal’ protective practices (engage inregular handwashing, wear face mask, avoid
touching the face, cover mouth and nose whencoughing and sneezing, bring personal utensils whendining out and close toilet cover when flushing), two‘household’ practices (disinfect household surfaces
and avoid sharing cutlery) and two ‘community’
practices (avoid crowds and mass gatherings andavoid travel) were identified. Tables 1–3 highlightthe potential health risk, desired behaviouralchanges, potential health co-benefits, enabling
and limiting factors and strength of evidence
available in published literature with regard to thesemeasures.
Of note, a number of the reviewed articles reportan assessment of more than one primary prevention
measure. The review results showed that ∼68% of
the studied literature was associated with personal
practices, 13% with household practices and 19%
with community practices. The measures of engaging
in regular handwashing, wearing face masks as well

as avoiding mass gatherings were among the mostcommonly studied preventive measures. Details ofeach utilized reference can be found in Appendix 2.

Discussion
Evidence relating to 10 common health-EDRM
behavioural measures for primary prevention against
droplet-borne biological hazards were identified
and reviewed. The information referenced here isbased on best available evidence and will need
to be updated as new studies and guidelines are
published, and the understanding of the scientificcommunity is enhanced. At the time of writing,there is an outstanding question as to whether
COVID-19 is transmitted through droplet or aerosolin the community. Following the writing of thisreview, certain areas of evidence have evolved.
On June 5, 2020, the WHO updated its official
guidance to recommend that face masks be wornby the general public as a preventive measureagainst COVID-19 transmission.122 The WHO had
previously recommended that masks be worn only
by healthcare workers and people confirmed to have
COVID-19, due to limited evidence that masks wornby health individuals may be effective as a prevention
measure.123 The knowledge and consensus within
the scientific community on COVID-19 continue to
evolve at an unprecedented rate.

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Fig. 1 The Oxford Centre for Evidence-Based Medicine (OCEBM) Levels of Evidence (adapted from www.cebm.net).18

Engage in regular handwashing

Wear face mask

Avoid touching the face

Risk

•

COVID-19 is transmittable through respiratory
fluid droplets4,19• Droplets can persist on hands and othersurfaces20• Droplets may be transferred if hands are notdisinfected• Respiratory droplets from other individuals
and hand-to-face contacts can result in
droplet intake through the nose andmouth4 ,21,22• Viruses have the potential to survive in the
respiratory tract.23 The virus may also enter
through ocular means, although studies
focusing specifically on COVID-19 arelimited24• COVID-19 has an incubation period of as
long as 19 days25 ; asymptomatic or mildly
symptomatic individuals may spread thevirus through coughing or sneezing• In 2010, WHO stated that where there is
improper mask usage, risk may increase26• Recent research has suggested
that nasal carriage27 andocular entry24 are key
alternative routes to oral entry
into the respiratory tract for
COVID-19• It has been demonstrated that
COVID-19 can be detected on
surfaces of plastic, stainlesssteel, copper and cardboard
for up to 72 hours20 after
contamination. Hand-to-facecontact following contact ofpublic surfaces may pose a risk

Behaviouralchange•Wash hands with soap25,28–34 for a minimum of
20 seconds using a step-by-step guideline suchas the WHO healthcare-based 11-stepguideline35• Wash hands before eating, after bathroom
usage, after mask removal, etc.
• Practice alternative handwashing routines aslong as they maintain the core principle of
ensuring that the entire surface area of thehands is scrubbed36• Ensure commonly missed areas are washed,such as the thumbs and fingertips37–40• Wear surgical face masks25,33,34,41–44 tocreate a physical barrier preventing the
spread or intake of the virus-containing
respiratory droplet (which are released bycoughing or sneezing) through facial
openings45• Wear face masks to minimize the touching of
the nose and mouth as these can serve astransmission routes for COVID-1921,46,22,4• Use face masks correctly to ensure the best
overall effectiveness, including one-timeusage; limiting usage to 1 day and avoid
touching the surface to minimize risk of
self-contamination47 ,48• Avoid touching the face tominimize the risk of
COVID-19 contact throughthe body’s main entry points
for transmittableconditions32 –34,41,49 : themouth, the eyes and the nose
• Exercise increased awarenessof this unwanted practice tominimize the risk of infection,
as self-touching of the face
may be spontaneous50 ,51

Continued

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Non-pharmaceutical H-EDRM measures for COVID-19, 2020
5

Table 1 (Part 1): Personal practices as preventive measure—risk; behavioural change; health co-benefits; enabling and limiting factors and strength ofevidence

Engage in regular handwashing

Wear face mask

Avoid touching the face

Co-benefit(s)• Prevention of other contact transmissible diseases
such as influenza,52 ,53 to some extent, diarrhoea54,55
and eye infections56• Potential for reduced infection transmission incommunity and household57•

Protection against other microbes
transmitted by respiratory droplets
through the nose, mouth or eyes24,27• Protection from air pollutants and otherair particles,58,59 which could cause otherrespiratory conditions60 such as asthma
and lung cancer61,62•

Enabling
factor(s)• Availability and affordability of sufficient runningwater, soap, and alcohol-based rubs••

Access to effective face masks
Information about the correct use of facemasks, including proper disposal• Information about when to wear
facemasks• Socio-cultural acceptance and habit on
wearing face masks (global East vs. West)•

Effectiveness may be limited for
infants, children and others who
do not have sufficient conscious
control of body movement

Limiting
factor(s)and/oralternative(s)• Alcohol-based formulas as an alternative; efficacy inkilling enveloped viruses has been demonstrated65• Use of ash and mud as an alternative in areas where
there is no access to soap or alcohol-based rubs.
Although these carry potential antimicrobial
properties,66 their efficacy in counteracting viral
infections is not well-evidenced67• Sharing and reusing water or water containers, inareas lacking running water, elevate the risk oftransmission through droplets.

•

For those who cannot access surgical facemasks, due to affordability, availability orotherwise, homemade masks69
accompanied with the same hygienic
measures can be considered70•

Where face touching is necessaryor difficult to control, forexample in infants or children,
handwashing will be a more
effective prevention measure

Minimizes contracting diseases
with similar transmission
pathways such as influenza49 ,63• Reduce risk of transferring
bacterial pathogens found on
hands64

Continued

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6
E. Y. Y. Chan et al., 2020

Table 1 (Part 1) Continued

Engage in regular handwashing
Strength ofevidence

•

•

•
•

•

•

•

Published evidence showed handwashing is a corecommunity prevention measure for COVID-19
transmission
Handwashing communities display lower risks ofdeveloping transmittable diseases when compared totheir non-handwashing counterparts, in both rural66
and urban populations71
The measure is recommended by multiple governing
bodies, including the WHO41 and CDC42
Studies from Severe Acute Respiratory Syndrome(SARS), although not conclusive, are suggestive ofhandwashing as an effective measure72
20 seconds may be considered a minimum duration
given that time reductions, for example to 5
seconds,73 have been demonstrated as less effective
Soap and alcohol-based rubs are well evidenced intheir capability to interact with and degrade
enveloped viruses43,65
Evidence of ash or mud-based alternatives as
antimicrobials is limited; no concrete evidence withrespect to efficacy against COVID-19 or other viral
infections was identified

Wear face mask

Avoid touching the face

• Multiple extensive studies on the similar
SARS coronavirus concluded that there isevidence of effective transmission risk
reduction28–30,74• Success of Hong Kong and Taiwan’s highcompliance to mask-wearing practices75
has been potentially reflected in the low
rate of locally infected cases of
COVID-19,76 with both communities
having reported periods of no new
infections despite initial surges77• Used in conjunction with other practices
such as social distancing, a model
simulation demonstrated
community-wide benefits ofmask-wearing78• Such measures have been
recommended for influenza inthe past31• There is strong evidence of viral
infections entering through thefacial entry points and has been
demonstrated for COVID-19,27 ,24
although evidence for the impactof face touching in diseasetransmission was not found• The stability of COVID-19 virus
on certain surfaces has been
evidenced. Similarly, previous
studies have demonstrated thestability of other coronaviruses
such as SARS, on such surfaces79

Continued

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Non-pharmaceutical H-EDRM measures for COVID-19, 2020
7

Table 1 (Part 1) Continued

evidence
Cover mouth and nose when coughing andsneezing
COVID-19 is transmittable through droplets19
and has the potential to remain stable onsurfaces up to 72 hours.20 Open coughing,sneezing, and talking may directly or indirectlytransmit COVID-19.49 Research suggests thatsuch pathogen-bearing droplets can travel up
to 7–8 m80

Risk

•

BehaviouralchangeCough/sneeze into tissue paper that is disposed
immediately• Replace mask after a major sneeze• Cough or sneeze into elbow or shirt if mask or
tissue is unavailable89• These practices25,30,34,41–43 minimize droplet
landings on the hands, which are most likely tocome into contact with oneself and othersurfaces. Hands should be disinfected after
coughing or sneezing

Co-benefit(s)••Minimizing risk of other droplet-transmittablediseases49

Bring personal utensils when dining out

Close toilet cover when flushing

There is a high possibility of
COVID-19 transmission through saliva
droplets81,82 in instances where publicutensils are not sufficiently
disinfected83,84•

Avoid food consumption with publicutensils, or utensils that have not been
confirmed to be disinfected• Use personal utensils34,90,91 that havebeen appropriately disinfected for foodconsumption•

Prevention of other diseases that aretransmitted through saliva63

•

•

•

•

There is growing evidence of
COVID-19 being present instool after clearance throughthe respiratory tract85,86• Virus particles present in stool
can be transmitted throughtoilet plume generated after
flushing,87 ,88 especially if the
toilet is unclosed
Cover toilets prior to flushing,both at home and in public• Avoid public toilets during
such a pandemic, especiallythose with toilets lacking lids92

Improved household hygieneand protection from pathogens
present in stool, such asbacterial or norovirus
infections causing
gastroenteritis88
Continued

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8
E. Y. Y. Chan et al., 2020

Table 1 (Part 2): Personal practice as preventive measure—risk; behavioural change; health co-benefits; enabling and limiting factors; and strength of

Cover mouth and nose when coughing and sneezing

Bring personal utensils when dining out

Close toilet cover when flushing

Enabling
factor(s)••Access to masks and tissue
Adequate mobility and reaction to raise elbow or
tissue to the face

• Access to personal reusable or single-use
utensils• Access to a toilet with afunctional lid

Limiting
factor(s)and/oralternative(s)•People with limited mobility, such as the elderly,93 ,94
may not be able to react in time. The alternative is tomaximize mask wearing as a permanent physicalbarrier• May not be applicable to contexts where
eating with hands is the tradition.
Handwashing should be the primarypreventive measure in these contexts• Where personal utensils are not available,
single-use utensils can be considered,although there are environmental
implications of disposable utensils95,96• Another study has suggested that
due to space between the lid andthe toilet bowl, shutting the lid
may not impede emissions
entirely97• For households lacking lidded
toilets, other protective measures
include regular cleaning; wearinga face mask during toilet usage
and avoiding sharing toilets

Strength ofevidence

There is strong evidence supporting the transmissionof COVID-19 through respiratory droplets, which canbe expelled in sneezing and coughing32 ,98,99• Some evidence indicates that wearing a mask redirects
coughed particles to a less harmful
direction44 —similar outcome may be inferred fortissue or elbow blockage, although it may not be aseffective• There is lacking evidence on how each of the
behavioural changes contribute to risk reduction for
COVID-19 specifically• There is no specific evidence of
COVID-19 transmitting through public
cutlery• Limited evidence suggesting restaurants
or caterers fail to properly disinfect theirreusable cutlery• Although this has not been
directly confirmed, there is
growing evidence that COVID-19
may be present in stool• There is evidence that toilet
plumes ascend when toilets
remain open
• This measure has been suggested
by authorities in places such as
Hong Kong33•

Continued

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Non-pharmaceutical H-EDRM measures for COVID-19, 2020
9

Table 1 (Part 2) Continued

10

E. Y. Y. Chan et al., 2020

Table 2 Household practices as preventive measure—risk; behavioural change; health co-benefits; enabling
and limiting factors and strength of evidence
Disinfect household surfaces

Avoid sharing utensils

Risk• COVID-19 has varying stability on different
household surfaces, including metal, wood,glass, plastic, paper and steel.100• Personal belongings such as mobile phones
and laptops have been shown to carry a highload of bacteria101,102 due to inadequate
cleansing and lots of hand contact. The same
may apply for virus particles

Studies have previously demonstrated
cutlery sharing practices as a risk for oraltransmission103• Due to the high possibility of COVID-19
transmission through saliva droplets,81,82 it
may pose similar risk
• There is additional unknown risk due topotential for asymptomatic transmission25

Behavioural change• Disinfect households regularly,29 ,30,32–34,42
especially frequently touched objects andsurfaces,48 with biocidal agents such as
62–71% ethanol, 0.1% sodium hypochlorite
or 0.5% hydrogen peroxide79• Use a dilution of 1:50 bleach for generalhousehold disinfecting of flooring anddoors79• Disinfect smaller objects, such as keys, or
surfaces that come in contact with the faceand mouth, such as mobile phones, with
62–71% ethanol or alcohol wipes instead,79
due to potential hazards from bleach104•

Co-benefit(s)• Improved general household hygiene, such as
mould reduction105,106• Opportunity for mild physical activity tocompensate for lack of outdoor exercise
during COVID-19 social isolation•

Enabling factor(s)• Access to proper disinfectants• Knowledge on safe use and storage ofdisinfectants••

Availability of serving utensils
Cultural appropriateness, such as when
seating in settings where such sharing is
expected

Limiting factor(s)and/oralternative(s)• Where resources are limited, households
should use the best disinfectant possible,
reduce the frequency of disinfection or target
frequently touched surfaces such as door
handles•

Where appropriate, hand consumption after
adequate handwashing may be considered
to avoid utensil sharing. Proper
handwashing practices must be observed

Strength of evidence• Studies exist on the effectiveness of various
household disinfectants against other viruses,
including coronaviruses79• Evidence on the effectiveness against
COVID-19 specifically is lacking••

Reduced risk of other saliva-transmitted
bacteria while utensil sharing90• Reduced risk of dental caries
transmission107

Given its transmission through droplets,19
and persistence in saliva,81 this prevention
measure should be considered good practice• This measure was recommended by the
CDC during the 2003 SARS outbreak.34• There is no study on the impact of utensil
sharing on COVID-19 specifically• Studies have noted potential spread of H.
pylori via shared chopsticks91

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Avoid sharing of utensils or serving foodfrom a communal dish with used utensils• Use designated serving utensils to prevent
saliva-based droplet transmission• Maintain hygiene practices, such asadequate cleaning of all utensils

11Non-pharmaceutical H-EDRM measures for COVID-19, 2020

Table 3 Community practice as preventive measure—risk; behavioural change; health co-benefits; enabling andlimiting factors and strength of evidence
Avoid crowds and mass gatherings

Avoid travel

Risk• Crowded areas with unknown people areconsidered high risk due to risk of droplet
transmission and infection throughcontaminated surfaces• Talking can potentially result in respiratory
infectious disease transmission108• Possibility of transmission by asymptomatic
carriers within a crowd increases risk109

Travelling to areas with confirmed
cases will increase an individual’s riskof potential exposure to COVID-19• The stability of the virus on
surfaces,20 the potential prevalence ofasymptomatic carriers,109 thedifficulty and lack of distancing,110
shared toilets and risk of toilet
plume86 and uncertain travel historyof others make environments. such as
trains and aeroplanes, challenging interms of protection and high risk interms of COVID-19 transmission

Behaviouralchange• Observe social distancing
measures4,19,25,32–34,42,78,111• A separation of 1 m is the minimum asrecommended by the WHO.41 Although most
droplets may not travel across this distance,
novel studies exploring the influence of
aerodynamics112 as well as the potential forsneezes to travel up to 8 m80 have led to therecommendation that possible distancing should
be maintained wherever possible• Avoid congregating and take precaution when in
public areas such as parks, cinemas andrestaurants. These areas should make face mask
wearing mandatory, carry out temperaturechecks, limit the number of people in attendance
and practice distancing of people•

Co-benefit(s)• Reduced outdoor pollution due to minimized
outdoor human activity.113 ,114
Lower exposure to outdoor air pollution, whichcauses respiratory illnesses such as lung cancer
and contributes to mortality60,115

Reduction of cross-bordertransmission111• Improved general hygiene ontransport such as trains or aeroplanes• Environmental benefit from reduced
air-travel carbon footprint116

Enabling factor(s)• Ability to avoid crowded areas as permissible bypopulation density, occupation, religion or
culture•Limiting factor(s)and/oralternative(s)• Crowded areas may not be avoidable due tooccupation, religious necessities or otherwise.
Where gathering is necessary, individuals shouldtake personal responsibility to wear masks, keep
hands clean and maintain maximum distancefrom others

Access to facemasks, goggles or
alcohol-based solution for personal
protection during travel• The necessity of travel, for personalor professional reasons, such as pilots
and the cabin crew••

Ability to make decisions on when or
how to travel•

Continued

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Avoid travelling to areas withconfirmed cases, which are ofsignificant risk25,33,34• Take all necessary personal protective
measures such as wearing of facemasks, eye googles, disinfecting
immediate area with alcohol-based
solution and avoiding food sharing• Implementing (for authorities)
appropriate protective measures suchas mandatory temperature checks
prior to travel and/or upon arrival,
reporting the travel and medical
history of each traveller anddistancing requirements on transport

12

E. Y. Y. Chan et al., 2020

Table 3 Continued

Strength ofevidence

Avoid travel

Studies on influenza and COVID-19117
indicate a potential role of mass gathering
reduction in limiting transmission,118 thoughstudies are limited and not yet conclusive• There are also studies on the elevatedtransmission of other viruses as a result ofmass gatherings119 –121••

Although direct evidence on the efficacy of
COVID-19-specific prevention measures is lacking,largely due to the novelty of the disease, five
behavioural measures were identified: regular handwashing, wearing face masks, avoiding touchingof face, covering during sneezing or coughing
and household disinfecting. Five other potential
behavioural measures were also identified throughlogical deductions from potential behavioural risks
associated with transmission of diseases similar to
COVID-19.79 Utensil-related practices, in particular,
were heavily limited in evidence to support theirefficacy against viral infections.
The efficacy and success of the 10 bottom-up
behavioural measures reviewed here are subject tospecific enabling and limiting determinants, ranging from demographic (e.g. age, gender, education),socio-cultural, economic (e.g. financial accessibility
to commodities) and knowledge (e.g. understandingof risk, equipment use). The viability and efficacy ofeach measure may be limited by determinants andconstraints in different contexts. Resource-deprived
areas may face constraints and reduced effectiveness of implementation, especially for measures that
require preventive commodities such as face masks
and household disinfectants. As such, special attention should be given to rural settings, informal settlements and resource-deficit contexts where accessto information and resources such as clean watersupply are often limited,124,125 and sanitation facilities are lacking.126 For hygiene measures, different
alternatives should be promoted and their relative
scientific merits should be evaluated, such as the use

The proximity and contact withindividuals heighten the evidenced
risk of taking in potential respiratory
droplets containing COVID-19 fromothers• There is no clear evidence regarding
increased risk from aeroplane travel
specificallyof ash as an alternative to soap for handwashing67
or the efficacy of handwashing with alcohol sanitizer, which has been demonstrated in previously
published studies for H1N1127 and noroviruses128 but
not yet concretely for COVID-19. Meanwhile, formeasures that have no direct alternatives available,
it is important for authorities and policymakers tounderstand the capacity limitations of certain target groups and provide additional support or put
in place other preventive measures. In cases wherematerial resources are scarce, the measures of awareness on sneezing and coughing etiquette as well as
avoiding hand-to-face contact are the most convenient to adopt as they require little to no commodities. However, it should be well noted that these measures are likely the most challenging in complianceand enforceability, as they rely on the modification of
frequent and natural human behaviours whose modifications would require awareness and practice.50,51
Furthermore, these can be challenging to implement
in target groups with less capacity for health literacy
and translation of education into practice, such as
infants and elderly suffering from dementia. Cultural patterns can be associated with behaviouralintentions. In the case of avoiding utensil-sharing
during meals, enforcing change may be conflictedwith cultural and traditional norms in Asia andcertain European communities.129
Of the enabling factors documented for each
proposed measure, shared enablers can be identified: accessibility and affordability of resources;
related knowledge, awareness and understanding of
risk; and associated top-down policy facilitation.

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Avoid crowds and mass gatherings

Non-pharmaceutical H-EDRM measures for COVID-19, 2020

as travel bans and social distancing rules may drive
bottom-up initiatives within communities underlegal deterrence.135 However, in order to ensure
population-level compliance to recommendations
that have wide-ranging socioeconomic impact andinvolve more than a day-to-day behavioural change,
careful risk and information communication isrequired, which takes into consideration practical,
legal and ethical aspects. Research into promoting
behavioural change during the COVID-19 pandemic
have suggested that public health professionals,
policy makers and community leaders can enhancecompliance by creating a sense of motivation in
individuals rather than creating anxiety that canlead to defensive avoidance.16 Information should
be tailored and account for language, educationand health literacy, with input from stakeholders,such as community leaders, religious heads or allied
health workers, who can advise on how to enhance
understanding of risks and benefits, especially
if targeted at marginalized populations.16 ,17 It is
important to create a bipartisan, shared sense ofidentity and cooperative responsibility within the
population, for example using collective terms suchas ‘us’ or ‘we’ in risk communication, and using
interdisciplinary approaches that bring together
groups from different backgrounds, such as medical
practitioners, epidemiology experts, community
leaders and non-governmental agencies working at
the grassroots level.17
With regard to the strength of evidence available
in the reviewed literature (Table 4), the largest proportion of studies fell into Level 5 (69%) classification, which encompasses a range of study designs
and methodologies such as narrative reviews, experimental studies, modelling studies and expert opinions. Less than 1% of the identified resources wereclassified into ‘Others’, which includes the WHO
Dashboard for latest figures on COVID-19. Level
4 studies, such as cross-sectional studies and caseseries, contributed a relatively large portion (16%)
with many focusing on the disease progression andpatterns of specifically identified patients. The low
proportion of Level 1 studies (7%) compared to
Level 4 or 5 may be attributed to the novelty of

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Majority of personal and household practices heavily rely on access to resources, such as adequate waterand soap supply for regular handwashing, quality
face masks and household disinfectants. Various
theories of the ‘Knowledge, Attitudes, Practices’model have assumed that individual knowledge
enhancement will lead to positive behaviouralchanges.130 Health measures targeting mask wearing
might aim to enhance (i) the individual’s risk
perception, knowledge and awareness on protection
effectiveness of masks, and how to properly wear
a mask so that the prevention is most effective;(ii) an individual or community’s attitude towards
the practice of mask wearing and encouraging
compliance in the west, as studies demonstrate
a relatively greater social stigmatization towards
mask wearing among Westerners than East Asians131
and (iii) normalizing the practice of habitual mask
wearing. Such a conceptual framework should
be utilized in the implementation of the healthinitiatives. In terms of overarching knowledge,
health education on symptom identification is also
important, as seen on government platforms suchas the CDC.42 Enhancing health-seeking behaviourof potential carriers is critical to promoting a rapid
response for quarantine or hospitalization.
At the individual level, behavioural changes
have different sustainability potentials and limitations. Measures can also result in unintended
consequences. For example, regarding the improper
disposal of face masks132 and the incorrect useof household disinfectants,133 careful monitoringis critical in order to maximize impact while
minimizing further health and safety risks. Topdown policy facilitation and strengthening of
infrastructure will be essential for effective implementation. Top-down efforts in resource provision,
such as the distribution of quality masks to all
citizens by the government or similar authority,134enhance personal and household capacities tomitigate infection risks. Regarding compliance, theeffectiveness of community practices, such as crowd
and travel avoidance, is highly dependent on theneeds and circumstances of an individual and acommunity. More assertive top-down policies such

13

14

E. Y. Y. Chan et al., 2020

Table 4 Overview of behavioural measures against COVID-19 transmission in the reviewed articles, categorized
by the OCEBM Levels of Evidence (See Appendix 2 for details)
Category

Householdpractices

Community
practices

Total

Number of referenced articles per OCEBM categorization level
1a

1b

1c

2a

2b

2c

3a

3b

4

5

OthersTotal

Engage in regular
handwashing

4

5

0

0

1

0

2

2

3

17

0

34

Wear face mask

0

2

0

0

1

0

0

2

7

18

1

31

Avoid touching the
face

0

0

0

0

2

0

0

0

1

10

0

13

Cover mouth and nose 0
when coughing andsneezing

0

0

0

0

0

0

0

2

15

0

17

Bring personal utensils 0
for when dining out

0

0

0

0

0

0

0

2

8

0

10

Close toilet coverwhen flushing

0

0

0

0

0

0

0

0

2

6

Disinfect household
surfaces

0

0

0

0

0

0

0

1

1

11

0

13

Avoid sharing utensils

0

0

0

0

1

0

0

0

4

4

0

9

Avoid crowds andmass gatherings

0

0

0

0

0

0

0

0

2

21

0

23

Avoid travel

0

0

0

0

0

0

0

3

6

0

9

4

7

0

0

0

2

5

27

116 1

5

8

167∗

OCEBM, Oxford Centre for Evidence-Based Medicine.
∗ Some of the 104 publications are referenced against more than 1 of the 10 primary preventive measures.

COVID-19. Higher level studies generally involve
more rigorous and stringent methodologies, which
would inevitably require more time.
Regarding individual primary prevention measures, evidence is most lacking at all levels for thepractices involving avoidance of utensil sharing(5%), bringing personal utensils (6%), travel
avoidance (5%) and the closing of toilet lids
when flushing (5%). On the other hand, most of
the available evidence supports measures such as
handwashing (20%), wearing face masks (19%)
and avoiding crowds (14%). Literature relevant

to regular handwashing was the strongest in termsof study design, with 26% of the total literature
identified for this particular practice being Level 1
studies and 82% of all Level 1 studies identified
being associated with regular handwashing. In thecase of a novel or emerging disease such as COVID19, there is limited available evidence that can be
related specifically to the disease and pandemic,
but some findings are deduced from studies onother similar viral infections and transmittableconditions, such as SARS or Influenza. Manymeasures proposed by health authorities are not

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Personal
practices

Primary preventive
measureNon-pharmaceutical H-EDRM measures for COVID-19, 2020

spectrum of terms relating to behavioural measures.
For community practices, the terms searched
included ‘mass gathering’ and ‘social isolation’ but
not ‘travel restriction’, although limiting travel waslater identified as a standalone measure throughreviewing the literature search results. Publications
documenting the experiences of traditional, nonEnglish-speaking, rural communities during the
COVID-19 pandemic may not have been identified
in this review. Further research should review theefficacy of various measures in different contexts andmake comparisons with their alternative measures.
Specifically, alternative preventive measures that canbe practiced in resource-poor, developing communities, whose health systems and economies generally
suffer the greatest impact during pandemics, areurgently needed. Increased understanding of how
to effectively mitigate against biological hazards
such as COVID-19 in various contexts will help
communities prepare for future outbreaks and build
disaster resilience in line with the recommendations
from the health-EDRM framework.
Despite the constraints, this review has nevertheless identified common, relevant behavioural measures supported by best available evidence for thedesign and implementation of health policies thatprevent droplet-borne biological hazards. Many ofthe measures recommended by authorities during
the pandemic are based on best practice available
rather than best available evidence. The possibilityof conducting large cohort or randomized controlled
studies is often complicated, and rather infeasible
during a pandemic, as noted for face masks.136 ,137
Further studies are needed to understand the efficacy
of frequently proposed measures for transmission
risk reduction. Nonetheless, each of the measures
identified has scientific basis in mitigating the riskof droplet transmission,19 either through personalmeasures such as handwashing or community-based
measures that aim to reduce person-to-person contact. The 10 measures identified in this review constitute only a portion of those non-pharmaceuticaland primary preventive behaviours that can mitigate against the transmission of a droplet-borne
disease and do not represent the entire spectrum

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based on rigorous population-based longitudinalstudies. While handwashing is well regarded as acore measure by global and national public healthagencies such as the WHO41 and CDC,42 andthe chemical properties of eliminating enveloped
viruses is well understood,43 ,65 specific studies on
the efficacy of practice and impact on COVID-19
transmission are lacking. Due to the uncertainties of
disease pathology and epidemiology, effectiveness of
behavioural measures against COVID-19 is far fromconclusive. Other uncertainties are also reported
on virus surface stability20 and whether the efficacy
of disinfectants against surface-stable viruses mayvary with COVID-19.79 Similar deductive evidence
approaches from studies on other viruses havebeen utilized to judge the efficacy of face masks
or the closing of toilet lids.87,88 Although publishedevidence suggested individual measures such as
covering coughs and sneezes to be helpful against
droplet transmissions,19 further research is needed
to understand the true efficacy of coverings such asmasks, tissues or elbows as an adequate preventive
measure against COVID-19.
Given the rapid knowledge advancement andresearch updates related to COVID-19, further study
updates will be warranted to identify the most appropriate behavioural measures to support bottomup biological hazard responses. Cost-effectivenessof the measures, their impact sustainability, cobenefits and risk implications on other sectors should
also be examined and evaluated. Standardized
studies across different contexts should be enhanced,
for example conducting tests on the efficacy ofdifferent disinfectants or soaps under a standardized
protocol. Such studies would increase evidence
on individual and comparative efficacy of the
behavioural measures.
The limitations in this review include language,
database inclusion, online accessibility of thearticle, grey literature and informal publication
outlets, and missed keywords. Search terms were
determined using variations of terms for COVID19 or respiratory viruses, as well as a numberof preventive practices that are well documented.
However, search terms did not encompass the full

15

16

environmental and community management expertise to develop a coordinated and comprehensive
approach in this globalized world.

Acknowledgement
The authors wish to thank Dr Ryoma Kayano, from the
WHO Centre for Health Development, for his valuable input
and support into this publication.

Conflict of interest statement
The authors declare no conflicts of interest.

Funding
The study is fully funded by the CCOUC-Universityof Oxford research fund (2019–2023).

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Downloaded from https://academic.oup.com/bmb/advance-article/doi/10.1093/bmb/ldaa030/5919554 by guest on 30 October 2020of either non-pharmaceutical or primary prevention
measures. Alternatively, the measures identified here
can also fall into other subsets such as ‘biologicalhazard prevention’ or ‘community outbreak prevention’. It is important to explore the efficacy ofalternatives, notably for transmission prevention andrisk communication in low-resource or developing
contexts where the capacity of the health system tomitigate and manage outbreaks is weak. For example, while face masks are understudied, the scientificstudy of cloth masks as an alternative is severely limited,70 although recommended by the CDC.138 Suchalternative studies should expand to consider different cultures and contexts where different varieties of
disinfectants, face masks and utensils may be used.
There is also potential for comparative effectivenessstudies to explore measures that provide the greatest
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23

Non-pharmaceutical H-EDRM measures for COVID-19, 2020

Appendix 1. Keywords and phrases searched, by subject grouping

Subject group
Virus

Keyword or phrases searched
COVIDspecificPublic Health

Epidemiology

Prevention andmanagement

Primary
prevention
practices

Personal

HouseholdCommunity

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Other related
viruses

COVID-19
SARS-CoV-2
COVID-19 stability
2019-nCOV
SARS-CoV-2 entry points
COVID-19 policies
WHO COVID-19
CDC COVID-19
COVID-19 advice
Ethics COVID-19
Droplet transmission
Virus
Coronavirus treatment
Severe acute respiratory syndrome
SARS
Coronavirus
Enveloped viruses
Respiratory virus
Respiratory hygiene
Respiratory emission
Epidemiology
Transmission
Virus stability
Virus transmission
Host responses to virus
Virus outbreak
Health-EDRM
Risk management
Global healthPrevention
Infection risk reduction
Hygiene education
Air pollution
Handwashing
Pollution mask
Face masks
Rural handwashing
Face touching
Coughing and sneezing
Toilet plumeDisinfection
Biocidal agents virus
Utensil sharing risk
Cutlery sharing risk
Phone hygiene
Sodium hypochlorite disinfection
Open defecation
Mass gatherings
Social isolation
Quarantine
Social distancing

Ref. Title
No.
4

19

Journal or
publication

Modes of Transmission WHO Scientific
Briefof Virus Causing
COVID-19:
Implications for IPC
Precaution
Recommendations
COVID-19: A Call for
Physical Scientists
and Engineers

Date ofpublication

Relevant
measure(s)(See Key 1)

OCEBM Level of Evidence
based on study design (SeeKey 2)

Relevant key finding(s) and/or conclusion

March 2020

A, B, I

Level 5: Expert opinion on
precaution recommendations,using research on thecharacteristics of COVID-19••

AmericanApril 2020
ChemicalSociety NANO

A, D, H, I

Level 5: Expert opinion basedon clinicians’ experiences andknowledge; presentation ofquestions, hypotheses andresearch needs regarding
COVID-19

•

•

•

20

Aerosol and Surface
Stability of
SARS-CoV-2 asCompared with
SARS-CoV-1

The New
England
Journal of
Medicine

April 2020

A, C, D, J

Level 5: An in vitro study of the •surface stability of the
SARS-Cov-2 strain comparedto SARS-CoV-1•

21

Community
Transmission of
Severe AcuteRespiratory
Syndrome
Coronavirus 2,
Shenzhen, China,
2020

Emerging
Infectious
DiseasesJune 2020(EarlyRelease)B

Level 4: A case series on
confirmed COVID-19 studied
in order to understand thepattern of community
transmission••

With knowledge of droplet
transmission (and particle size), droplet
and contact precautions arerecommended for COVID-19
Importance of PPE and other practices
such as frequent hand hygiene isindicated
Elucidates basic biology of viruses andtheir transmission and infection
pathway
Importance of handwashing andhygiene is demonstrated via
explanation of the need to deactivate
released virions before they reach a
host
Identifies the major complications andunderstandings associated with current
measures such as PPE and surface
sanitization and makerecommendations accordingly
SARS-CoV-2 has similar surface
stability compared to SARS-CoV-1
under experimental circumstances
Demonstrates stability on surfaces
such as plastic and stainless steel withpotential for aerosol and fomitetransmission
COVID-19 became endemic to
Shenzhen. Community, intrafamily andnosocomial transmission routes were
found.
Maintenance strategies are derived,such as minimizing public activity,
using personal protection measures andthe importance of early screening,
diagnosis and isolation
Continued

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24
E. Y. Y. Chan et al., 2020

Appendix 2. Relevant measure(s), study design, relevant key finding(s) and/or conclusion of each utilized referenceRef. Title
No.

Date of
Relevant
OCEBM Level of Evidence
publication
measure(s)based on study design (See(See Key 1)
Key 2)

Relevant key finding(s) and/or conclusion

The Lancet
A Familial Cluster ofPneumonia
Associated with the2019 Novel
Coronavirus
Indicating
Person-to-Person
Transmission: A
Study of a Family
Cluster
EuropeanTropism and Innate
Host Responses ofRespiratory
JournalInfluenza A/H5N6
Virus: An Analysis of
Ex Vivo and In Vitro
Cultures of the
Human RespiratoryTract2019-nCoV
The Lancet
Transmission
Through the OcularSurface Must Not Be
IgnoredFebruary
2020

B

Level 4: A case series exploring
epidemiological, clinical,
laboratory, radiology andmicrobiological findings of afamily cluster of (initially)
unexplained pneumonia• Indicating person-to-persontransmission via nosocomial andintrafamily means• Noted that many findings were similar
to those of SARS patients in 2003
• One patient was initiallyasymptomatic—suggestion for earlytracing, quarantine and control
measures

March 2017

B

Level 5: An in vitro study on
tropism, replicationcompetence and cytokine
induction of virus isolates incultures (Ex Vivo and In
Vitro) derived from humanrespiratory tract• Human H5N6 virus adapted to human
airways, indicating a risk pattern for
the virus upon entry into respiratory
tract

February
2020

B

Level 5: An ophthalmologist’s
expert perspective on
additional risk throughmucous membrane of eyes

25

Presumed
Asymptomatic
Carrier Transmissionof COVID-19

Journal of theAmerican
Medical
Association

February
2020

A, B, D, I, J,
H

Level 4: A case series on afamilial cluster of five patientswith COVID-19

26

Emergencies
Preparedness,
Response: What Can
I Do?

WHO

January
2010

B

Level 5: A compilation of
information on pandemic
response (2009 H1N1)
protective measures• Suggestion for consideration of studies
into conjunctival scrapings to look forsigns of ocular transmission• Ophthalmologists must wear
protective eyewear when examining
suspect cases• There is a potential mechanism of
COVID-19 transmission via an
asymptomatic carrier• Further study on the relevantmechanism is suggested• Regarding masks specifically, itsuggests that masks are only needed if
you are sick
• Remarks on the importance of propermask-wearing practice if the measure isadopted

22

23

24

Journal or
publication

Continued

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Non-pharmaceutical H-EDRM measures for COVID-19, 2020
25

Appendix 2. Continued

Date ofpublication

Relevant
measure(s)(See Key 1)

OCEBM Level of Evidence basedon study design (See Key 2)

Relevant key finding(s) and/or conclusion

SARS-CoV-2 Entry Nature
Medicine
Factors Are
Highly Expressedin Nasal Epithelial
Cells Together
with Innate
Immune Genes
Journal of
Use of Disposable
Epidemiology
Face Masks forandPublic HealthCommunityProtection against
HealthSARS

April 2020

B, C

Level 5: A study on SARS-CoV-2
tropism study via study of
expression of viralentry-associated genes• Genes found to be co-expressed in nasal
epithelial cells, indicating a role in the initial
phase of viral infection, spread and clearance

April 2004

A, B

29

SARS Transmission, Emerging
Infectious
Risk Factors, andDiseasesPrevention in
Hong Kong

April 2004

A, B, G

30

Respiratory
Infections during
SARS Outbreak,Hong Kong, 2003

Emerging
Infectious
DiseasesNovember
2005

A, B, D, G

Level 5: Expert opinion on the use • States that protection against SARS for
healthcare workers is different from the generalof face masks and practice of
public, as the latter is not subject to continuous
personal hygiene as important
exposure to droplet transmission from anmeasures to protect the general
infected patientpublic from SARS
• Expresses reduced risk of aerosol droplet
transmission with masks• Notes importance of proper usage and frequentchanging of masks• Also extends to mention importance of otherpersonal hygiene practices such as handwashing
due to survival of the virus on surfaces
Level 3b: A case–control study to • Concluded that risk factors for SARS infection
include visiting mainland China, hospitals andcompare SARS case patientsthe Amoy Gardens (an estate with a SARS
with undefined sources ofoutbreak)infection with community• Indicates that frequent mask use in public
controls
venues, frequent handwashing and household
disinfection were prominent protective factors
Level 4: A cross-sectional study to • No direct causal relationship was established• However, the study suggests a positive
compare the proportion of
association between reduced
respiratory virus-positive
influenza/respiratory infection incidence andspecimens in 2003 and those
population-based hygienic measures includingfrom 1998 to 2002
face mask wearing, hand washing after contact
with potentially contaminated objects, using
soap for handwashing, mouth covering whensneezing or coughing and household
disinfection

Ref. Title
No.
27

28

Journal or
publication

Continued

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26
E. Y. Y. Chan et al., 2020

Appendix 2. Continued

Ref. Title
No.

Journal or
publication

Date ofpublication

Relevant
measure(s)(See Key 1)

OCEBM Level of Evidence basedon study design (See Key 2)

Relevant key finding(s) and/or conclusion

31

Controlling the Novel A The Journal of
Hospital(H1N1) Influenza
Infection
Virus: Don’t TouchYour Face!

November
2009

A, C

Level 5: A letter to the editor on a •study of surface swab specimensfrom patients with confirmed•
influenza A

32

Stopping the Spread of
COVID-19

March 2020

A, C, D, G, I

Level 5: A set of guidelines withpotential measures to stop the
spread of COVID-19

33

Prevention ofCoronavirus Disease2019 (COVID-19)

May 2020

34

Fact Sheet for SARS
Patients and Their
Close Contact

2003
Centres for
Disease Control
and Prevention

35

WHO Guidelines on
Hand Hygiene in
Health Care

WHO

36

Simplifying the World
Health Organization
Protocol: 3 Steps
Versus 6 Steps for
Performance of Hand
Hygiene in a
Cluster-Randomized
Trial

Clinical Infectious August 2019
DiseasesA, B, C, D, F, G, Level 5: A set of guidelines with
I, J
information related to
COVID-19 such as prevention
suggestions and clinical featuresof the coronavirus
A, B, C, D, E, F, Level 5: A set of guidelines with
H, I, J
information related to SARS
such as symptoms, mode oftransmission and prevention
measures
A
Level 5: An extensive
evidence-based guideline on thepractice and science behind
handwashingA
Level 1b: A cluster-randomized
trial assigning three-step versus
six-step handwashing protocol

Journal of theAmerican
Medical
Association
Hong Kong
Centre for
HealthProtection

2009

•

•

•

•

•

Indicates that virus strains of influenza A
are found in surfaces such as bed rails,
walls and sofas
Further implies the importance of handhygiene, droplet and contact precautions
and behavioural conditioning such as
avoiding touching of the nose, eye or
mouth to prevent and control influenza
Different methods of infection prevention
including hand hygiene, social distancing,household disinfection and generalpersonal hygiene are suggested
Prevention advice such as mask wearing,
avoidance of face touching, coveringmouth and nose, putting the toilet lid
down when flushing and general traveladvice is suggested
Personal protection measures, such as the
avoidance of silverware sharing,handwashing and covering mouth andnose when coughing or sneezing, arerecommended
Extensive findings on best handwashingpractice and efficacy of soap-based
washing and alcohol against enveloped
viruses
Findings suggest that both significantly
reduced the bacterial colony (with nosignificant difference between the two)but that the three-step guidelines had
higher compliance
Quantity of steps is not of great concern
as long as areas are covered

Continued

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Non-pharmaceutical H-EDRM measures for COVID-19, 2020
27

Appendix 2. Continued

Ref. Title
No.

Journal or
publication

Date ofpublication

Relevant
measure(s)(See Key 1)

OCEBM Level of Evidence based on Relevant key finding(s) and/or conclusion
study design (See Key 2)

August 2019

A

Level 4: A cross-sectional study
looking at a cohort in Hong Kongand their handwashing and handhygiene practices

A

Level 1a: A systematic review of
RCTs and quasi-randomized trials(+others). Studies observed ratesof handwashing with soap invarious populations and scenarios
Level 2b: An individual cohort study • Certain areas of the hand achieved lower
areas of compliance during handwashingobserving hand hygiene techniques
over a period of 5 months

37

The Common Missed
Journal of
Handwashing Instances
Environmental
and Areas after 15 Yearsand Publicof Hand-Hygiene
Health
Education

38

Hygiene and Health:
Systematic Review ofHandwashing Practices
Worldwide and Updateof Health Effects
Assessment of Hand
Hygiene Techniques
Using the World HealthOrganization’s Six Steps
Bacteriological Aspects ofHand Washing: A Key
for Health Promotion
and Infections Control
Coronavirus Disease(COVID-19) Advice for
the Public

Tropical Medicine May 2014
and International
HealthHow to Protect Yourself& Others

39

40

41

42

• Indicates several areas of the hands which
are commonly missed, as well as occasions
during which handwashing should be
performed• Relationship between age or education andhand hygiene practice is indicated• Significant global problem regarding poor
practice of handwashing after contact withexcrete is found

Journal of
Infection andPublic Health

December 2015

A

International
Journal ofPreventative
Medicine
WHO

March 2017

A

Level 3a: A systematic review ofcase–control studies• Handwashing can reduce infectious agent’s
transmission in the community andhealthcare settings

April 2020

A, B, C, D, I

Level 5: Expert opinion on personal
protection from COVID-19 suchas safe use of alcohol-based handsanitizers

Centres for Disease April 2020
Control andPrevention

A, B, D, G, I

Level 5: Expert opinion on how
COVID-19 spreads and personal
protection measures for
COVID-19• Informs the public of the importance ofactions such as regular handwashing withsoap and water; cleaning hands withalcohol-based rub; social distancing;
avoiding crowds; avoiding eye, nose, mouth
touching; covering mouth and nose; staying
home and health-seeking behaviour under
the pandemic• Precautions on alcohol-based hand sanitizer
use are also mentioned• Informs the public of person-to-person
spread of the virus, the lack of vaccine toprevent COVID-19 and the importance ofactions such as regular handwashing withsoap and water, avoiding close contact,covering mouse and nose with a cloth facecover, covering coughs and sneezes, as well
as cleaning and disinfecting frequently
touched surfaces and households under the
pandemic
Continued

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28
E. Y. Y. Chan et al., 2020

Appendix 2. Continued

Ref. Title
No.

Journal or
publication

Date ofpublication

Relevant
measure(s)(See Key 1)

OCEBM Level of Evidence based on Relevant key finding(s) and/or conclusion
study design (See Key 2)

43

The Journal of
Hospital
Infection

March 2020

A

Level 5: Expert opinion on theimportance of practicing
respiratory and hand hygiene, as
well as using personal protective
equipment in healthcare settings

Hand Hygiene and theNovel Coronavirus
Pandemic: The Role ofHealthcare Workers

•

•
44

A Schlieren Optical Studyof the Human CoughWith and Without
Wearing Masks for
Aerosol Infection
Control

Journal of theRoyal Society,
Interface

December 2009

B, D

Level 5: A study comparing the fluid •dynamics of coughing with orwithout standard surgical or N95 •mask wearing using video records

45

Respiratory Virus
Shedding in Exhaled
Breath and Efficacy ofFace Masks

Nature Medicine

April 2020

B

Level 1b: A randomized controlled
trial comparing exhaled breath
samples (for respiratory virus
shedding) in mask-wearing versus
non-mask-wearing individuals

Early Transmission
Dynamics in Wuhan,
China, of Novel
Coronavirus-Infected
Pneumonia
Contamination by
Respiratory Viruses on
Outer Surface ofMedical Masks Used by
Hospital Healthcare
Workers

The New England
Journal of
Medicine

January 2020

B

Level 4: A case series looking at•
characteristics and illness timelines
of laboratory confirmed cases of
COVID-19

BMC Infectious
DiseasesJune 2019

B

Level 1b: An individual randomized
controlled trial with two pilot
studies (cohort). Participants told
to wear medical masks and thenmasks were checked forrespiratory viruses on the surface

46

47

•

•

•

•

•

Details the role of healthcare workers,
nurses and midwives in providing primarypoint of care in communities and for
pregnant women, respectively, especiallyduring infectious disease outbreaks
Mentions details and precautions when using
alcohol-based hand rubs for hand hygiene
Human coughing projects a rapid turbulent
jet into the surrounding air
Wearing a surgical or N95 mask interrupts
the natural mechanism of airborne infection
transmission through blocking turbulent jet
formation (N95 mask) or redirecting theexhalant (surgical mask)
Surgical face masks can prevent transmissionof human coronaviruses and influenza
viruses from symptomatic individuals
Surgical face masks reduce detection ofcoronavirus RNA in aerosols, with a trend
towards reduced detection of coronavirus
RNA in respiratory droplets
Human-to-human transmission has occurred
and that measures must be implemented
towards populations at risk

Virus presence on the face mask was higher
when worn for a longer period of time (inthe 6> subgroup)
The study concluded that because of thisrisk, the pathogens on the outer surface may
cause self-contamination, with greater risk
when worn for >6 hours
Indications that there should be a maximum
time on mask usage
Continued

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Non-pharmaceutical H-EDRM measures for COVID-19, 2020
29

Appendix 2. Continued

Ref. Title
No.

Journal or
publication

Date ofpublication

Relevant
measure(s)(See Key 1)

OCEBM Level of Evidence based on Relevant key finding(s) and/or conclusion
study design (See Key 2)48

Stability of SARS-CoV-2
in Different
Environmental
Conditions

The Lancet

May 2020

B, G

Level 5: An experimental study on
the stability of COVID-19 indifferent induced environmental
conditions such as under heatstress and on different surfaces

49

What You Need to Know
About Infectious
DiseaseUS Institute ofMedicine

2010

C, D

50

Face Touching: A
American Journal
Frequent Habit that Hasof Infection
Implications for Hand
Control
HygieneFebruary 2015

C

51

Self-touch: Contact
Durations and Point ofTouch of Spontaneous
Facial Self-touches
Differ Depending on
Cognitive andEmotional Load
Protective Effect ofHand-washing andGood Hygienic Habitsagainst Seasonal
Influenza: A
Case–Control Study
Hand Hygiene and Risk
of Influenza Virus
Infections in theCommunity: A
Systematic Review andMeta-analysis

PLOS ONE
Medicine(Baltimore)

March 2019

C

Medicine(Baltimore)

March 2016

A

Level 3b: A single case–control study • Frequent handwashing and better hygiene
habits were associated with a reduction in
testing the link between influenza
the risk of influenza infection
transmission and self-reported
handwashing/unhealthy hygiene
habitsEpidemiology &Infection

May 2014

A

Level 1a: A systematic review of 10
randomized controlled trials
aiming to evaluate the efficacy ofhand hygiene measures against the
reduction of influenza
transmission

52

53• Infectious virus was not detected after
5-minute incubation at room temperature• Virus found to be stable at wide range ofpH, and stable on surfaces such as outer layof surgical masks• Virus was susceptible to disinfection
methods
Level 5: A book that contains expert • The mouth, the eyes and the nose are theopinion on infectious diseases andbody’s main entry points for transmittable
the nature of their transmission
conditions such as influenza• Coughing and sneezing facilitate the spreadof droplet transmittable diseases
Level 2b: A behavioural observation • Even among medical students, there wasstudy of 26 participants exploring
frequent face touching behaviour
the habit of face touching• This indicates towards the importance ofhand hygiene too apart from the risk of
self-inoculation from face touching whichneeds to be elucidated
Level 2b: A cohort study exploring• Results showed that both the point of touchthe behaviour of face touching andand contact durations were under influence
its link to cognitive and emotionalfrom emotional and cognitive triggers
loads• Findings suggested that while hand washing
may be effective (modest efficacy) against
one mode of transmission, i.e. contact,
further measures may also be important tocontrol influenza transmission, for example
face masks
Continued

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30
E. Y. Y. Chan et al., 2020

Appendix 2. Continued

Ref. Title
No.

Journal or
publication

Date ofpublication

Relevant
measure(s)(See Key 1)

54

Effect of Washing Hands Cochranewith Soap on Diarrhoea
Database of
Risk in the Community:
Systematic
A Systematic Review
Reviews

September 2015 A

55

Hand Washing Promotion Cochrane
for Preventing
Systematic
Diarrhoea
Review

September 2015 A

56

Reducing the Risk of
Infection: Hand
Washing Technique

57

The Effectiveness of Hand American Journal
Hygiene Procedures inof Infection
Control
Reducing the Risks of
Infections in Home andCommunity Settings
Including Handwashingand Alcohol-Based
Hand Sanitizers

58

Effectiveness of
Science of the Total September 2018 B
Commercial Face Masks
Environment
to Reduce Personal PM
Exposure

Community Eye
HealthMarch 2008

A

December 2007

A

OCEBM Level of Evidence based on Relevant key finding(s) and/or conclusion
study design (See Key 2)
Level 1a: A systematic review of 22
randomized controlled trials tocompare diarrhoea occurrence inchildren and adults with orwithout handwashing measures

Handwashing measures result in diarrhoea
episode reductions in child day care centres
in high-income countries as well as
communities in low- and middle-income
countries• It is a challenge to encourage the habitual
maintenance of handwashing habits inpeople in the long term
• Hand washing most likely reduces diarrhoea
Level 1a: A systematic review of
episodes in certain communities, as per the
randomized controlled trials andstudy’s findings
cluster RCTs to compare theeffects of measures associated with • There may be lack of understanding on how
to help people maintain habits related tohandwashing on the occurrence ofhandwashing in the long term
diarrhoea episodes in children
Indicates that handwashing is critical toLevel 5: Expert guidance on
infection control and that there may becomponents of a goodinadequate awareness on importance ofhandwashing routehandwashing techniques, which may be
impeding effectiveness• Hand hygiene is a significant component ofLevel 5: A report reviewing thegood hygiene in households andevidence on hand hygiene and its
link to infectious diseasecommunities and has significant benefit
transmissions
towards the reduction of infection
transmission, including respiratory tract
infections• Further conclusion that hand hygiene’s
impact towards infectious disease reduction
can be enhanced by improved persuasion ofcommunity handwashing (properly and at
the right times) and that hand hygiene
promotion should come hand in hand withother aspects of hygiene and associatededucation
Level 5: A model-based study• Facemasks reduce exposure to urban
evaluating the efficacy of facepollutionmask respirators towards the
The efficacy of available face masks can
reduction of airborne particle
vary in achieving exposure reduction to
exposure and subsequent pollutant
urban pollution
exposure•Continued

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Non-pharmaceutical H-EDRM measures for COVID-19, 2020
31

Appendix 2. Continued

Ref. Title
No.

Journal or
publication

Date ofpublication

Relevant
measure(s) (SeeKey 1)

OCEBM Level of Evidence based on
study design (See Key 2)

Relevant key finding(s) and/or conclusion

59

Globalization and
HealthDecember 2018

B

Level 4: A cross-sectional survey
exploring the role of socio-cognitive
factors in affecting the decision ofwearing a pollution mask in thecontext of young educated people•

Exploring Motivations
behind Pollution-Mask
Use in a Sample of Young
Adults in Urban China

60

WHO | Air Pollution

WHO

N/A

B, I

61

Air Pollution: A Smoking
Gun for Cancer

Chinese Journal ofCancerApril 2014

B

62

A Retrospective Approachto Assess Human Health
Risks Associated with
Growing Air Pollution in
Urbanized Area of Thar
Desert, Western
Rajasthan, India
Saliva and Viral Infections

Journal ofEnvironmental
Health Scienceand Engineering

January 2014

B

Periodontology
2000

December 2015

C, E

June 2019

C

63

64

Detection of Bacterial
Journal of
Pathogens in the Hands ofPreventive
Rural School Children
Medicine andAcross Different Age
HygieneGroups and Emphasizing
the Importance of Hand
Wash•

Level 5: A collection of resources•
including global data on air pollution
and subsequent protective measures
Level 5: A review on various articles to •discuss key questions surrounding
the link of air pollution with cancer
incidence, with a focus on China
Level 2b: A retrospective cohort study
looking into the air pollution
measures and associated statistics on
disease burden

Level 5: A review on various
publications associated with viral
infections via the oral cavity anddiscussing assays••

Mask-wearing practice is influenced by various
reasons including but not limited to level of
education, social norms, self-efficacy, attitudes
and past behaviour
The conclusion indicates the need towards
changing the social perception towards
mask-wearing practiceDemonstrates that 9/10 people breathe air
containing high levels of pollutants andconcludes these as risk factors towards healthAir pollution was and is a risk for cancer; itmakes final recommendations such as the needfor personal pollution monitoring devices aswell as increase international collaborations
upon this matter
Environmental burden of disease andassociation to air pollution is a main concern inthe fast-developing areas of India
Households exposed to high vehicle-caused
pollution presented with greater prevalence of
respiratory diseases for example

Regarding saliva and its role in viral infections,
it indicates that it plays a key role and that themouth and eye are common sites for viral entry• Conclusion that the oral cavity is a significant
area for infection as well as virus transmission
Level 4: A cross-sectional observational • Concluded that in this rural-based cohort, thestudy on hand pathogens in 200 rural
hands of the children were harbouring various,
school children
potentially fatal, pathogenic organisms andcould thus be a major source of infection• Indication towards the importance of handwashing and the need to provide materials(which are not available to these groups) inorder to reduce spread of infection, which isotherwise reducible via hand hygiene•

Continued

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32
E. Y. Y. Chan et al., 2020

Appendix 2. Continued

Ref. Title
No.

Journal or
publication

65

Viricidal Activity of World
Health OrganizationRecommended
Formulations Against
Enveloped Viruses,
Including Zika, Ebola,and Emerging
Coronaviruses
Effect of Handwashing onChild Health: A
Randomised Controlled
Trial

Relevant
measure(s) (SeeKey 1)

OCEBM Level of Evidence based on
study design (See Key 2)

Relevant key finding(s) and/or conclusion

The Journal of
March 2017
Infectious Diseases

A

Level 5: An in vitro experiment testing
the efficacy of two WHO
recommended alcohol-based
formulations against different
enveloped viruses•

The Lancet

July 2005

A

Level 1b: A randomized controlled trial •randomly assigning of handwashingpromotion to one group and nopromotion to the other versus
randomized controls. Outcomes
explored included diarrhoea and•acute respiratory tract infections•

Hand Cleaning with Ashfor Reducing the Spreadof Viral and Bacterial
Infections: A Rapid
Review
Comparison of Four
Methods of Hand
Washing in Situations of
Inadequate Water Supply

Cochrane

April 2020

A

West African
Journal of
Medicine

January 2008

A

Level 5: A systematic review using•
different types of studies to assess theadvantages and disadvantages of ash
as an alternative to soap or othermaterials against viruses and bacteria
Level 1b: A randomized controlled trial •comparing different methods of handwashing developed for use in•developing countries

69

Testing the Efficacy ofHomemade Masks:
Would They Protect in an
Influenza Pandemic?

Disaster Medicine
and Public HealthPreparedness

August 2013

A

Level 1b: A randomized controlled trial •on the effectiveness of different
household materials in making
homemade masks as an alternative tocommercial face masks

70

Aerosol Filtration Efficiency American Chemical
Society Nano
of Common Fabrics Used
in Respiratory Cloth
Masks

April 2020

B

Level 5: An experimental approach toassess common fabrics (such as
cotton) and their filtration
efficiencies

66

67

68

Date ofpublication••

WHO recommended alcohol-based
formulations worked against the different
enveloped viruses and the viricidal effect wasstrongStudy found that households receiving plain
soap with handwashing promotion had lower
incidence of the studied infections and that
there was not much difference between plain
versus antibacterial soap
Indicates the importance of such programs anddistribution of soap
Concluding that handwashing was effective inpreventing conditions like diarrhoea andrespiratory disease
Studies were unreliable and rarely adequate
examined rate of infection. Therefore, ash could
not be concluded as a suitable alternative

The ‘Elbow way’ of handwashing is the gold
standard with no evidence of
post-contamination
Bucket and bowl as well as the single-bowl
method result in cross contamination
While a homemade mask also results in adecrease in number of microorganisms expelled
by volunteers, a homemade mask is
significantly less effective than surgical masks
and should only be a last resort for droplet
transmission prevention
Found that in general, cloth masks could
potentially offer notable protection against
transmission of particles, which have sizes
within the aerosol range
Further findings on factors limiting effectivenesssuch as leakages due to fitting issues andinfluence of factors such as humidity, repeateduse and washing
Continued

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Non-pharmaceutical H-EDRM measures for COVID-19, 2020
33

Appendix 2. Continued

Ref. Title
No.

Journal or
publication

Date ofpublication

Relevant
measure(s) (SeeKey 1)

OCEBM Level of Evidence based on
study design (See Key 2)

Relevant key finding(s) and/or conclusion

Collects the key points on handwashing as well as
the science behind the measure to ultimately
make recommendations regarding when towash and how to wash
• Only three studies out of the 10 reviewed were
statistically significant• While there is no conclusive evidence on theeffectiveness of handwashing, this measureremains suggestive to protect against SARStransmission in the community and healthcare
settings• The use of soap, longer duration of
handwashing and towel drying significantly
remove microorganisms compared to plain
water, shorter duration and air drying,
respectively• Towel drying presented with a greater
person-to-person variability. The presence offood debris made handwashing less effective• Concluded that chronic medical conditions, visit
to fever clinics, eating outside home andfrequent taxi taking were risk factors in casepatients• Also indicated that mask wearing is strongly
protective in reducing risk for SARS
• Indicates that compulsory social distancing andmass masking are the measures that appear to
be temporarily successful in China• Expresses that while the efficacy of mask
wearing may be lacking evidence, the absenceof evidence should not be equated to inefficacy,
especially in the context of COVID-19 withlimited alternatives.
• Suggests that masking can intercept thetransmission link and urges governments andhealth authorities to make advance
preparations on mass masking locally to
prepare for challenges ahead• Community-wide mask wearing may potentially
improve COVID-19 control through reducing
infected saliva and respiratory droplet emission
from infected individuals

71

Handwashing: Clean Hands Journal of
Save Lives
Consumer Healthon the Internet

February 2020

A

Level 5: An expert collection of
information on handwashing as wellas the explanations behind it

72

Effectiveness ofHandwashing inPreventing SARS: A
Review

Tropical Medicine
and International
HealthSeptember 2006

A

Level 3a: A systematic review ofcase–control studies to evaluate
effectiveness of handwashing inprotecting against SARS transmission

73

Efficacy of Handwashing
Duration and Drying
Methods

International
Association for
Food Protection

July 2012

A

Level 1b: A randomized controlled trial
on the impact of soap or plain water,
duration of practice, presence ofdebris and drying method on
microorganism removal from hands
through handwashing74

Risk Factors for SARS
among Persons Without
Known Contact withSARS Patients, Beijing,
China

Emerging Infectious
DiseasesFebruary 2004

B

Level 3b: An individual case–control
study to compare unlinked probable
SARS patients with othercommunity-based controls

75

Mass Masking in the
COVID-19 Epidemic:
People Need Guidance

The Lancet

March 2020

B

Level 5: Expert opinion on theimportance of plans for mass
masking adoptions in the community
under the emergence of COVID-19

76

Journal of Infection
The Role ofCommunity-WideWearing of Face Mask forControl of Coronavirus
Disease 2019
(COVID-19) Epidemic
due to SARS-CoV-2

April 2020

B

Level 4: A cross-sectional observational
study with epidemiological analysis
on COVID-19 confirmed cases inHong Kong with community-widemasking and that ofnon-mask-wearing countries

Continued

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34
E. Y. Y. Chan et al., 2020

Appendix 2. Continued

Ref. Title
No.

Journal or
publication

Date ofpublication

Relevant
measure(s) (SeeKey 1)

OCEBM Level of Evidence based on
study design (See Key 2)

77

WHO Coronavirus Disease(COVID-19) Dashboard

WHO

N/A

B

78

To Mask or Not to Mask:
Modelling the Potential
for Face Mask Use by theGeneral Public to Curtail
the COVID-19 Pandemic

Infectious Disease
Modelling

April 2020

B, I

Others: Provides latest figures on•
COVID-19 new cases, confirmed
cases and deaths in a timely manner
Level 5: A study on hypothetical mask •adoption scenarios. Proposed model
simulations were used to evaluate theeffect of mask-wearing on mortality•
reduction and reduced COVID-19
transmission.

79

Persistence ofCoronaviruses on
Inanimate Surfaces andTheir Inactivation with
Biocidal AgentsThe Journal of
Hospital Infection

March 2020

C, G

Level 5: A literature review on thepersistence of coronaviruses on
inanimate surfaces and chemical
disinfection strategies for biocidal
agent inactivation

Relevant key finding(s) and/or conclusion

•

•
•

80

81

Turbulent Gas Clouds andJournal of the
March 2020
Respiratory Pathogen
American Medical
Emissions: Potential
Association JAMA
Implications for Reducing
Transmission of
COVID-19

D, I

Human Saliva:
Non-invasive Fluid for
Detecting Novel
Coronavirus(2019-nCoV)

E, H

International
Journal ofEnvironmental
Research andPublic Health

March 2020

Level 5: Expert opinion on turbulent
gas clouds and respiratory pathogen
emissions••Level 4: A case series on viral detection •in saliva samples of COVID-19
patients on the first day of•
hospitalization•
82

Consistent Detection of2019 Novel Coronavirus
in Saliva

Clinical Infectious
Diseases

Feb 2020

E, H

Level 4: A case series on saliva viralload in self-collected saliva of
COVID-19 patients••

Latest figure updates on COVID-19

Mask wearing by the general public may bepotentially effective in reducing community
transmission and relieving the pandemic burden
Suggests that the community-wide benefits arelikely to be the most significant when facemasks are used with other protection practices
such as social distancing, and when adoption isnearly universal with a high compliance
Human coronaviruses can persist on inanimate
surfaces like metal, glass or plastic for up to
9 days
They can be efficiently inactivated using
biocidal agents
Early containment and prevention of further
COVID-19 spread is crucial
Suggests that pathogen-bearing droplets from ahuman sneeze can travel up to 7–8 m underforward momentum of the gas cloud
Indicates implications for prevention andprecaution in COVID-19, including
maintenance of distance away from infectedindividuals in healthcare settings
Indicates consistent detection of coronavirus insaliva of COVID-19 patients admitted fromfirst day of hospitalization
Demonstrates advantage of saliva sampling
comfortability in epidemic situations such as
COVID-19
Suggests further investigation on human saliva
diagnostic capacity for coronaviruses
Indicates consistent detection of live virus insaliva by viral culture
Suggests that saliva sampling is a promising andnon-invasive method with high diagnostic,
monitoring and infection control capacity inpatients with COVID-19 infection
Continued

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Non-pharmaceutical H-EDRM measures for COVID-19, 2020
35

Appendix 2. Continued

Ref. Title
No.

Journal or
publication

Date ofpublication

Relevant
measure(s) (SeeKey 1)

OCEBM Level of Evidence based on
study design (See Key 2)

Relevant key finding(s) and/or conclusion

83Ciência & Saúde
Coletiva

2010

E

Level 5: A study on the levels of
microbiological contamination on
restaurant surfacesCiência & Saúde
Coletiva

September 2011

E

Level 5: A study on the levels of
microbiological contamination infood processing plants

Extensive contamination by bacteria wasobserved in restaurant surfaces such as utensils,
equipment and stainless steel benches• Suggests further sanitary measure to reducerisks of foodborne diseases
Significant contamination by bacteria wasidentified in over 30% of the equipment andutensils studied in food processing plants

Journal of Medical
Virology

March 2020F

The Chinese
University ofHong Kong

March 2020

F, J

Level 4: A case series in which
information of COVID-19 infectedchildren was collected, such as
clinical characteristics and chest
imaging
Level 4: A case series on the viral loadof faecal samples from COVID-19
patients

Journal of Applied
Microbiology

June 2005

F

Level 5: A study to determine the levelof aerosol formation and fall out
within a toilet cubicle after toilet
flushing through mimicking
infectious diarrhoea

American Journal of October 2012
Infection Control

F

Level 5: A review on the potential
health risks of aerosol production
during toilet flushing

Infection Control in
the Dental OfficeD

Level 5: Expert opinion on respiratory
hygiene and cough etiquette

84

85

86

87

88

89

MicrobiologicalContamination ofEnvironments andSurfaces at Commercial
Restaurants
Contamination by Bacillus
cereus on Equipment andUtensil Surfaces in a Foodand Nutrition Service
Unit
Detectable SARS-CoV-2
Viral RNA in Faeces ofThree Children During
Recovery Period of
COVID-19 Pneumonia
CUHK Finds that theCoronavirus Can Persist
in Stool after Its
Clearance in Respiratory
Tract; Will Conduct Stool
Test for People in
Quarantine Camps for
Early Identification
The Potential Spread of
Infection Caused by
Aerosol Contamination ofSurfaces after Flushing a
Domestic Toilet

Lifting the Lid on Toilet
Plume Aerosol: A
Literature Review with
Suggestions for Future
Research
Respiratory Hygiene andCough Etiquette

April 2020•

Concluded that SARS-CoV-2 viral RNA isdetectable in the faecal samples of threechildren during their recovery from COVID-19
pneumonia
Concluded that all studied patients have
COVID-19 virus detected in their faecal samples• For a minority of patients, virus was still present
in the faecal sample 1–2 days after the
respiratory sample tested negative•

Large numbers of microorganisms remained on
the toilet bowl surface and in the bowl water,which are further dispersed to the air throughfurther toilet flushing.
• Indicates potential health risk to individuals
who are unaware of this mode of transmission
within the household• Toilet plume under toilet flushing may
contribute to infectious disease transmission• Further research to assess toilet plume risks,
especially in healthcare settings, is encouraged•

Prevention is the best method for respiratory
disease management• Proper hand hygiene and awareness on coughand sneeze etiquette is encouraged forsuccessful prevention•

Continued

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36
E. Y. Y. Chan et al., 2020

Appendix 2. Continued

Ref. Title
No.
90

91

Journal or
publication

Graduate School of
Bacterial Transfer from
Clemson
Mouth to Different
University
Utensils and from Utensils
to Food
Helicobacter pylori:
Epidemiologic
Epidemiology and Routes
Reviewsof Transmission

Date ofpublication

Relevant
measure(s) (SeeKey 1)

OCEBM Level of Evidence based on
study design (See Key 2)

Relevant key finding(s) and/or conclusion

August 2009

E, H

Level 5: A study on the transfer ofbacteria from mouth to different
utensils•

There is a significant bacterial transfer frommouth to utensils and further to foodJuly 2000

E, H

Level 5: A review on the epidemiology
and routes of transmission of
Helicobacter pylori•

H. pylori infection is prevalent in Chinese
immigrants in Australia who share chopsticks
for communal dishes
A common mode of H. pylori transmission
involves an oral-to-oral route through saliva
Lidless toilets may lead to environmental
contamination by microogranisms andassociated health risks. Use of lidless toilets isthus discouraged.

•
92

93

Potential for Aerosolization The Journal for
Hospital Infectionof Clostridium difficile
after Flushing Toilets: The
Role of Toilet Lids inReducing Environmental
Contamination Risk
Mobility Decline in Old
Exercise and Sport
Age: A Time to Intervene
Sciences Reviews

December 2011

F

Level 5: A study on in situ testing using •faecal suspensions to mimic disease
bacteria and measure microorganism
aerosolization as well as extent ofsplashing when toilet flushing

January 2013

D

Level 5: Expert opinion on mobility
impairment in ageing populations

•
•
•
•

94

95

Age-related Change in
Mobility: Perspectives
from Life Course
Epidemiology andGeroscience
Plastic Waste Inputs fromLand into the Ocean

March 2016
The Journals ofGerontology.
Series A,
Biological Sciences
and Medical
Sciences
ScienceFebruary 2015

D

E

Level 5: Expert opinion on mobility
impairment in ageing populations,
explored through the perspectives of
epidemiology and geroscience•

Level 5: A report on the estimation ofplastic waste mass in oceans bylinking relevant worldwide data

•

•

•

•

96

Microplastic
Contamination of Wild
and Captive Flathead
Grey Mullet (Mugil
cephalus)

International
Journal ofEnvironmental
Research andPublic Health

March 2018

E

Level 5: An investigation on
microplastic ingestion in flatheadgrey mullets••

Mobility decline is prominent in the old aged
It is important for behavioural measures to be inplace for mobility function improvement
Further rigorous clinical trials are needed
The treatment and prevention of mobility
impairments through expert collaboration are
essential
Physical deterioration in older persons results inmobility loss and impairment
It is important for behavioural measures to be inplace to reduce the disability burden in
populations
The amount of plastic waste generated across
192 coastal countries is determined
The major determining factors of a country’s
contribution to plastic waste would be
population size and waste management system
quality
An estimation is made on the cumulative plastic
waste quantity if waste management
infrastructure is not improved
There was evidence of microplastic ingestion in
the mullets
Individual, local and global actions tocounteract the issue of plastic waste disposal
into seas are encouraged
Continued

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Non-pharmaceutical H-EDRM measures for COVID-19, 2020
37

Appendix 2. Continued

Ref.
Title
No.

Journal or publication

Date ofpublication

Relevant
measure(s)(See Key 1)

OCEBM Level of Evidence basedon study design (See Key 2)

Relevant key finding(s) and/or conclusion

97

CityU Experts: Aerosol Dropletsfrom Toilet Flushing Can Rise
Up to One Metre; Covering
Toilet Lid may not Completely
Eliminate Disease Transmission;
Toilet Bowl Must Be Regularly
CleanedThe City University ofHong Kong

February 2020

F

Level 5: A study on how toilet
flushing may produce aerosol
droplets that facilitate diseasetransmission•

The Coronavirus Pandemic andAerosols: Does COVID-19
Transmit via Expiratory
Particles?

Aerosol Science andTechnology

98

•

•

April 2020

DLevel 5: Expert opinion on thepotential of COVID-19
transmission through expiratory
particles

•
•
•

99

100

101

Air, Surface Environmental, andPersonal Protective Equipment
Contamination by Severe AcuteRespiratory SyndromeCoronavirus 2 (SARS-CoV-2)
from a Symptomatic Patient

Journal of theAmerican Medical
Association

Protection and Disinfection Policies
against SARS-CoV-2(COVID-19)

Le Infezioni in
Medicina

Prevalence of Multidrug-ResistantBacteria on Mobile Phone
SurfaceJournal of
Microscopy andUltrastructure

March 2020

2020

2020

D

G

G

Level 5: A study on the
SARS-CoV-2 contamination andpersistence on environmental
surfaces and personal protective
equipment around COVID-19
patients in isolation rooms•

Level 5: Expert opinion on
COVID-19 transmission, thestability of the virus and relevantmeasures of prevention
Level 5: A study on
multi-drug-resistant bacteria on
mobile phones

•

•

•
•

•
102

Degree of Bacterial Contaminationof Mobile Phone and Computer
Keyboard Surfaces and Efficacy
of Disinfection with
Chlorhexidine Digluconate andTriclosan to Its Reduction

International Journalof Environmental
Research Public
HealthOctober 2018

G

Level 5: A study on the bacterial
contamination of mobile phoneand computer keyboard surfaces
as well as the subsequentdisinfection efficacy of selected
disinfectants••

A single toilet flush can contaminate the washroom
through the spread of pathogens in the air
The covering of toilet lid before flushing for
washroom and air contamination reduction isrecommended
Toilet lid covering may not completely inhibit
pathogenic dissemination due to potential space
between the lid and the bowl
Aerosol transmission may play a major role in thehigh transmissibility of COVID-19
Ordinary speech has a potential of aerosolizing
respiratory particles.
There are scientific unknowns relating to the modeof transmission
It is important for experts to collaborate closelyand effectively inform the public of potential
infectious aerosol emission all the time, such as
during coughing and sneezing
Environmental contamination is a highly potential
route of transmission for coronaviruses, which may
contribute to incidences of nosocomialtransmission of COVID-19 in hospitals
Further studies need to be conducted on the modeof transmission of COVID-19 and the extent ofenvironmental contamination
The coronavirus can remain in airs and surfaces forsustained periods of time
Recommendation of household disinfection is made
Nosocomial infection spread is accelerated by
microorganism presence on the mobile phones ofhealthcare workers
Disinfection practices for phones in hospitals to easepotential health risks are recommended
A high degree of surface contamination is found on
both surfaces
Disinfection with simple antibacterial wet wipes tosignificantly reduce microbial contamination isrecommended

Continued

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38
E. Y. Y. Chan et al., 2020

Appendix 2. Continued

Journal or publication Date of
publication

103

Association of Household
Food- and Drink-Sharing
Practices with Human
Herpesvirus 8
Seroconversion in a Cohortof Zambian Children
The Clinical Toxicology of
Sodium Hypochlorite

The Journal of
Infectious Diseases

January 2018

Occurrence of Household
Mould and Efficacy of
Sodium Hypochlorite
Disinfectant
Efficacy of Sodium
Hypochlorite Disinfectant
on the Viability andAllergenic Properties ofHousehold Mould
Transmission of Mutans
Streptococci inMother–Child Pairs

Aerosol Emission andSuperemission during
Human Speech Increase
with Voice Loudness

Scientific Reports

COVID-19 Transmission
through Asymptomatic
Carriers Is a Challenge toContainment
Routes of Transmission of
Influenza A H1N1, SARS
CoV, and Norovirus in Air
Cabin: Comparative
Analyses
Epidemiological
Characteristics of the First
53 Laboratory-Confirmed
Cases of COVID-19
Epidemic in Hong Kong, 13
February 2020

Influenza and Other
Respiratory Viruses

April 2020

I, J•
Level 5: A review on the transmission of
COVID-19 through asymptomatic
individuals and the associated challenges

International Journalof Indoor
Environment and
HealthJanuary 2018

J

Level 5: A model simulation to assess the•transmission routes of various infectious
viruses•

Eurosurveillance

April 2020

I, J

Level 4: A case series on the key
epidemiological parameters of
COVID-19 cases in Hong Kong

104

105

106

107

108

109

110

111

Level 2b: An individual cohort study on
the link between household food anddrink sharing behaviour and the risk of
HHV-8 transmission•

G

Level 5: A review on the clinical
toxicology of sodium hypochlorite

2012
Journal of
Occupational andEnvironmental
HygieneJournal of Allergy and February 2004
ClinicalImmunology

G

Level 5: A study on the appearance ofhousehold mould and the disinfecting
capability of sodium hypochlorite on
household surfaces
Level 5: A study on the efficacy of sodium
hypochlorite as a disinfectant forhousehold moulds

The unintended ingestion of household bleach in large
amounts may pose severe health risks such as
corrosive injury that may be fatal• Low concentrations of sodium hypochlorite
significantly reduce mould and related allergens

The Indian Journal of
Medical Research

H

Clinical Toxicology
Philadelphia

October 2017

Relevant
measure(s) (SeeKey 1)H

OCEBM Level of Evidence based on study Relevant key finding(s) and/or conclusion
design (See Key 2)

Ref. Title
No.

August 2016

February 2019

G

I

•

There is a temporal association between food- anddrink-sharing practices and HHV-8 transmission
Such sharing practices should be minimized toreduce transmission risks, in particular forhouseholds with large sibling numbers•

Low concentrations of sodium hypochlorite
significantly reduce mould and related allergens

Level 4: A case series evaluating thetransmission of dental caries (mutans
streptococci) from mother to child•

Level 5: A review on the potential ofaerosol emission and diseasetransmission through human speech•

A vertical transmission of mutans streptococci frommother to child is concluded
Further development of strategies to reduce foodand utensil sharing between mothers and children
is recommended
Particle emission during speech has a positive
correlation with speech loudness
Respiratory infectious disease transmission isfacilitated by many unknown physiological factors
such as speech
Asymptomatic transmission of COVID-19 ispossible between persons within communities

•

•

•
•

Virus control in indoor environments such as
airplanes should take into consideration respiratory
and enteric transmission routes
A method to analyse the comparative significance ofdifferent modes of virus transmission is highlighted
The risk of transmission may be heightened throughincreased social contact
Physical distancing is a key measure to counteract
the pandemic

Continued

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Non-pharmaceutical H-EDRM measures for COVID-19, 2020
39

Appendix 2. Continued

Ref. Title
No.

Journal or publication Date of
publication

OCEBM Level of Evidence based on study Relevant key finding(s) and/or conclusion
design (See Key 2)

112

Towards Aerodynamically
Journal Pre-Print
Equivalent COVID19 1.5 m
Social Distancing for
Walking and Running

January 2020

Relevant
measure(s) (SeeKey 1)I

113

COVID-19 Lockdowns Cause
Global Air Pollution
Declines with Implications
for Public Health Risk

Journal Pre-Print

April 2020

I

Level 5: A study on the declination of
global air pollution as a result of
reduced activity in COVID-19

114

COVID-19 as a Factor
Influencing Air Pollution?

Environmental
Pollution

April 2020

I

Level 5: A review on the impacts of
COVID-19 on air pollution

115

Air Pollution and Public
Health: Emerging Hazards
and Improved
Understanding of Risk

Environmental
Geochemistry and
HealthJune 2015

I

Level 5: A study on air pollution as an
emerging public health hazard

116

Point of View: How Scientists
Can Reduce Their Carbon
FootprinteLife

March 2016

J

Level 5: Expert opinion on the impact of
reduced long-distance air travel on
carbon footprint and the reduction ofgreenhouse gas emissions

Level 5: A mathematical model tounderstand the aerodynamics associatedwith virus transmission and thereasoning behind social distancing• The 1.5-m social distancing suggestion may not
suffice if the aerodynamics associated with walking
and running is taken into consideration• Further work to understand the effect ofaerodynamic factors such as headwind on droplet
transmissions is necessary• Health hazards such as premature deaths andpaediatric asthma associated with air pollution
have been minimized as a result of reduced activity
in COVID-19• There are potential health benefits from reduced air
pollutant emissions as a result of decreased
economic activity during the pandemic• The emergence of COVID-19 has been followed bydecreased air pollution in areas like China, andsubsequently a reduced number of fatalities as aresult of air pollution• There are potential benefits of non-communicabledisease prevention due to air pollution reduction• Air pollution is historically linked to increased
respiratory and cardiovascular mortality• Air quality improvement is a significant challenge• There is a need for effective policies to ease theburden of air pollution on health hazards• Carbon dioxide emissions are significantly reduced
under decreased long-distance travel among thescientific community

Continued

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40
E. Y. Y. Chan et al., 2020

Appendix 2. Continued

Ref. Title
No.

Journal or publication Date of
publication

117

Centre forEvidence-Based
Medicine

What Is the Evidence for
Mass Gatherings During
Global Pandemics?

March 2020

Relevant
measure(s) (SeeKey 1)I

OCEBM Level of Evidence based on study Relevant key finding(s) and/or conclusion
design (See Key 2)
Level 5: A review on the potential effects•
of mass gatherings on infectious diseases
•

118

119

120

121

Could Influenza Transmission Journal of
Be Reduced by Restricting
Epidemiology and
Mass Gatherings? Towards
Global Healthan Evidence-Based Policy
Framework
Mass Gatherings Medicine:
Public Health Issues Arisingfrom Mass Gathering
Religious and Sporting
EventsInfluenza Outbreaks During
World Youth Day 2008
Mass Gathering

The Lancet

August 2011

I

Level 5: A narrative analysis on the effectof mass gathering restrictions on
influenza transmission risks••
May 2019

I

Level 5: A review on the association ofmass gathering events with potential
public health hazards••
Emerging Infectious
Diseases

Measles Virus Spread Initiated Eurosurveillance
at International Mass
Gatherings in Europe, 2011

May 2010

I

Level 5: A review on influenza outbreaks
during the 2008 World Youth Day mass
gathering••

September 2014

I

Level 5: Expert analysis on the associatedmeasles virus spread during the 2011
mass gatherings••

Measures involving the restriction and cancellationof mass gatherings appear important, but relevant
evidence is lacking
Active analysis of risks associated to mass
gatherings is encouraged on a case-by-case basis
While mass gathering restrictions together withother social distancing measures may help reducetransmission, the individual effects of mass
gathering restriction remain inconclusive
The duration of the event and crowd density may
significantly influence influenza transmission risks
Extensive crowd interactions raise burdens on
health systems, especially for large-scale sporting or
religious events
Further research into public health prevention andsurveillance is recommended
Mass gatherings introduce and amplify viruses
Isolated viruses may impose unpredictable risks oncommunities
Authorities and hospitals are responsible formanaging influenza outbreaks with greater
flexibility
Transmission chains of the measles virus originatedfrom mass sporting events
Importance of measles virus transmission chain
monitoring and surveillance is reinforced

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Non-pharmaceutical H-EDRM measures for COVID-19, 2020
41

Appendix 2. Continued

42

E. Y. Y. Chan et al., 2020

Key 1—measures
Engage in regular handwashing
Wear face mask
Avoid touching the face
Cover mouth and nose when coughing and sneezing
Bring personal utensils when dining out

F
G
H
I
J

Close toilet cover when flushing
Disinfect household surfaces
Avoid sharing utensils
Avoid crowds and mass gatherings
Avoid travel

Key 2—OCEBM Level of Evidence (adapted from www.cebm.net)
Level
1a
1b
1c
2a
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SR (with homogeneity) of case–control studies
Individual case–control study
Case series (and poor quality cohort and case–control studies)
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For example, model simulations, non-human-based experiment, in vitro or in situ studies, and statistical reports or dashboards

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The current issue and full text archive of this journal is available on Emerald Insight at:https://www.emerald.com/insight/1759-5908.htm

Managing and responding topandemics in higher educational
institutions: initial learningfrom COVID-19
Takako Izumi
International Research Institute of Disaster Science (IRIDeS),
Tohoku University, Sendai, Japan

Managing andresponding topandemics

Received 3 June 2020
Revised 14 June 2020
15 June 2020
Accepted 15 June 2020

Vibhas Sukhwani
Graduate School of Media and Governance, Keio University, Yokohama, Japan

Akhilesh Surjan
Humanitarian Response and Disaster Management Studies,Charles Darwin University, Darwin, Australia, andRajib Shaw
Graduate School of Media and Governance, Keio University, Yokohama, Japan

Abstract
Purpose – The purpose of this paper is to understand the key challenges, approaches and lessons of thehigher educational institutions (HEIs) in the context of COVID-19.

Design/methodology/approach – A survey was conducted to understand the key challenges being
faced by the HEIs around the world during the ongoing COVID-19 pandemic. A total of 150 responses werecollected from 65 universities, located in 29 countries.

Findings – The results show that 47% of respondents with deﬁned universities believe their institutions
lacked a permanent or dedicated emergency management ofﬁce, and 41% said their HEIs lacked a generalbusiness continuity plan for an emergency. In universities with BCPs, 33% of the plans do not cover biologicalhazards and pandemic risk management, and 60% of the plans did not include conducting any advanced
simulation exercises. More than 70% the responded said their instruction, information sharing and decisionmaking process were timely and open. The major challenges identiﬁed were a lack of adequate preparedness
for pandemic and of pandemic-speciﬁc advanced simulation exercises. The next major challenges were thechange in the mode of teaching to online lectures and working from home. Based on these challenges, a set ofshort- and long-term recommendations were proposed.
Originality/value – This was the ﬁrst survey in academic institutions in post COVID-19 context. The
ﬁndings will be useful for preparing for biological and other related hazards.
Keywords COVID-19, University responses, Online classes, Shifting academic calendar,
Community and local government collaboration
Paper type Research paper

1. Introduction
Coronavirus disease (COVID-19) was ﬁrst reported in Chinese city of Wuhan in December
2019, was recognized by China as a new virus in the third week of January 2020. The WorldInternational Journal of Disaster
Resilience in the Built
Environment© Emerald Publishing Limited
1759-5908
DOI 10.1108/IJDRBE-06-2020-0054

IJDRBE

Health Organization (WHO) initially described it as a Public Health Emergency ofInternational Concern (PHEIC) at the end of January, and ﬁnally recognized it as a pandemic
on March 11, 2020 (WHO, 2020). Chronology of events in China, East Asia and several othercountries have been discussed in recent publications (Hua and Shaw, 2020; Shaw et al., 2020
and reference therein).
Currently, the USA has the largest number of infected people and death, and all thesefactors have made COVID-19 the worst pandemic in recent years. Shaw et al. (2020)
identiﬁed the following characteristics of COVID-19:
 rapid spread; heightened vulnerability among aged and low immune people; and differential recovery rates in different countries and age groups.
In the interconnected world, the pandemic has not only affected lives but also had a strong
impact on various sectors. The education sector is among the most frequently impacted
service sectors from the pandemic, having already experienced SARS and MERS. The main
reason for this is the closure of schools and universities, which disrupts the academic
calendar and causes stress to parents and students alike. In response, many educational
institutions have started offering online classes/courses and some have shifted theiracademic calendars to cope with this extraordinary situation.
Understanding this as the “new normal” while also thinking of possibilities for future
pandemic or biological hazards and their impact on the higher educational institutions(HEIs), this paper highlights the challenges that HEIs face in starting or continuing theircourses and conduct research. The purpose of the paper is to understand and learn fromlessons from the responses of different universities to deal with the COVID-19 and share thelessons widely.
2. Higher educational institutions and disaster preparedness
2.1 Major issues that higher educational institutions are facing
The COVID-19 disease made a signiﬁcant impact on HEIs mainly in two areas:(1) shifting a major educational form from a face-to-face to online; and(2) tackling the ﬁnancial challenges.
Shifting in education from traditional classroom learning to online-based learning createdtremendous changes for both lecturers and students. A survey conducted in India targeting
200 students showed that 74% of the respondents liked studying through online classes. Its
most common reason (49%) was the ﬂexibility of the study time. On the other hand, thebiggest drawback of online classes addressed was a lack of co-curricular activities in the
online education, followed by not meeting friends (Lall and Singh, 2020).
While such positive side of online-based learning has been reported, De Oliveira Araujo
et al. (2020) emphasized the negative impact of the COVID-19 on students’ mental health.
Many students face anxiety and panic owing to the numerous implications for courses,
assignments, seminars and thesis defenses (The Guardian, 2020). In addition, lack of selfdiscipline, suitable learning materials, or good learning environments were serious issues
when they are self-isolated at home (Bao, 2020). The effectiveness of the online learning is
also an issue in a country such as Singapore that started to embrace the use of digitalplatforms to facilitate teaching and learning nearly ten years ago. Some students found outthat they were more easily distracted during a lecture by doing an internet surﬁng or talking
to friends on messaging applications without any repercussions. Even though digital tools

can add values to teaching and learning and online learning has become an important partof university education, going fully online is not the best long-term plan and plays acomplementary role (Tan, 2020). Blended learning models could be a mainstream and takeover as the norm in the future learning and education.
Another signiﬁcant issue that many HEIs have faced is the ﬁnancial challenges. These
concerns extend to the ﬁnancial future of HEIs such as considerable ﬁnancial instability,
both in the form of unexpected costs and potential reductions in revenue, i.e. owing tocancelation of enrollment of both domestic and international students and refunds on fees,
room and board and the need to scale virtual engagement modalities (The NCSL Podcast,
2020; Rosowsky, 2020). The global economic recession puts a great impact on the HEIs’
ﬁnancial management and operation. To survive in these difﬁcult times, leadership willneed to prepare for numerous possible scenarios, seek creative solutions and stay ﬂexible in
the face of continuous change (Deloitte, 2020).
2.2 Overview of emergency preparedness/management plans in higher educational
institutions
Most, if not all, universities develop guidelines that detail how to prepare for and respond to
emergencies in the form of “Emergency Management Plan (EMP),” “Emergency Response
Plan,” “Crisis Management Plan,” “Business Continuity Plan (BCP)” and others; however,
the key information included in these plans have common elements.
The major part of most documents consists of a description of the roles andresponsibilities of speciﬁc ofﬁces, departments and divisions and the structure of theincident command mechanism for emergency responses. In addition, some EMP also include
a summary of the risk assessment and mitigation strategies. Most of the plans have two
approaches in common: an all-hazard approach and four phases of emergency management,
namely, preparedness, response, recovery and mitigation (University of Sydney, 2016;
University of Auckland, 2013; University of Houston, 2020).
In these plans, emergencies are considered events that can cause death or signiﬁcantinjuries to staff, students, or the public. No further detailed deﬁnition is included on thetypes of incident categories (University of Auckland, 2013), nor on which incidents cansuspend business, disrupt operations, create signiﬁcant physical or environmental damage,or threaten the university’s ﬁnancial standing or public image (University of Otago, 2018). In
principle, different types of hazards such as natural, biological, technological chemical, manmade attacks are the targets of an emergency/crisis management plan. However, dependingon the type of frequent hazards in each country, their emergency management could have a
different focus.
Because of the unique circumstances of university campuses, no one plan ﬁts all
templates applicable to all educational institutions. Campuses have to develop an
individualized plan based on the speciﬁc threats and vulnerabilities that they face Kapucu
and Khosa (2013). However, Zdiarski et al. (2007) provide guidance on a possible common
template that includes the following: clear lines of authority that create a hierarchy of roles that lead to the campus
president;
 action steps that give campus ofﬁcials the roadmap of what to do depending on thenature of a crisis;
 established communication methods including a communications center that will
ensure effective information exchange; andManaging andresponding topandemics

IJDRBE

a clariﬁed role for campus security and outside agencies and planning for businessresumption such as a detailed continuity of operations plan, which will help torestore operations.

For HEIs, it is crucial to consider continuity of campus operations such as teaching, researchand other auxiliary services and develop a BCP. As suggested by Zdiarski, a BCP is ideally apart of the management plan. Some universities have documents called “Emergency
Management/Response and Business Continuity Plan” (Lamar State College, 2013; Pace
University, 2014); however, many universities have a BCP that is separate from an EMP.
The intended purpose of BCP is to ensure business continuity, that is, to provide a
detailed methodology governing how business is restored after a disaster, including for local
incidents such as building ﬁres, regional incidents such as earthquakes or national incidents
such as pandemic illnesses (San Jose State University, 2020). Alternatively, some BCPs
include the basic policy and procedures for initial response, business recovery and campus
reopening in the event the university encounters a situation in which continuation ofbusiness activities becomes difﬁcult (Waseda University, 2019). One of the characteristics ofa BCP is that its development is often a responsibility for each department, and universities
provide the template for a BCP document (Pace University, 2014; California State University,
Los Angeles, 2019). Most BCPs are developed by academic departments or divisions and notby universities.
To conduct further research on a BCP or an EMP, the limitation and challenge is that not
all the documents are open to the public, or some of them were written in the local language
and English translated copy is not available; therefore, it is not easy to ﬁnd these in an online
search. At a result, it is extremely challenging to perform a detailed and speciﬁc analysis of
the prevalence of an emergency plan and BCP in general in higher education settings.
A BCP and an EMP often take an all-hazards approach; however, some have focused onparticular areas. The EMP developed by the University of Otago (2018) in New Zealandparticularly includes a section of special provisions relating to pandemics/epidemics. The
section consists of the following: a pandemic planned response; and pandemic communications.
Furthermore, a more speciﬁc BCP is dedicated only to pandemics. The pandemic inﬂuenza
BCP of Massey University (2009) states that the motivation and reason for developing sucha BCP is that the risk of an inﬂuenza pandemic is high, and the pandemic is certain to occur.
The document has also indicated that “social distancing” serves as one of the“containment activities” through people avoiding face to face meetings and classes; using
virtual meetings/classes and conference calls; avoiding unnecessary travel and canceling or
postponing non-essential meetings; studying/working from home or ﬂexible hours; andavoiding all public transport. The reality is that many faculty and students are ﬁnding it
difﬁcult to adjust to the shift of the mode of education delivery, as it has never been
expected; however, the university has already warned that these are the activities to betaken in case of pandemic.
California State University, Los Angeles (2019) has developed a pandemic BCP because
pandemics can last long, can occur in the form of multiple events or waves and can disrupt
every phase of every one’s lives – goods, services and transportation are all affected bydelays to total shutdown. Therefore, the impact on universities will be enormous unless they
are well prepared. The plan also suggests “Alternative methods to deliver services andclasses” assuming the teaching system needs to be changed. As an alternative, itrecommends using the learning management system for the courses, which is a type of elearning.
One of the obvious post COVID-19 phase work should be to initiate a comprehensive
review of BCPs/EMPs to get a realistic understanding of what worked and what did not andhow current practices could be improved. If they worked, it might be asked whether each
university should develop a BCP/EMP that focuses on different hazards/disaster types suchas biological, chemical and natural disasters, or whether an all-hazards approach would be
sufﬁcient to cover different types of hazards.
2.3 Initiatives for creating a safe campus
To understand the level of disaster preparedness on campus including the existence of adisaster management plan at the university level, a survey was conducted in 2015 by the
Association of Paciﬁc Rim Universities (APRU) Multi-Hazards (MH) program. APRU is a
network of 55 universities from 19 APEC economies in the Paciﬁc Rim. Under the APRU, theMH program was established in 2013 and is led by Tohoku University in Japan. One of the
major program activities is to support universities’ disaster preparedness by conducting asurvey and research on campus safety and organizing a biennial workshop.
The survey focused preparedness only for natural hazards. The survey showed only
45% of the respondent universities conducted a risk assessment, and out of the 45%, only
36% used the result of the risk assessment to discuss how to strengthen their risk
management and/or mitigation strategies. Risk assessment and related information sharing
were addressed as the biggest shortcoming on campus safety issues, and the major
challenges were the lack of collaboration in universities, budget, awareness and humanresources to enhance the disaster preparedness capacity on campus (APRU, 2015).
Even among the APRU member universities, conducting a risk assessment and sharing
information targeting natural hazards was one of the challenges. If so, the risk assessment
for all hazards could be a signiﬁcant burden for universities. However, the concept of an “allhazards approach” has been advocated for many years especially in the USA and Europe(Baucher et al., 2018; FEMA, 1996). The need for this approach in Asia, which is the mostdisaster-prone area in the world will be high; however, the implementation level is still low.
In the post COVID-19 phase, universities in Asia must seriously mainstream disaster risk
management in their strategic and operational planning.
3. Covid-19 impacts on higher educational institutes
This study aims to understand the key challenges being faced by the HEIs around the world
during the ongoing COVID-19 pandemic. The major ﬁndings of this study are derived fromdata collected with an online questionnaire survey that was conducted during April 10–27,
2020. The questionnaire was widely circulated among universities and research institutions
through reliable networks such as APRU, the Integrated Research on Disaster Risk, the UN
Ofﬁce for Disaster Risk Reduction and the Asian Universities Network and was answeredby 150 people from 65 universities, located in 29 countries, who belong to teaching andresearch professionals. This was speciﬁcally signiﬁcant for the Asian universities, most ofwhich have a semester starting from April. Thus, the initial challenges for the start of theseminars were captured properly.
3.1 Research methodology
A mixed research method combining qualitative and quantitative data was used to collate
data. The process is as described below:

Managing andresponding topandemics

IJDRBE

The ﬁrst step aims to understand the organizational preparedness and response.
toward this end, information about disaster management and/or business continuity
planning alongside the operational aspects and roles of disaster/emergency
management unit or sections were sought from HEIs. Organizational response wascollated through speciﬁc questions about response guidance, information sharing
and decision-making in the HEI’s in relation to COVID-19. Tables 1 and 2 provide
details of the questions asked. The analysis was made at the organizational levelbased on the number of universities, not number of respondents. This is because, insome cases, there was more than one respondent from a speciﬁc institution. In casewhere multiple responses were received from one university, it was counted as one
response only if all the responses are the same. In case where the answers aredifferent, the responses were not analyzed.
The second step was to ascertain if there is a relationship between organizational
preparedness and the organizational response determinants. The study results (Yes/
No coded to 1/0) were analyzed using a Peraman’s correlation matrix that wasdeveloped using the IBM SPSS statistical software platform, The Speraman’s
correlation technique was speciﬁcally selected owing to the nominal data (Yes/No)
derived from the study.
The third step aimed to derive the key preparedness lessons and makerecommendations for future pandemics and biological hazards based on the
response activities taken at the organizational and personal levels and thechallenges experienced COVID 19. Table 3 highlights the survey questions created
for these purposes.

3.2 Key results and observations
A total of 150 responses from more than 65 universities located in 29 countries were received
for the online survey. Majority of responses (75%) received were from the Asian region. The

Table 1.
Questions to assess
the organizational
preparedness

Table 2.
Questions to assess
the organizational
response to COVID19

S.No.

Key determinant and question

Scale

1

Emergency management unit: Does the emergency management ofﬁce exist
permanently in your university?
Business continuity planning: Has your university had a general BCP to prepare for an
emergency?
(a) If yes, does this BCP also target a biological hazard/pandemic?
(b) If yes, has the simulation exercise been conducted in advance?

Yes/NoS.No.

Key determinant and question

Scale

1

Response guidance: Was the response guidance and instruction communicated quickly
from the HQ to faculty and staff?
Information sharing: Was the information sharing in university open and smoothenough?
Decision-making: Was the decision-making process regarding change in academic
activities timely?

Yes/No2

2
3

Yes/NoYes/NoYes/NoYes/NoYes/Nosurvey respondents represent a mixed gender composition, including both teaching andresearch staff from public and private universities. Close to half of the respondents reported
having added management and outreach responsibilities owing to the pandemic. The
quality of study (risk perception) results were afﬁrmed as majority of the survey
respondents (68%) have more than ten years of experience in higher education institutions.
In other words, majority of the respondents have provided higher education and/or
conducted research under different types of HEI leadership as well as local, regional andnational regimes.
3.2.1 University-level analysis of organizational preparedness and response to COVID19. Ninety-three of the 150 survey respondents disclosed the names of their universities/
HEIs. After ﬁltering the multiple responses from the same university and omitting thediscrepant responses (process explained in subsection 3.1), the unique data of 51 universities
from 22 countries was used to assess the organizational preparedness and response
determinants.
3.2.1.1 Organizational preparedness. Figure 1 shows that 47% of respondents withdeﬁned universities believe their institutions lacked a permanent or dedicated emergency
management ofﬁce, and 41% said their HEIs lacked a general business continuity plan foran emergency. This shows that closed to half of the responding universities have notdeveloped BCP yet. As such a key preparedness plan is crucial to maintaining safety on
campus, the situation has to be ﬁxed urgently.

Key determinantResearch question

Response activities at theorganizational level
Identiﬁed challenges at theorganizational level
Preparedness lessons at theorganizational level
Responses activities at thepersonal level
Identiﬁed challenges at thepersonal level
Preparedness lessons at thepersonal level

What kind of response activities were taken by your university against
COVID-19? (multiple choice question)
What kind of challenges did you ﬁnd in your university’s preparedness
and response? (multiple choice question/top 3)
Based on your experience, what kind of preparedness measures would you
recommend for the University in future? (Short text answer)
What were your personal response activities against COVID-19 pandemic?
(multiple choice question/top 3)
If you switched over to online teaching, what were the key challenges?
(multiple choice question/top 3)
If you can bring one key lesson from the pandemic for your future
professional preparation, what would be that? (short text answer)

Managing andresponding topandemics

Table 3.
Questions to assess
the COVID-19
response activities
and challenges

Figure 1.
Organizational
preparedness
determinants for the
51 deﬁned
universities

IJDRBEIn universities with BCPs, 33% of the plans do not cover biological hazards andpandemic risk management, and 60% of the plans did not include conducting any advanced
simulation exercises. Based on these reported ﬁgures, it can be deduced that several
organizations were not prepared for a global pandemic such as COVID-19. While many
universities did not have a permanent emergency management ofﬁce or business continuity
plan in place, there was also very limited focus on biological hazards and advanced
simulation exercises.
3.2.1.2 Organizational response. In relation to the organizational response determinants,
Figure 2 shows that more than 70% of the respondents said the instruction, information
sharing and decision-making processes were timely and open. However, 30% of the
respondents said their HEIs need to urgently improve in these areas. It is assumed that with
better plans and resources such as BCPs and EMUs, more universities can potentially makefaster and effective responses to global scale disasters including pandemics. In total, 67% of
the universities that did not have BCPs said instructions were communicated quickly
enough but the information sharing process was not open and smooth enough.
3.2.1.3 Correlation analysis. Spearman’s correlation matrix was used to analyze thestrength of association (signiﬁcance levels of co-relation) between the deﬁned determinantsof organizational preparedness and response. It is important to note that the values in
Spearman’s correlation always range from “ 1” to “1” with a value close to the extreme
ends denoting stronger association. Also, as the correlation matrix is symmetrical, thevalues above the diagonal will have the same values as below. The positive signiﬁcancevalues of co-relation denote a positive relationship among all the concerned determinants.
That is, if the response for one of them is “Yes,” the other determinants have a highprobability of being “Yes” too.
Table 4 shows that the highest signiﬁcance levels of co-relation below the diagonal (0.70)
indicates that the determinants of “Smooth Information Sharing” and:
Timely Decision making are strongly associated. Further, it shows that the presence of a BCP andpermanent EMU in universities is positively associated with all the response determinants of‘Quick Response Guidance’ and ‘Smooth Information Sharing’Notably, the relationship between BCP and the organizational response determinants isstronger that with the EMU. The study found that a pre-determined BCP, and an established
EMU in a university can considerably enhance the organizational response to hazards suchas COVID-19. The strong relationship among the three organizational response
determinants is clear from their high correlation values (0.53, 0.43 and 0.70), which

Figure 2.
Organizational
response
determinants for the
51 deﬁned
universities

underscore the strong link between them (quick response guidance and instruction may leadto smooth information sharing).
3.2.2 Individual-based analysis of COVID-19 university response activities, challenges andkey lessons.
3.2.2.1 Types of organizational responses. Figure 3 highlights the COVID-19 response
activities carried out by the universities. It shows that majority of the respondents reported
that the physical locations of the HEIs are afﬁliated with are temporarily closed down
tuition is now through online classes. In addition to tweaking the academic calendar, several
universities have reportedly extended support to their immediate communities and local
governments. This is in the form of technical assistance such as modeling and forecastingand health-care support such as production of personal protective equipment and handsanitizers and data sharing. In the “Others” category, the respondents provided additional
response activities at the organizational level. These support activities range fromconverting university hostels into quarantine centers, to fundraising campaigns, volunteer
services, ﬁnancial and psychological support to stranded students, etc.
3.2.2.2 Key challenges at organizational level. The respondents were asked to selectthree key challenges that their HEIs have had to face during the COVID-19 pandemic(Figure 4). The major challenges identiﬁed were a lack of adequate preparedness for apandemic and of pandemic-speciﬁc advanced simulation exercises. The study found that
half of the responding universities did not have BCPs and EMUs, which correlates with theresults from questions on organizational preparedness.

Determinant nameEmergency
management unit
Business continuity
planning
Quick response
guidance
Smooth information
sharing
Timely decisionmaking

Emergency
management unit

Business
continuity
planning

Quick response
guidance

Smoothinformation
sharing

Timely decisionmaking

1

–

–

–

–

–

–

–

0.57

1

0.27

0.34

1

–

–

0.21

0.47

0.53

1

–

0.03

0.19

0.43

0.7

1

Managing andresponding topandemics

Table 4.
Spearman’s
correlation matrix for
preparedness andresponse
determinants

Figure 3.
COVID-19 response
activities atorganizational level

IJDRBE

Figure 4.
Key challenges atorganizational level

The other two challenges identiﬁed in the survey were the change in the mode of teaching toonline lectures and working from home. Most HEIs have never experienced a global scale
pandemic and making the shift from face-to-face classroom teaching to online teaching wasa major change that posed a signiﬁcant challenge for many HEIs. In particular, the course
which has laboratory experiments and studio work, it was rather difﬁcult to make thechanges instantly. On the other hand, it also provided an opportunity for universities toinvest in adopting an innovative educational system which can support teaching, interaction
and discussion in multiple ways and modes. It is, therefore, unsurprising that in the“Others” category, the importance of strengthening internet access to students and teachers
was highlighted.
3.2.2.3 Key lessons for future organizational preparedness. Seven recommendations for
future organizational preparedness were made from the responses received:
 Planning and familiarization for multiple educational method and tools: there is aneed to develop backup plans for meeting various academic requirements such as
conducting end-of-term and thesis examinations, during emergency situations. It isextremely important to provide necessary support to students for internet-basedteaching, discussions, educational systems and examination methods.
 BCP: to prepare for emergencies, a university-level and a faculty, graduate school,
academic department level-BCP is required. The BCP should establish guidelines forswitching to an online education delivery system, including the process,preparation, communication with students and providing necessary support tothem.
 Emergency management unit (EMU): A dedicated emergency management unit
should be created in all HEIs. The mandates and responsibilities of the EMU should
be communicated to all staff, faculty and students. EMUs should proactively
conduct and lead simulation exercises at regular intervals on different scenariosthat include biological hazards and ensure timely training and capacity building oftask forces dedicated to such events at campus and department level.
 Risk communication: HEIs should conduct regular awareness programs on risks,
preparedness and responses for staff, faculty and students. To realize this, athorough risk assessment is crucial, and it should follow all hazard approaches.
Currently, risk communication strategies at HEIs are framed around natural
disasters and laboratory based ﬁre/chemical safety risks. Potential biological







hazards, risks of sudden attack/mass shooting, riots, stampede, etc. should also bepart of the risk communication strategy.
Blended learning approaches: HEIs are urgently required to upskill in the use of
online platforms/modes alongside classroom/ﬁeldwork teaching. To regularize theblended approach, a fair share of lectures/classes every year/semester can be
conducted online.
Networking: to enable knowledge and information sharing during emergencies,
universities should establish strong networks with local governments, otheruniversities, the private sector, civil society organizations and communities. These
partnerships will help to advance the risk reduction agenda not only at HEIs but inthe larger system within which HEIs exist.
Designated funding: universities should set aside reasonable designated funds toboost research and innovation against all forms of hazards. In addition, they need toplan for tough times when disasters have widespread impact on all sectors of theeconomy.

Managing andresponding topandemics

3.2.2.4 Personal responses to COVID-19. Figure 5 highlights a wide range of personal
response activities carried out by respondents in response to COVID-19. It shows thatmajority of the respondents have been giving online classes while working from home. Thismeans the respondents have spent considerably more time getting used to providing online
lectures, attending online courses and webinars while also managing routine academic
administration and research activities. This leaves little time for conducting additional
activities such as community services or even shopping for their routine needs. Moreover,owing to the nature of coronavirus disease and its mode of contraction, the assistanceprovided in the form of community service remains extremely limited.
3.2.2.5 Personal challenges in online teaching. Figure 6 highlights the key challenges
reportedly being faced by the respondents in switching to online delivery of lectures.
Majority of the respondents identiﬁed conducting group works, technical difﬁculties (suchas slow internet speed, unstable internet connection, etc.) and maintaining student
motivation (because students are used to studying in a classroom environment) as the top
three challenges they face. The further pointed out that group discussions and assignments
are difﬁcult to effectively conduct in online environment. This was identiﬁed as major
disadvantage for both students and faculty.

Figure 5.
COVID-19 response
activities at personallevel

IJDRBE3.2.2.6 Key lessons from COVID 19: Academic/research continuation on future
pandemics. Key lessons for better preparedness for future disasters were identiﬁed by the
respondents through short descriptive answers. They are summarized as follows: Personal safety: there is a dire need for everyone to take adequate precautions andsafety measures such as wearing masks, optimal personal hygiene and maintaining
physical distance to prevent infections. It is important to rely on authentic sourcesof information, rather than social media posts which are often half baked or
exaggerated.
 Raising awareness on epidemics and pandemics: every academic faculty andadministrative staff at HEIs should get training on adequate and up-to-dateawareness on safeguards against biological hazards. It is common to haveknowledge of local natural hazards, but one must not forget that “disasters” and“risks” can also be from non-natural and human-induced hazards.
 Wider range of teaching methodology and tools: It is important for every HEI topromote and effectively provide resources for teaching by exploring theimmense power of internet. It was recommended that universities provide
suitable exposure and training to faculty, staff and students and also help themwith reasonable resources to learn effectively through Web-based teaching
methods. It is also crucial that the homes of faculty and students alike are
equipped with stable and high-speed internet connection for smooth applicationof various methods.
 Research and innovation: COVID-19 has triggered an urgent need to invent
alternatives to the conventional classroom-based teaching methods. Laboratorybased research has certainly been hit hard owing to restricted movement within andoutside university campuses and social distancing rules that make it hard to
conduct lab-based research in collaborative teams.
4. Key immediate and long-term mitigation measures
The survey results show that many universities do not have BCPs or, in cases where a BCP
exists, have not conducted simulation exercises for a pandemic scenario. Further, at theorganizational level, in most HEIs, the faculty, staff and students face signiﬁcant difﬁculties
in adjusting to the switch to online delivery of classes. This is because of technical issues
such as a lack of strong internet connectivity, unfamiliarity with online classroom/
conference platforms and inability to use different approaches to teaching and learning suchas group work and discussions.

Figure 6.
Identiﬁed personallevel key challenges
of online teachingAs a positive side, the survey also showed that universities have been working
actively with local governments and other partners by sharing data and providing
technical advice. Thus, universities are expected to play a crucial role and contribute tosociety.
Based on the survey ﬁndings, the following recommendations are expected to strengthen
the current disaster preparedness capacity in HEIs.
4.1 Governance/planning (short term)
A planning document such as an emergency management plan/BCP provides thefoundation for risk management. It is crucial to develop a plan based on capacity,vulnerability and needs assessment and to identify clearly what needs to be done ineach stage to manage a disaster and ensure safety on campus. This includes
establishing an incident command system for emergencies and conducting regularmock exercises, drills and simulations to test the plan and determine its effectiveness(APRU, 2015). While developing a campus emergency plan, it is important to make it
an adaptable document that can address a variety of emerging hazards andthat provides strategies and practical approaches to tackle different types ofdisasters.
In addition, universities urgently need to consider carrying out simulation exercises andmaking it a regular disaster preparedness activity. The simulation exercise must takedifferent scenarios including pandemics into account because responses may differ fromdisaster to disaster.
4.2 Infrastructure/educational system (short term)
The lessons learned from the current pandemic that are addressed in the survey include theneed to adopt a new and innovative educational system. This requires both technicalsupport in the form of training and ﬁnancial support with investment in high-speed andstable internet connectivity not only on campus but also at home. Furthermore, it is crucial
to include clearly stated guidelines in a BCP on the procedure to be followed for making
changes while conducting crucial ceremonies and activities such as graduations,commencement ceremonies and examinations.
4.3 Physical/mental health
A sizeable portion of students live in the university dormitories and rented
accommodations. Owing to strict lockdown in many countries, the students
experienced high level of stress. Many students also experienced ﬁnancial stress andwere unable to pay rent, utility bills or internet as many students’ support from family
also dried because, at times, family members also lost jobs. Owing to lack of planned
approach and inexperience to work from home, many felt that their functionality isimpacted. On the contrary, a sizeable number of people also reported that they weremore productive while working from home and some felt that their workload isincreased after the pandemic related restrictions are implemented.
4.4 Reopening of campuses
There is a big uncertainty around re-opening of university campuses. In many
university campuses, classroom or face-to-face teaching is completely stopped until
July 2020 or later. In addition, a number of universities have shifted the dates of theirentrance/ﬁnal exam and of semester start/ﬁnish without further notice of new dates ofManaging andresponding topandemics

IJDRBE

conducting these activities. Senior high-school students and ﬁnal year university
students are facing unique situation owing to ongoing restrictions around organizing
welcome/orientation/graduation ceremonies. Current students are also going throughanxiety owing to uncertainty around campus reopening dates and many are
considering to return to their families to save on rents and other expenses.
5. Conclusion
Most universities do not have experience dealing with a pandemic such as COVID-19,
unlike responding to natural disasters. Therefore, this is their ﬁrst signiﬁcant
experience with changing the styles, systems and methodologies of education,
research and contributing to society. This sends a clear message regarding thenecessity to prepare for both frequent disasters and unfamiliar ones such as chemical,
technological and biological disasters that take a heavy toll. The most importantelements for creating a disaster-resilient university are developing an all-hazard plan,
conducting regular trainings and exercises, developing strong community
partnerships (Kapucu and Khosa, 2013) and taking innovative approaches to
education and research.
Universities in English-speaking countries are facing a rather unique challenge of loss of
income. However, they possess a rich experience of providing online classes. Therefore, thisis the time to promote north–south collaboration among universities continue to generate,
distribute and share knowledge even when a pandemic such as COVID-19 disrupts theworld order.
This study has helped to better understand challenges faced by and opportunities
available to HEIs. HEIs will have to consider post-COVID-19 scenarios seriously andhow they can remain relevant to their students and the society at large. Internet-basedteaching is relatively new for most universities in Asia, and to some extent, is forced.
However, this also opens a dialogue to prove the effectiveness of HEIs in creating aknowledge society. Beyond digital technologies, HEIs need to reposition themselves toaugment the skills needed to prepare a workforce that is better prepared to respond to
future disasters of a similar scale.
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Managing andresponding topandemics

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Further reading
Djlante, R., Shaw, R. and DeWit, A. (2020), “Building resilience against biological hazards andpandemics: COVID-19 and its implications for the Sendai framework, in ”, Progress in Disaster
Science, Vol. 6, doi: 10.1016/j.pdisas.2020.100080.
Corresponding author
Rajib Shaw can be contacted at: shaw@sfc.keio.ac.jp

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Progress in Disaster Science 6 (2020) 100090

Contents lists available at ScienceDirect

Progress in Disaster Sciencejournal homepage: www.elsevier.com/locate/pdisas

Governance, technology and citizen behavior in pandemic: Lessons fromCOVID-19 in East Asia⁎

Rajib Shaw a, , Yong-kyun Kim b, Jinling Hua aabKeio University, Japan
Ministry of Interior and Safety, Republic of Korea

A R T I C L E

I N F O

Article history:
Received 29 March 2020
Accepted 30 March 2020
Available online 06 April 2020
Keywords:
COVID-19 pandemic
Governance response
Emerging technology
Citizen behavior
East AsiaA B S T R A C T

Corona Virus (CODID-19) was ﬁrst reported in Wuhan in December 2019, then spread in different parts of China, andgradually became a global pandemic in March 2020. While the death toll is still increasing, the epicenter of casualty
has shifted from Asia to Europe, and that of the affected people has shifted to USA. This paper analyzes the responses
in East Asian countries, in China, Japan and South Korea, and provides some commonalities and lessons. While countries have different governance mechanism, it was found that a few governance decisions in respective countries madea difference, along with strong community solidarity and community behavior. Extensive use of emerging technologies
is made along with medical/health care treatment to make the response more effective and reduce the risk of the
spread of the disease. Although the pandemic was a global one, its responses were local, depending on the local governance, socio-economic and cultural context.

1. Introduction
It is now widely acknowledged that the Corona virus (COVID-19, as formally known) was ﬁrst reported in Wuhan, China in December 2019, andwas recognized by Chinese authorities as a new virus in January 2020.
WHO (World Health Organization) declared this as a PHEIC (Public Health
Emergency of International Concern) in the end of January 2020. After the
initial delay in the source point (Wuhan), Chinese authorities took utmost
efforts to control the spread of the disease, however, it has already started
impacting other parts of China as well as other countries during mid to
end of January. A term “infodemic” has been used by the WHO Director
General at the initial stage of the spread of the disease (during midJanuary 2020: [1] in Lancet), which seems to be still valid while writing
the paper in the end of March 2020. WHO colleagues have warned the tsunami of information, especially with social media, which many times callfor panic situation. We have observed this in several countries, as well as
fake news spreading through social media. On 11th of March 2020, WHO
has declared this as a global pandemic, and as of 23rd of March 2020, thevirus has affected 172 out of 195 countries.
While the statistics of infected people, casualties changing rapidly overtime, it is very difﬁcult to put a number. As of 29th of March, there are morethan 30,000 death reported, while more than 23,000 people are in criticalconditions globally. More than 650,000 people are affected. Although it isearly to make any comment on the nature of its spread, a few characteristics
can deﬁne this new virus as follow:⁎ Corresponding author.
E-mail address: shaw@sfc.keio.ac.jp. (R. Shaw).

- High rate of spread: Within three months the virus has spread globallyand is considered as a global pandemic. The rate of its spread is high,which happened due to higher mobility of people in a globally interconnected world. It can be said that people to people transmission rate ofvery high.
- Aged and low immune people more vulnerable: Data shows that theaged population [2] and people with low immunity (with diabetes orother chronic disease) are more vulnerable to this virus.
- Differential recovery rate: While the global average of recovery rate isrelatively low (like 28 to 30%), different countries have differential recovery rate. While China, Korea, Japan has relatively high recovery
rate, Europe, Iran, USA showed relatively lower recovery rate. Of
course, this is constantly changing, and hopefully gets better soon.
Over last few weeks, there are several words which got signiﬁcant attention like: “community spreading”, “social distancing (physical distancing)”,“self-isolation”, “14 days quarantine”, “lockdown,” “break the chain” etc.
All these are used for one purpose, which is to stop spreading the virus. Although there are reported use of medicines from different countries (without proper conﬁrmation); there is no conﬁrmed medicines used to cure thisvirus, or no vaccine available for COVID-19 as of March 23, 2020. Thus, theonly way to stop the spread is to isolate us from social gathering or masses,
and isolate conﬁrmed people for quarantine. This process needs a combination of strong governance, use of existing and next technologies in innovative ways, and strong community participation and solidarity. Anderson
et al. [3] made interesting analysis on how the country-based mitigation
measures inﬂuence the course of epidemic (while they wrote the paper,
the COVID-19 status was not a pandemic).

http://dx.doi.org/10.1016/j.pdisas.2020.100090
2590-0617/© 2020 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.
0/).

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Progress in Disaster Science 6 (2020) 100090

March, when USA declared emergency), the virus has taken a signiﬁcantnumber of lives, affected a large number of people, and brought down
many countries, including the economic hubs under lockdown. Several
countries have made travel bans, lock down of cities and provinces,which has also impacted signiﬁcantly the local as well as global economy.
As of 27th February 2020, a report by Mckinsey [6] has identiﬁed six
global clusters as follow: Mature propagation (china complex), Early propagation (East Asia and Middle East complex), New propagation (Western
Europe), and No propagation (Africa and America complex). However,one month has changed the scenario, where Western Europe complex has
become the new epicenter, and America has observed a signiﬁcant propagation. Based on the simulation, Mckinsey [6] proposed three global scenarios of quick recovery, global slowdown and global pandemic andrecession. This would affect differentially the second and third quarter ofthe year. While the base scenario talks on the control of spread in East
Asia in Europe in early second quarter, the early recovery predicts that it
would be in late ﬁrst quarter, while the recession/pandemic scenario
talks about middle to late second quarter.

While acknowledging that governance, citizen participation/awareness, penetration of technology varies from country to country, this paper
makes a modest effort to analyze the experiences of China, Japan and
Korea as East Asian cluster. Time series analysis of the key governance decision is made and its correlation with the spread of the virus within thesethree countries are observed. A few common lessons are drawn, which havelarger implications to the society in this critical phase of COVID-19 global
pandemic.
2. Global chronology of COVID-19
WHO Beijing ofﬁce got the ﬁrst information of an unknown virus on
31st of December 2019. From that point, three months are passed. In thissection, a few global measures (mainly excluding East Asia, which will be
described later), especially the role of WHO is narrated. Within two
weeks from the ﬁrst report in WHO Beijing ofﬁce, ﬁrst overseas case was reported in Thailand on 13th of January 2020. WHO Director General met
Chinese President on 28th January and declared it as PHEIC (Public Health
Emergency of International Concern) on 30th January. On the following
day, Italy declared a national emergency with two case reported there.
The virus spread continued in China as well as overseas after that, and on
11th February WHO has named the virus as COVID-19. A United Nations
CMT (Crisis Management Team) was formed with WHO as the coordinating
agency. WHO has appointed a few prominent persons as their COVID envoy
on 21st of February to provide advices to different countries. A series of missions were organized by WHO team: one in Italy (24th February), one joint
mission in China (25th February), and one in Iran (2nd March). 24th February was the time when the global epicenter has started shifting from China
to other countries, with number of affected people outside China crossingthat within China. Two major clusters were observed, apart from Kore
and Japan: one in Iran and the other in Europe (northern Italy). Early
March showed steady growth of affected people globally. WHO declared
its research road map on 6th of March, and on 7th of March, it was foundthat the virus has affected 100 countries, and more than 100,000 people.
This prompted WHO to declare COVID-19 as a global pandemic on 11thof March, and USA declared national emergency on 13th of March. Fig. 1
shows the number of affected people globally with key WHO decisions
stated above.
The above description shows that within two months (from 13th of January, when ﬁrst case was reported in Thailand, outside China to 13th of

3. Chronology of events in East Asia and key policy decisions
Fig. 2a shows a comparative analysis of total number of conﬁrmed, recovered and death in China, Korea and Japan. Fig. 2b shows the same on
daily increase in these three countries. In both of Figures, since the numbers
in China exceeds that in Korea and Japan by a signiﬁcant percentage, thevalues are provided to show the highest numbers in China. China sees asharp increase in number of conﬁrmed cases from the third week of January, while a sharp increase in both recovered and death from the ﬁrst
week of February. Korea saw a sharp increase in number of cases fromthird week of February, while Japan saw an increase in the ﬁrst week ofMarch.
3.1. China
Detailed time series analysis of China is presented in Hua and Shaw[7], where the responses have been divided into ﬁve phases: 1) very
early phase (up to 31st of December 2019), 2) investigation phase (upto 20th of January 2020), 3) early intensiﬁcation phase (up to 31st ofJanuary 2020, 4) criticism, agony and depression phase (up to 14th ofFebruary 2020) and 5) positive prevention and curative control phaseFig. 1. Growth of globally affected COVID-19 affected people with key WHO decisions (drawn by authors with basic data from John Hopkins Corona virus Resource Center[4] with WHO rolling updates [5].
2

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Progress in Disaster Science 6 (2020) 100090

Fig. 2. a. Total number of conﬁrmed, recovered and death in China, Korea and Japan. Panel b. Daily increase of conﬁrmed, recovered and death in China, Korea and Japan.

(up to 29th February 2020). This paper also looks at the other events in
March until 25th of March 2020. While looking at the key policy decisions taken over the course of action, a few clusters can be observed asfollow (Fig. 3).

symptoms. This was a key turning point to identify new cases of affected
people. A sharp increase in the number is also observed as a result ofpolicy decision taken in Cluster 1 and 2 (Fig. 3). To stop spread of thedisease, it was important to identify all possible sources. Thus, the strictdecisions taken in cluster 1 and 2 were crucial. QR code was introduced
for all residents on February 18, and this was a good check to distinguish between the affected and non-affected people. The next couple
of weeks were devoted to implement the policy decisions and be vigilant for its violation.

Cluster 1 (20–25 January 2020): On 20th January 2020, Dr. Zhong
Nan Shan made ofﬁcial announcement in CCTV about the new type ofvirus identiﬁed in Wuhan, followed by announcement of emergency
in Hubei province on 22nd of January, and decision on constructing
new hospitals on 23rd and 25th of January. During this cluster thesource area went under lockdown, and emergency response started ofﬁcially. Based on these key decisions, emergency supplies including
goods and medical teams arrived in Wuhan from different parts of thecountry.

Cluster 3 (10–13 March 2020): Visit of President Xi Xinping to Wuhan
was a key turning point of the epidemic, which sent a message that thedisease spread was under control. On 11th of March, WHO declared
COVID-19 as a global pandemic. On 13th of March, the city of Qianjiangcity in Hubei province has opened its business for the ﬁrst time since thelockdown. This was also another indicator that the situation within
China is under control, with appropriate preventive and curative measures are placed.

Cluster 2 (2–5 February 2020): On 3rd of February 2020, city sanitization started with public spaces, parks etc. On 5th of February, a majordecision was taken on “no one will be spared”, which enabled the government ofﬁcials to enter into people's house and check virus
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Progress in Disaster Science 6 (2020) 100090

Fig. 3. Chronological changes and key policy decisions in China.
[Source: This ﬁgure was prepared by the authors using original data from: Sina, Tiki-Toki, Caixin, Baidu, seereferences].

and 6) provision of free medical treatment of the affected people not having
medical insurance in Taiwan. The entry from Europe and middle east was
restricted on 11th March, and total travel ban was announced on 19th ofMarch to be effective from 24th of March to 7th of April. On 25th March,
all night entertainment was banned, and gathering more than 100 people
in one place was prohibited. Experience of Taiwan points out that an
early level of risk identiﬁcation, risk understanding and risk control andmitigation are key to prevent the spread of the disease. Prior experienceof SARS may have been utilized to take early decision making, along with
the inputs from the experts.

Cluster 4 (19–22 March 2020): This cluster is characterized by the affected people arriving from overseas. The case of affected people entering the country from overseas was noticed on 6th of March 2020
reported in Shanghai and Shenzhen. This sent an alert to the Chinese authorities for the preparation of the returnees from overseas countries
and urged stricter control on entry to the country. On 19th of March,in-bound ﬂights to Beijing were advised to divert to other nearby airports aiming to reduce the burden to the capital city, and ﬁnally all overseas ﬂights to Beijing was cancelled on 22nd of March. Selected
hospitals were designated as specialized hospitals to treat the affected
people, which other hospitals started sanitization. On 23rd of March,
Wuhan lifted emergency and lockdown, however full normalization oflife was aimed until 8th of April.

3.2. Japan
Japan reported the ﬁrst case of COVID-19 between 10 and 15 January
2020 from a Chinese national who travelled from Wuhan. The second
and third cases were reported on 24 and 25th January. It gradually spreadthrough tourism industry (like bus driver, tour guide etc.). During 28th January to 17th February, Japan evacuated more than 800 Japanese nationalfrom Wuhan through ﬁve chartered ﬂight. A detailed description of appearance of different cases in Japan can be found in Wiki [8]. Here, a few criticalissues on Japan's approach is described below:

In case of Taiwan, the time series analysis points out an early preparation. As early as 31st of December 2019, Taiwan announced medical advisory (14 days self-vigilance, wearing mask, temperature check etc.) to
inbound visitors on the Wuhan and started medical test. Speciﬁc warning
was issues to all in-bound people from Wuhan on 6th of January, and was
repeated four times (10th, 11th and 17th January). A team of experts wasdispatched to Wuhan on 6th of January to identify the new disease spread.
There was an early warning issued on restraining and legal actions on fakenews spread, which was also repeated several times (11th, 17th, 21st and23rd January). First conﬁrmed case was reported on 21st January in
Taiwan, which also prompted some other key decisions. To protect panic
buying, the government bought masks, and started its own distribution system through national insurance card. Number of masks entitled per insurance card was strictly monitored, and masks were distributed free ofcharge in the rural areas. This system started at the early stage (3rd of February), and system was developed and customized based on the need andsupply of masks, and ﬁnally the online shopping system started on 12thof March.
Other measures in Taiwan include: 1) introduction of health declaration
card at entry points (airports and ports) on 11th February, 2) pre-entry electronic health declaration on 14th of February, 3) issuing travel advisory to
mainland China (in January), Korea and Japan (on 22nd February), 4) provide special allowance to all medical staffs (from 23rd of February), 5) provide ﬁnancial assistance to family of affected people (on 11th of March),

Diamond Princess Experiences: The Cruise ship “Diamond princess”
arrived at the port of Yokohama on 3rd February 2020 and received
world attention due to reported conﬁrmed case in the ship. On 5th February, after a report of conﬁrmed case, passengers were asked to stay intheir rooms in the ship for quarantine and to avoid spread. At that time,
there were 3711 individuals, which includes 1045 crew members. Although there was an initial delay in testing, Disaster infection Control
Team (DICT) under the Japanese Society for Infection Prevention andControl started conducted test in the ship along with DMAT (Disaster
Medical Assistance Team) [9]. DICT team comprised of approved infection control doctors, approved infection management nurses, as well as
experts from university hospitals and other institutions. The crew members were provided with personal protective equipment (PPE) andinstructed on appropriate IPC (Infection Prevention and Control) practices. The passengers were given thermometers and asked to record
their body temperatures. Those passengers with lab-conﬁrmed
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Fig. 4. Basic concept of countermeasures of COVID-19. (Translated and prepared by authors from original ﬁgure of MoHW [13]).

COVID-19 were disembarked and transferred to an isolation ward at
healthcare facilities [10]. There was a zoning planned in the ship forthe infected areas, as well as to store the infection prevention gears.
With regards to the passengers, guidance was given through the incruise announcement repeatedly, and the video on the appropriate
ways to remove masks and to sanitize ﬁngers, created by the DICT,
was delivered to the smart phones provided to each passenger for
public awareness. As of 18th February, there have been 531 conﬁrmed cases (14.3% of all individuals on board on 5 February), including 65 crew and 466 passengers. Based on the number of
conﬁrmed cases by onset date, there is clear evidence that substantial transmission of COVID-19 had been occurring prior to implementation of quarantine on the Diamond Princess on 5 February[10]. The disembarkation of all passenger was completed on 27th
February.

epidemiological investigation”. On 25th February, MHLW prepared“Cluster Response Section,” in accordance to the Basic Policies forNovel Coronavirus Disease Control. The cluster approach targeted to
identify the cluster to spread the disease, and quickly take actions tostop the spread from the clusters. Japan has identiﬁed 15 coronavirus
clusters nationwide in its ﬁrst “cluster map”, released on 16th March.
Although the data changes over time, in the map, the biggest cluster,which accounts for more than 80 cases, involves four live music venues
in Osaka. Another live house in Sapporo was also identiﬁed as a cluster[8]. Keeping in mind the increasing growth of affected patients, as wellas identiﬁcation of clusters, the Governor of Hokkaido had announced“a state of emergency” in Hokkaido on 28th of February and urged
the residents to stay indoor over the weekend.
Temporary closure of schools across nation: Prime Minister Shinzo
Abe had requested for the voluntary closure of school in the last
week of February, and as a result, most of the schools across nations
were closed from 3rd of March 2020. This apparently abrupt decision drew criticism from many schools, teachers and parents since
it was announced with little preparation. However, this decision
was on the crucial trigger to increase the urgency in people's understanding and actions. The only effective way at the moment to prevent the spread of this novel coronavirus is decrease personal
contact among people and to increase personal hygiene, such as
hand-washing [8].

Border control phase to Infection spread phase: Japan has been
doing Border Control measures (Mizugiwa Taisaku in Japanese) to control the spread of infections in Japan. The measures in Diamond Princess is the reﬂection of that. Also, Japan had put speciﬁc measures tocontrol inbound visitors from Hubei province and asking for ﬁlling up
health forms, as well 14 days quarantine. However, from 15th of February, there have been reports of transmission cases for which routes
could not be identiﬁed. In such situation, the focus shifted from Boarder
control to infection spread control phase [11]. As of February 20, threedeaths have been reported, and severe cases have started to be reported
in the elderly and patients with underlying diseases. As per the experts,
during the epidemic phase, the treatment of the serious patients was required. Border control measures continued with quarantine restrictions
on travel of passengers from China and Korea on 5th of March, which
gradually extended to other high-risk countries also. Once the diseasestarted spreading, it was essential to identify the clusters from where
it started spreading, which is stated below.

Basic Policies for COVID-19: On 25 February, the Abe Administration
adopted the “Basic Policies for Novel Coronavirus Disease Control”
based on the advice that it received from the Expert Meeting. First,
the new policies advised local medical institutions that it is better for
people with lighter, cold-like symptoms to rely on bed rest at home,rather than seeking medical help from clinics or hospitals. The policy
also recommends people at a higher risk of infection -including the elderly and patients with pre-existing conditions – to avoid hospital visits
for such non-treatment purposes as completing prescription orders byletting them ﬁll the forms over the telephone instead of in person. Second, the new policies allow general medical facilities in areas of a rapid

Cluster approach: The analysis by Tohoku University virology professor Hitoshi Oshitani, who is on a government panel of medical experts,
comes as Japan ramps up contact tracing efforts with a focus on “active

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and conduct a thorough investigation on all visitors from Wuhan, leading
to a transparent disclosure of processes and results [15].
On January 30 and 31, 2020, the Ministry of Foreign Affairs, MoIS, andrelated ministries worked together to transport Koreans residing in Wuhan,
China, back to Korea. MoIS formed a joint government support group to ensure the returnees were regularly monitored while adhering to a 14-day
quarantine at the government facilities in Asan City and Jincheon City.
Thanks to the government's transparent and proactive response, step-bystep strengthening of foreign entry procedures, and voluntary participation
by citizens to self-quarantine and self-isolate, there were only 30 conﬁrmed
cases of COVID-19 by February 18. The situation seemed to gradually beturning to a stable phase.

COVID-19 outbreak to accept patients suspected of infection. Before
this, patients could only get tested at specialized clinics after making
an appointment with consultation centers to prevent the transmissionof the disease. Third, the policy asks those with any cold symptoms totake time off from work and avoid leaving their homes. Government ofﬁcials urged companies to let employees work from home and commute
at off-peak hours. The Japanese government also made an ofﬁcial request to local governments and businesses to cancel large-scale events.
Telework has been promoted very strongly with the private and publiccompanies. However, in spite of several appeals, it was found that only 13%
of are doing telework, while 38% who wish to do telework could not due toseveral issues, including technical problems [12]. The survey was conducted between 9 and 15 March with 21,000 company employees.
On 5 March 2020, Prime Minister Abe introduced a draft amendment to
the “Special Measures Act to Counter New Types of Inﬂuenza of 2012”. This
would allow the Prime Minister to declare a “state of emergency” and mandate the prohibition of large-scale gatherings and the movement of people
during a disease outbreak.
The basic countermeasures of COVID-19 is presented in the Fig. 4(MoHW, [13]). There are three phases considered in this approach: 1) domestic spread prevention, 2) prevent spread of infection, and 3) Prevent severe spread. It seems that Japan is currently in the second phase, whichaims at preventing spread of infection. The key target is to reduce the number of affected people by lowering the peak, and strengthening medical system. The crucial in this phase is to prevent the outbreak and control the
speed of infection, so as to provide enough time to the medical facilities
to get prepared. This can be done also with strengthening other countermeasures like border control, identifying key clusters, closing of school,
promoting telework, and avoiding gathering of people in public places
like abandoning key sports events, festivals (like cherry blossoms viewing)etc.

(2) The rapid escalation of COVID-19 by members of the “Shincheonji
Church of Jesus”: As the number of conﬁrmed cases surged due tothe unexpected “Shincheonji” emergency, the Korean government
raised the alert level to Red (Level 4) and put all available resources
to tackle the crisis along with designating special management regions
against infectious diseases.
On February 19, the KCDC identiﬁed the 31st conﬁrmed case who was a61-year-old Korean female, a member of Shincheonji. Just after that the
number of conﬁrmed cases spiked and most of them came from the
Shincheonji Cluster. The COVID-19 situation in Korea took on a completely
new aspect of the noble crisis situation. Consequently, the Daegu City government acquired a list of the 9336 Shincheonji members from the headquarters of the Shincheonji and cross referenced the list with the KCDC,
then asked all members to be tested for symptoms and to self-isolate. The
Korean government subsequently scaled up the alert level to Red (Level4) and took extreme proactive actions in order to avoid a nation-wide transmission. As a follow up activity, Central Disaster and Safety Countermeasures Headquarters (CDSCHQs), headed by the Prime Minister, were
installed [16]. The HQs focused on isolating and treating potential casesin the specially managed regions of Daegu City and Cheongdo-gun in
Gyeongbuk province, and in other regions conducted epidemiological investigation and environmental disinfection to prevent a sporadic community epidemic as well as to identify Shincheonji-related cases.

3.3. Republic of Korea (South Korea)(1) The occurrence of ﬁrst conﬁrmed case and subsequent successful initialmanagement: From the beginning of the COVID-19 situation, the Korean government, centered around the Korea Centers for Disease Control and Prevention (KCDC), has shared information with relatedorganizations and established an effective response system.

(3) Protecting Daegu and Gyeongbuk and stopping a national spread: The
government's transparent and democratic response, the voluntary participation of citizens, and the efforts of hidden heroes prevented the
spread of Covid-19 nationwide.
On February 26, the total number of conﬁrmed patients was 1261, andthe rapid increase raised the sense of a crisis across the country. Amongthem, the conﬁrmed cases in Daegu and Gyeongbuk were 75% of thecases with 945 conﬁrmed patients. Instead of blockading the Daegu andGyeongbuk regions, the Korean government conducted a thorough surveyof the members of the Shincheonji Cluster, who triggered the community
spread in Daegu and Gyeongbuk; feasibly across the country, and conducted around 10,000 diagnostic tests per day to quickly identify conﬁrmed cases.
At the same time, measures were implemented to secure the necessary
beds for the cases with the highest severity, and to solve the shortage of
medical staff. In cases where life was threatened, patients were hospitalized
and placed in negative pressure rooms or moved to infectious disease designated hospitals. Non-threatening cases were provided with medical support
at a designated ‘Life treatment Center’ within each region. Moreover, Doctors and nurses from other regions voluntarily and swiftly ran to Daegu andGyeongbuk to relieve the shortage of medical personnel. The Korean government also expedited the hiring of 724 public health doctors earlier
than originally planned and deployed them to each region. On March 4,
the KCDC developed and implemented standard operating guidelines fordrive-through testing centers as an effective and rapid diagnostic test processing destination versus hospitals; multitudes quickly opened soonafter. Additionally, 254 hospitals were designated as ‘for public use;’ a hospital the public could visit without fear of infection.

When reports were received of pneumonic patients arising from an unknown origin in Wuhan, China, in December 2019, the KCDC strengthened
the quarantine process for people entering Korea from the Wuhan region incooperation with Chinese health authorities and the World Health Organization (WHO). After a 36-year-old woman of Chinese nationality was classiﬁed as suspected of hosting the novel disease and quarantined on January
8, 2020, the Korean government issued a Blue Alert Level (the lowest
among the 4 alerts along the national crisis management system) andestablished a joint response system by sharing immigration information
among the KCDC, the Ministry of Interior and Safety (MoIS), the Ministryof Justice (MoJ) and other related agencies.
On January 20, 2020, the KCDC conﬁrmed the ﬁrst imported case of
COVID-19. The case was a 30-year-old Chinese woman living in Wuhan,
China, and four days later conﬁrmed the second imported case; a 55-yearold Korean male working in Wuhan. On the same day, the Korean government raised the alert level from Blue (Level 1) to Yellow (Level 2) and set up
the Central Discharge Countermeasures Headquarters (CDCHQs) to initiate
the 24-hour emergency response system [14]. In addition, the KCDC began
to conduct a thorough survey of all visitors from the Wuhan region to prevent the inﬂux of potentially infected people, and to strengthen the quarantine and public relations efforts to prevent the spread of COVID-19 during
the lunar new year holiday season; a time when millions of people are on
the move. Accordingly, President Moon emphasized that the government
should mobilize all available resources to prevent the spread of COVID-19
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The Korean government continued its vocal call and support for citizenry participation in personal hygiene practices and social distancing.
The MoIS, by this time, had developed and released a safety protection application for self-isolated people to self-diagnosis their health status, to be
informed of self-isolation life rules, and to automatically send alerts to a
dedicated ofﬁcial when the person leaves the self-isolation site without approval. Also by this time, as sales and usage of face masks spiked, temporary
mask shortages began to be felt by everyone. To mitigate potential problems, the Ministry of Food and Drug Safety (MFDG) implemented a ﬁveday rationing system for selling and purchasing facemasks.
On March 13, the government prepared guidelines for stronger preventative measures towards the usage of public spaces, call centers, and facilities that could accommodate many people. Religious groups cooperated
with the government measures and calls by holding weekly worships online
and postponing or canceling large-scale religious events.
With the government's proactive actions and citizens' participation, thenumber of conﬁrmed cases decreased to 75 on March 15 and graduallybegan to show a stabilizing trend.

and gradually to all over the country, there was strict measures not topromote fake news and panic from the initial stage. Supreme court advisory was issued on the fake news at an early stage. Also, different provincial governments helped the most affected province and city (Hubei
and Wuhan) with different types of supplies and resources.
Transparency and democracy: South Korea proved to be successful in
responding to COVID-19 through disclosing accurate information transparently and holding to the democracy of the whole society [17]. Since
January 20, 2020, when the ﬁrst COVID-19 case was conﬁrmed, the Korean government, centered around the KCDC, shared relevant information among the WHO, Chinese authorities and other related agencies,
and transparently disclosed the government's responses; leading to voluntary participation of citizens without protest.
The national and local governments of Korea quickly identiﬁed the
movement path of the conﬁrmed cases through big data analysis; data obtained through credit card usage history, CCTV analysis, etc., and disclosed
them transparently through the Cell Broadcasting System's (CBS) mobile
service and government's website [18]. The citizens who received the information were able to determine whether or not they had contact with the
conﬁrmed case. If so, most citizens voluntarily reported to a public healthcenter. If they showed any signs of having the virus, a diagnostic test was
requested. Due to the fact that the Korean government is well prepared
for testing and conducting diagnostic analyses, all potentially infected citizens were able to be promptly analyzed, resulting in preventing the spreadof infectious diseases.

(4) Preventing overseas re-inﬂow and strengthening physical distancing:
The Korean government applied special entry procedures to block theinﬂux of COVID-19 from foreign countries, and shifted physical distancing policy from a voluntary participation to a strong administrative
recommendation.
With the declaration of the Corona Pandemic by the WHO and the rapid
expansion in the number of conﬁrmed cases in Europe and the UnitedStates, concerns about a re-inﬂux of COVID-19 hosts from overseas to
Korea began to increase.
On March 15, the Korean government expanded the scrutiny of special
entry procedures to those entering from ﬁve European countries: France,
Germany, Spain, the UK and the Netherlands; on March 19, travelers
from all countries received special scrutiny. In addition, the government
strengthened countermeasures to block the re-introduction of foreign risk
factors into Korea; including a 14-day self-isolation for all travelers from
Europe and a special travel advisory for Koreans, urging the cancellationor the postponing of all overseas trips until mid-April at the very earliest.
Moreover, the Korean government started to support the return of Korean
citizens residing abroad; starting with those in Iran. Upon arriving at Incheon Airport, returnees were tested, and if found to be negative of thevirus, they agreed to self-quarantine at home. If found to be positive, returnees were taken directly to a hospital for treatment.
The two policies of postponing the start of schools' spring semesters andforcing social distancing had been stronger measures that the Korean government took to tackle the COVID-19 spread. It was on March 18 that the
special decision was taken to delay the start of the spring semester for
daycare centers, kindergartens, elementary schools, junior high schools,
high schools, and special schools nationwide by April 6. On March 21 and22, the government strongly recommended to facilities with a high risk ofcollective contagion, such as religious facilities, indoor sports facilities,
and entertainment venues, to close their doors to the public for two
weeks, and asked all citizens to refrain from gathering at multi-use facilities
and indoor sport arenas, or doing outdoor activities collectively for thesame period.

Clear roles & responsibilities and Uniﬁed efforts: An effective response against a novel infectious disease like COVID-19 requires avery specialized knowledge and expertise, thus it is essential to develop
and implement a holistic response plan by an expert group. From the beginning of the COVID-19 response, the Korean government set up adecision-making process centered around the quarantine countermeasure headquarters operated by the KCDC. On top of that, as thegovernment-wide response became more vital due to the rapid increasein the number of conﬁrmed cases, MoIS took charge of the monitoringand management of people self-isolating, ﬁnding and surveying those
who had visited the Wuhan region and may be contagious, locating
and securing temporary living facilities and lifetime treatment centersthrough Countermeasures Support Headquarters (CSHQs). This delineation of roles and responsibilities between the responsible agency(KCDC) and the coordination agency (MoIS) made it possible for the
KCDC and the Ministry of Health and Welfare (MoHW) to focus on epidemiological investigations and responses to the infectious disease.

This effective response system was developed based on the double-loop
learning process during the MERS experience in 2015, the novel swineorigin inﬂuenza A(H1N1) in 2009, and severe acute respiratory syndrome(SARS) in 2003. Consequently, the successful COVID-19 response can be directly attributed to the leadership of the President to accurately understandthe ﬂuctuating situation and emerging risk factors, and make accurate decisions based on the advice of expert groups, and the dedication of the Prime
Minister who stayed in the Daegu and Gyeongbuk regions for three weeks
to concentrate the capabilities of all ministries to cope with the crisis
situation.

4. Commonalities and key lessons
4.1. GovernanceExpert based advices: Japan took a different cautious approach not tocall for a national emergency and lockdown. The legislation in Japan
does not permit a forced lockdown, but a request/advisory for the lockdown. Japan's decision was based on close interaction with the expert
group, which comprised of a diverse experts from the medical side, as
well as economic, political and social side. Based on the expert advices,
regular government brieﬁngs and press meet by the Prime Minister,

Different countries have different styles of governance. This section
summarizes some of the key lessons on governance at different level.
4.1.1. National government's decision
Strong government control: China showed a very strong government control from the third week of January when the COVID-19 case was ofﬁcially conﬁrmed. Apart from the lockdown in Wuhan, Hubei province,
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country became serious, members of non-proﬁt organizations such as the
Jeju Women's Association of Seogwipo city and the Cheonan city HappinessSupport Group started to produce face masks for those incapable of easily
securing supplies far from home such as the elderly and the disabled.
China also showed strong community governance with people making
their community watch to strictly maintain the entry or exit from the community. This was not only implemented in the urban areas but also in therural areas.

minister or senior ofﬁcials were arranged. Japan's governance approach
was to ﬂatten the growth curve, so that the health response mechanism
has enough time and resources to respond to the situation, and thatwould possibly provide enough time to develop the vaccine and preventive measures.
4.1.2. Provincial/local government's decision
Proactive prevention activities: The Seoul and Gyeonggi-do governments; with the highest populations in Korea, took proactive measuresfrom the initial outbreak. The Seoul City government promptly produced and distributed guidelines on special entry procedures detailingthe diagnosis and preventive tips for a corona virus, and temporarily restricted the use of large public squares. In addition, after a mass infection occurred at the Guro Call Center, the Seoul city government
urgently conducted a survey of 417 private call centers and feasibly
prevented a spread of COVID-19 by improving the environment for telecommuters [19]. The government of Gyeonggi-do, where the headquarters of the Sincheonji Church of Jesus is located, conducted a thoroughinvestigation of all Sincheonji churches in the region and ordered thetemporary closure. Also, it ordered the members of the Shincheonji toreport to local public health centers and to self-isolate.

4.2. Innovative technologies
Several innovative technologies were used in different countries to
identify affected people, to check their mobility, to reduce the risk of contamination, as well as to develop proactive recovery strategies and actions.
Artiﬁcial Intelligence (AI), Big data, 5G technologies were used in combination with other emerging technologies like drones, automated vehicles, robotics etc.
In case of China, on 14th of February, the Ministry of Transport ofPeople's Republic of China [20] issued a circular to use new technologies
for addressing COVID-19 risk as well as to develop recovery strategy. Highlights of China's use of technologies are described as follow:
AI: Fudan University and Shanghai city government, along with the
CDC (Center for Disease Control) develop a unique AI based medical
screening and check-up for respiratory blockage, which enhanced the
speed of decision making of the scan system. The system was usedwith more than 93% of Shanghai residents to make quick scan of the respiratory system [21].

In Daegu City and Gyeongbuk Province, where the largest number of
conﬁrmed cases were identiﬁed, the governments established a system
for investigating all members of the Shincheonji and monitoring them exclusively by public ofﬁcials. In addition, when hospital capacities became
overwhelmed by the inﬂux of patients, the government ordered the use ofnegative-pressure beds for the treatment of cases of highest severity only,
and moved the cases with less severity out of the hospitals and into life
treatment centers equipped with makeshift facilities where people could recover. Business sectors, religious group and other regional governments
assisted Daegu and Gyeongbuk during the crisis. For example, companies
such as Samsung and LG, and the religious community provided their training centers and facilities as life treatment centers. Other local authorities including Gwangju Metropolitan City persuaded its citizens to open its
hospitals and facilities for patients from Daegu and Gyeongbuk so that theregions could recover more rapidly.
In case of China, Hubei province showed a strong leadership in
implementing stricter measures within the province. In Japan, Hokkaido
announced an emergency in early March, and restricted gathering in public
spaces. Also, several other prefectures in Japan (like Osaka, Hyogo) advised
not to travel between the prefectures. Tokyo Metropolitan Government also
communicated with neighboring prefectures to advise travel limitations.

Big data: Baidu big data was used to identify clusters of infected people.
People's mobility data was used to identify movement of people fromone place to another during an early stage of spread of the disease,which helped to take critical decisions on lockdown certain high-riskareas. This was also used in the recovery process, when the shops or factories are reopened to identify potential future risk areas as well
[22,23].
5G: 5G data was used extensively in combination with different othertechnologies. Primarily, it was used in transport system to identify themobility of vehicles and related information (like number plates, driveretc.). Combination of drones and 5G was used in the transport system toidentify violation of laws in the emergency time. Thermal camera wasused with helmet of police and other public ofﬁcials for quick thermal
screening of people in Guangdong, and the date was sent using 5G.
Combination of robotics and 5G was used for city sanitization in thepeak period in Wuhan when public services were also at risk. Similarly,
combination of automated vehicle and 5G was used for goods delivery
in certain highly contaminated areas. 5G was also used for telemedical care and advices in the newly built hospital in Wuhan. [21,24].

Prompt dissemination of the movement path of the conﬁrmed
cases: Local governments, in cooperation with the KCDC, quickly identiﬁed the movement path of the conﬁrmed cases and informed the residents of the areas in real-time via mobile text message using the CBS. In
addition, they promoted safety rules through 24-h broadcasts, andposted on the governmental homepages COVID-19 prevention tips
and the movements of conﬁrmed cases so that any citizen could ﬁnd
the information at any time.

Health barcode: A unique health barcode system was developed to
identify the affected people, as described in Hua and Shaw [7]. Hangzhou city was ﬁrst to use this system on 11th of February 2020, which
gradually used in 200 other cities in China [25] For developing thehealth barcode, user sign up for the “close contact detector” app by registering their phone number, name and ID, and then scanning a QR codeon their smartphones [26]. The app will tell them whether they havebeen in proximity to someone who has been infected. The barcode system has three color coding: green (good health), yellow (caution required), and red (infected people), which enable or disable them toentering from different public buildings as well as public transport.
With the health barcode, online mapping of affected people could bedone, and people could avoid the clusters where affected people areconcentrated. If a user is found to have in close contact with the affected

4.1.3. Community governanceCommunity-based activism, such as aggressively ﬁnding suspectedcases and supporting vulnerable groups, was another advantage of Korea
to overcome the crisis. For example, in Chungcheongbuk-do, a safetygroup organized from community units; such as a grassroots women'sgroup and safety guards, actively participated in ﬁnding the peoplesuspected of carrying the virus, and in sympathetically and humanly reported them to the Community Service Center. In Chungju city and
Boryeong city, local autonomous disaster prevention groups and women's
associations voluntarily disinfected multi-use facilities and vulnerable facilities. Furthermore, as the phenomenon of mask shortages across the8

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self-isolation under their own responsibility, and frees-up vital ofﬁcials by
allowing many administrative personnel not to have to visit the selfisolators' home or check their status by phone regularly [30].

person, the app recommends self-quarantine and also send an alert tohealth ofﬁcials. Career's big data was used in combination with Baidu's
location (GPS) data to develop the health barcode. This was also used in
Wuhan on 18th February onward, and eventually to all Hubei province
from 10th March onward. On 21st March, the government announced
to develop health information platform for the whole country using
the same system. Chen [26] argued positive and negative consequenceof the system on the ground that tools like surveillance and epidemic
maps need to be combined with a view of how people react underpressure.

4.3. Citizen behavior
Compliance with citizens' voluntary codes of conduct and refrainfrom large-scale gatherings of religious groups: A group outbreakoccurred in Daegu and Gyeongbuk after the 31st conﬁrmed case was announced; a Shincheonji believer in Daegu, but the national government
did not take any mandatory blockade measures in this regions, instead
provided all ﬁnancial and administrative support so that Daegu andGyeongbuk could overcome difﬁculties. The citizens in Daegu andGyeongbuk also voluntarily participated in refraining from leaving
their homes, self-reported 1339 cases of suspicion, and complied withstricter hygiene rules. The phenomenon of stockpiling daily necessities
did not appear. Citizens from other regions faithfully fulﬁlled thegovernment's request to refrain from visiting Daegu and Gyeongbuk.

Rapid diagnostic test kit and an innovative test method: In Korea,
the development of a kit for rapidly diagnosing the potentially infected
and innovative test methods such as drive-through screening centers,
enabled thousands of people to be tested every day. This large-scale diagnosis for COVID-19 was able to detect and conﬁrm cases in their earlystages, thus lowering the fatality rate and preventing the wide spread of
the infectious disease. The new diagnostic kit using Real-time reverse
Transcription Polymerase Chain Reaction (RT-PCR) reduced test timefrom 24 h to 6 h. This kit was able to be used thanks to the efforts of asmall business company that has been working on development irrespective of deﬁcits and the rapid approval by the KCDC and MFDG.
The KCDC and the MFDG reduced the administrative process, which
normally takes one year from development to approval, to one month,
so that it could be applied quickly in the ﬁeld [27].

All over the country, citizens made washing their hands a daily life
habit. In business ofﬁces, public facilities, and facilities where large numbers of people come and go, hand sanitizers had been prepared so that people could use them freely and frequently. Citizens wore face masks whengoing out in order to prevent the spread of the infection. For example, thethird conﬁrmed person in Incheon on February 25, 2020, voluntarily
stopped working and began self-isolating at home as soon as a suspected
symptom occurred. He even wore a face mask inside the house andrefrained from going out. Thanks to his efforts, all the 23 people who
were in contact with him; including his mother whom he lived together
with, proved to be negative.
Most religious groups also refrained from large-scale gatherings byconducting online worship services and delaying Buddha's Day celebrations, and actively participated in the “Social Distancing” campaign.

In addition, the drive-through screening method made it possible forsuspected cases to receive the result of the COVID-19 diagnostic test fromtheir vehicle within 10 min, reducing the risk of cross-infection. While
the general screening center took 2 samples per hour or 20 possible cases
per day, the drive-through method was able survey 6 people per hour and
60 possible cases per day [28]. The United States and Germany alreadyadopted this driving-thru method as a way to reduce the possibility ofcross-infection and increase the efﬁciency. In Korea, the ‘Walk-Thru Test
Booth’ and ‘Open Walk-Thru Booth’ evolved from the drive-through screening method. For this method, a potential patient enters a booth, and then amedical staff securely outside the booth checks their condition verbally via
an intercom and take on-the-spot samples from patients outside the boothby using a stethoscope. This method takes only 6–7 min per person and results in a much smaller chance of contagion thanks to a complete separation
between patient and doctor. On March 16, the Yangji Hospital, located inSeoul, started to implement this method for the ﬁrst time; on March 25
the Korean government installed the Open Walk-through Booth at Incheon
Airport in order to deal with the thousands of travelers from overseas
countries.

Nation-wide volunteer and donation: By the end of February 2020,
the number of conﬁrmed patients had rapidly increased in Daegu andGyeongbuk, making medical examination and treatment of all conﬁrmed and suspected cases in the regions impossible. Upon hearing
their desperate circumstances, medical doctors, nurses, and clinical pathologists from all over the country moved in to provide medical treatment, assistances, and relief. According to the CDSCHQs, from February
24 to February 27, a total of 853 people (58 doctors, 257 nurses, 201
nursing assistants, and 110 clinical clinicians) participated in volunteer
services [13]. In particular, more than 3000 people applied to volunteer
as a nurse, and Korea was able to ﬁnd hidden heroes such as nurse Kim
who gave up her immigration to the United States in the process of applying for this volunteer service, or nurse Oh who sent a sincere lettersaying, “If I am not selected as a volunteer, I would suffer the fact that
I can't help others in trouble. [31]”. They stayed in Daegu andGyeongbuk for more than a month, devoting themselves to the treatment and prevention of the infection. Additionally, the president of ahotel in Changwon City provided hotel rooms free-of-charge for thevolunteering medical doctors and nurses who had a hard time ﬁnding
adequate accommodations. Efforts were also made to overcome
COVID-19 on the basis of community consciousness, such as donations
from all around the country.

Enhancing self-responsibility and improving administrative efﬁciency using ICT: The KCDC developed a self-diagnosis mobile application to strengthen monitoring by allowing domestic and foreign
travelers entering Korea to self-diagnose fever and health conditions related to COVID-19, and report it to their local health center or the KCDC.
As users typed quarantine-related information such as passport information, nationality, and names in the app, the KCDC was able to monitor
their status during their stay in Korea [13,29].
In addition, the MoIS developed a self-quarantine safety protection mobile application to reduce the enormous administrative costs used to monitor self-isolators by public ofﬁcials for local governments. In general, publicofﬁcials check the status of self-isolators by daily phone or irregular visit,
but they cannot prevent people from leaving home without approval.
This app helped to overcome previous shortcomings by including a GPSfunction, so if a self-isolating person left their home without approval, awarning message is automatically sent and a dedicated ofﬁcial is notiﬁed
and sent to the scene to prevent the patient from violating the selfisolation if necessary. This app allows self-isolating people to complete

Good landlord movement: With the prolongation of COVID-19, consumption contracted signiﬁcantly and the domestic economy wasstarting to stagnate. As the economic crisis for small business owners
or self-employed people with a large rent burden increased, the “goodlandlord movement” that temporarily lowers rent spreads across thecountry. For example, more than 5000 stores in Dongdaemun Market,
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Gwangjang Market, and Tongin Market in Seoul City participated in the‘good landlord’ campaign and cut the rent by 20–30%. In addition, a variety of “Good Landlord Movements”, such as the exemption of franchise commissions from the food brand Chaeseondang, and a subsidyof 1 million Korean won for afﬁliates of mega coffees, gave hope tothe small-business owners facing difﬁculties.

MSMEs (Micro, small and medium enterprises) are possibly the hardest
hit in all the countries need special economic revitalization package.
Socio-psychological impacts and lifestyle changes: Country wide orpartial local down in cities have initiated a different work culture in East
Asian countries, as well as in most of the other countries. Tele-work is
becoming popular, online meetings, online classes in the universities
are getting common, online education for school children becoming obvious. Thus, there has been a life-style change in many countries andcommunities, which may have relatively longer socio-psychologicaland behavioral implications.

Community support and solidarity: Chinese people showed a stronglevel of community solidarity for the affected people in Wuhan. Not
only they provided resources, including ﬁnancial, human resources,
they also helped in boosting morals of the frontline health workers,
and shared different positive stories and experiences through the social
media.

CRediT authorship contribution statement
5. Way forward
Rajib Shaw:Conceptualization, Methodology, Formal analysis, Writing- original draft.Yong-kyun Kim:Formal analysis, Writing - original draft.
Jinling Hua:Formal analysis.

While the world is still struggling with the pandemic, the number of
conﬁrmed cases and casualty is growing higher, the East Asian examples
and analysis draw a few important lessons as follow:

Declaration of competing interest

Pandemic is global, but its response is local: In the growing interconnected world, our movement is quite high and fast, and that possibly
enhanced the spread of the virus globally very quickly, making it a
global pandemic. However, different country showed differences in approaches in responses. Thus, although the medical treatment is universal, we need to keep in mind that the healthy emergency response
measures are not universal. It is a combination of country's regulation,
governance mechanism, link to science-based decision making, local
governance as well as community behavior. Thus, learning from eachother's experience is very important.

The authors declare that they have no known competing ﬁnancial interests or personal relationships that could have appeared to inﬂuence thework reported in this paper.
References[1] Zaroncostas J (2020): How to Fight an Infodemic in www.thelancet.com, Vol 395,
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[3] Roy M Anderson, Hans Heesterbeek, Don Klinkenberg, T Déirdre Hollingsworth (2020):
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[17] Normile D. Coronavirus cases have dropped sharply in South Korea. What's the secret toits success? Science 2020 available from www.sciencemag.org/news/2020/03/
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https://doi.org/10.24171/j.phrp.2020.11.1.09.

Use of technology: In the advanced stage of technological intervention,a pandemic response is not just a medical response anymore. It needs tolink different types of technologies in an appropriate way. COVID-19 response in East Asia showed extensive use of emerging technologies (likebig data, AI, drone, 5G, robotics, automated vehicle, block chain etc.)
linked to medical technologies.
Risk assessment: Djlante et al. [32] in a quick analysis has pointed out
the need of converging the health response, emergency response and disaster risk reduction in the viewpoint of the Sendai Framework. They
analyzed and concluded that current mechanisms and strategies for disaster resilience, as outlined in the SFDRR, can enhance responses to epidemics or global pandemics such as COVID-19. Some of therecommendations are as follow: recommendations concern knowledge
and science provision in understanding disaster and health-related
emergency risks, the extension of disaster risk governance to manage
both disaster risks and potential health-emergencies, particularly forhumanitarian coordination aspects; and the strengthening ofcommunity-level preparedness and response. A proper risk assessment
is required taking into consideration of health risk, exposures, behaviors
and policy framework.
Use of social media and sensitization on fake news: In different
countries, with different level of social media penetration, the importance of distinction of proper news and fake news becomes more relevant. Importance of negative consequences of fake news is wellunderstood in longer run, not only to ﬁght this pandemic, but also forthe longer-term recovery process.
Economic implications: The global economic impacts of the pandemic
are yet to be understood, but there is a unanimous agreement of a global recession due to the pandemic. However, in different countries, sectorial impacts are already prominent, especially in tourism and hospitality sectors.

10

R. Shaw et al.

Progress in Disaster Science 6 (2020) 100090[32] Djlante R, Shaw R, DeWit A. Building resilience against biological hazards and pandemics: COVID-19 and its implications for Sendai Framework. Progress in Disaster Science; 2020. https://doi.org/10.1016/j.pdisas.2020.100080 April 2020.

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qq.com/, Accessed date: 27 March 2020.

11

International Journal ofEnvironmental Researchand Public Health
ArticleCorona Virus (COVID-19) “Infodemic” and Emerging
Issues through a Data Lens: The Case of China
Jinling Hua and Rajib Shaw *Keio University, Fujisawa 252-0082, Japan; hana@sfc.keio.ac.jp* Correspondence: shaw@sfc.keio.ac.jp
Received: 13 March 2020; Accepted: 25 March 2020; Published: 30 March 2020


Abstract: Coronavirus (COVID-19) is a humanitarian emergency, which started in Wuhan in China inearly December 2019, brought into the notice of the authorities in late December, early January 2020,
and, after investigation, was declared as an emergency in the third week of January 2020. The WHO
declared this as Public Health Emergency of International Concern (PHEIC) on 31th of January
2020, and finally a pandemic on 11th March 2020. As of March 24th, 2020, the virus has caused acasualty of over 16,600 people worldwide with more than 380,000 people confirmed as infected by it,of which more than 10,000 cases are serious. Mainly based on Chinese newspapers, social media
and other digital platform data, this paper analyzes the timeline of the key actions taken by thegovernment and people over three months in five different phases. It found that although there wasan initial delay in responding, a unique combination of strong governance, strict regulation, strong
community vigilance and citizen participation, and wise use of big data and digital technologies, weresome of the key factors in China’s efforts to combat this virus. Being inviable and non-measurable(unlike radioactive exposure), appropriate and timely information is very important to form the basic
foundation of mitigation and curative measures. Infodemic, as it is termed by WHO, is a key word,
where different stakeholder’s participation, along with stricter regulation, is required to reduce theimpact of fake news in this information age and social media. Although different countries will needdifferent approaches, focusing on its humanitarian nature and addressing infodemic issues are thetwo critical factors for future global mitigation efforts.
Keywords: COVID-19; Coronavirus; infodemic; humanitarian emergency; data science; good
governance; citizen participation

1. Introduction
Coronavirus (COVID-19) started spreading in December 2019 and was noticed in early January
2020. It started spreading in China in mid- to late-January. Among the different types of confusion
and information challenges, we need to recognize that COVID-19 is first and foremost a humanitarian
challenge [1]. As of 24 March, 2020, the virus has caused the death of over 16,600 people worldwide
with more than 380,000 people are confirmed as infected by it, of which more than 10,000 are serious.
As many as 184 out of 195 countries are affected. Solving the humanitarian challenge is the key priority
through proper preventive measures to stop its spread, as well as curative measure to develop a
vaccine. The impact of this public health emergency has affected countries and communities in termsof economic, socio-psychological issues, as well as international relations.
“We’re not just fighting an epidemic; we’re fighting an infodemic”, said WHO Director–General
Tedros Adhanom Ghebreyesus at the Munich Security Conference on 15 February 2020. WHO
Information Network for Epidemics (EPI-WIN) was launched as a new information platform after
WHO declared COVID-19 as a Public Health Emergency of International Concern (PHEIC). The goal

Int. J. Environ. Res. Public Health 2020, 17, 2309; doi:10.3390/ijerph17072309

www.mdpi.com/journal/ijerph

Int. J. Environ. Res. Public Health 2020, 17, 2309

2 of 12was to share customized information with specific target groups [2]. Finally, on 11th March, WHOdeclared it this as a pandemic.
“We know that every outbreak will be accompanied by a kind of tsunami of information, but also
within this information you always have misinformation, rumors, etc. We know that even in the Middle
Ages there was this phenomenon. “But the difference now with social media is that this phenomenon
is amplified, it goes faster and further, like the viruses that travel with people and go faster and further.
So it is a new challenge, and the challenge is the [timing] because you need to be faster if you wantto fill the void...What is at stake during an outbreak is making sure people will do the right thing tocontrol the disease or to mitigate its impact. So it is not only information to make sure people areinformed; it is also making sure people are informed to act appropriately.” Said Sylvie Briand, Directorof Infectious Hazards Management at WHO’s Health Emergencies Program and architect of WHO’s
strategy to counter the infodemic risk. This poses the real challenge of mitigating the risk occurringfrom Coronavirus.
One of the key issues of the “invisible disaster” is obtaining correct information. In 2011, Japan
had a triple disaster, caused by an earthquake-induced tsunami, which caused a nuclear meltdown.
A that time, there was a severe panic in and around Japan about the level of radiation, which was also
an invisible disaster. However, radiation could be measured, whereas the level of penetration of thevirus is not measurable. Therefore, providing the right information from a reliable source is the key
issue in this type of pandemic.
Keeping this infodemic challenge in mind, this paper tries to analyze three months of happenings
in China from December 2019 to February 2020, drawing and analyzing data from different Chinese
websites, social media and research institutes. The value addition of this paper lies in the fact thatoriginal data were collected and analyzed in Chinese, and from Chinese social media. Although acharacteristic information censorship exists in China, there were several positive and negative things
that happened in the last three months. This paper is a narrative of those events and provides an
original analysis.
There are three characteristics/impacts of the paper: (1) this is possibly the first analytical paper
which uses firsthand social media and internet data and information from China to describe thetime-series narrative in Wuhan and China with a focus on key policy decision, (2) it also uses original
survey raw data to understand the types of media people used to get information, and (3) the relianceof different types of online services at different phases of the lockdown.
Of course, the paper has its own limitation, since, due to the evolving nature of the pandemic, thepaper analyzes the spread in the original hotspot (although, as of late March 2020, the hotspot has
shifted to Europe), which was Wuhan and the Hubei province of China. However, the key findings,
which are described in Section 5, are useful to other parts of the world, which is currently suffering theimpacts of COVID-19, as well as in future pandemic responses.
2. Characteristic of COVID-19
The data on Coronavirus are changing on daily basis, and it is difficult to provide current statistics
for the affected, recovered and casualties. However, based on some initial studies, a few characteristics
are emerging for this virus. It is reported that the case-fatality-rate (CFR) for Coronavirus was 2.3%,
initially; however, the age group of 70 to 79 has an 8% CFR, and CFR is 14.6% for those more than 80
years old [3]. This means that the virus has a stronger impact on the aged population.
The other characteristic of the virus is its speed in spreading. When Dr. Zhong Nan Shan made apublic announcement of this virus in CCTV on the 20th of January, the virus had already spread in
different provinces in China, as well as outside China. Every day, some new countries are added to thelist, which has already reached more than 100 countries and regions. It took only 30 days to spreadfrom one city to the entire country of China. The early cases may have been spread from the Wuhan
seafood market, while later cases were spread from person to person, the speed of which surprised
the health workers in Wuhan city and Hubei province. The epidemic curve shown in [4] as well as

Int. J. Environ. Res. Public Health 2020, 17, 2309

3 of 12presented later in this paper, shows that the second to the third week of January was the most crucial
time, when the spread was very high.
There are some similarities and differences among COVID-19, Severe Acute Respiratory Syndrome:
2002–2003 (SARS) and Middle East Respiratory Syndrome: 2012-ongoing (MARS). SARS also had azoonotic transmission in markets in Guangdong Province, China. It is said that COVID-19 is likely
to have been transmitted from bats via palm civets. Similarly, MERS was also traced to zoonotic
transmission of a novel coronavirus (likely from bats via dromedary camels) in Saudi Arabia. All threeviruses have similar syndromes like fever and cough, which frequently lead to lower respiratory tract
disease. However, SARS has a higher CFR of 9.6%, while MARS is even higher at a rate of 34.4%.
Despite much higher CFRs for SARS and MERS, COVID-19 has led to more total deaths due to thelarge number of cases.
Projection shows a significant recession in the global economy due to Coronavirus spread [1].
The global surge reflects a new inflection point in this epidemic. Four ‘major transmission complexes’(i.e., China, East Asia, Middle East, Europe) are now active, while the US is already at a tipping point.
The analysis says that continued spread within established complexes plus community transmission in
new complexes drives a ~0.3%–0.7% reduction in 2020 global GDP growth. The impact on demandslows down the growth of the global economy by between 1.8%–2.2%, instead of the 2.5% growthenvisioned at the start of the year. Sectors are impacted differently. Certain sectors (e.g., aviation,
tourism, hospitality) see lower demand for a longer duration. For others (e.g., consumer goods),
demand is initially lower but expected to rebound quickly. The report also argues that 24th of February2020 was a turning point, when the cases outside Chine exceeded in-China cases for the first time. South
Korea, Italy, Iran, Japan and Singapore are the top five countries outside China which have reported amaximum number of cases, with Iran reporting the largest number of casualties outside China.
3. Data Source and Methodology
To focus on the key word “information”, which is crucial for any invisible disaster, a series ofdifferent types of data were analyzed. Primary data sources include:(1) Sina Weibo’s (Chinese social media) hot search list (in which a key word has been accessed
every day for how many times as well as how many hours) [5](2) Corona Virus timeline data in China (which are compiled by the authors from different
data sources like Sina, Tiki-Toki, Caixin, Baidu, Tencent and provincial and municipal governmentdata) [6–21](3) CSM media research data on the use of different types of media to acquire information [22,23]; and(4) Mob-Tech Research Institute data of use of internet during the Corona virus spread [24,25].
Four specific types of analysis were made based on the above-mentioned data sources:(a)Timeline narrative, number of affected people and public concern: The timeline narrative isdeveloped based on the sequential events in the country, and important measures taken, which isalso juxtaposed to the major public concerns. Weibo’s data (2020) have been analyzed for the top
206 to 360 hits per topic (depends on the daily variation) over a period of three months, from
1 December 2019 to 1 March 2020 [24]. Tiki-Toki’s data [9] is the Chinese government big data
platform, and provides information on different government measures, news, policies, and also islinked to major global milestones in the related topic (here, Coronavirus-related topics). Sina’s
data was on (1) the number of affected people (confirmed cases, recovery, and death) at both thecountry level and in Hubei province, (2) Sina Weibo data to analyze social media information.
Figure 1a,b show the growth in the number of affected and recovered people and casualties in
Hubei province and the whole of China, which is referred to in a later section. Figure 2 was also
prepared as an original diagram to highlight different phases of this disaster. Specific attention
was made on the day to day changes in numbers, any significant policy actions taken, andany significant incidence (positive or negative) reported on social media or a website. Social

Int. J. Environ. Res. Public Health 2020, 17, 2309

4 of 12

media/website information (both government official sites as well private sites) were used to
draw the timeseries narrative. Word Cloud analysis was made using the key words used insocial media for all the five phases mentioned in the text, and the top five most commonly used
words are picked to highlight the key discussion in the social media, as well as to understandcitizens’ agony.
(b) Media use during/after Coronavirus spread and information types: This is mainly derived
from the analysis of [23] on February 20–21, 2020, with more than 1500 residents from all 31
provinces in China, to understand the use of media to acquire information related to Corona
virus. The analysis used the data of CSM survey to draw original graphs and diagrams with
its interpretation;
Int. J. Environ.
Res. Public Health 2020, 17, x FOR PEER REVIEW
4 of 12(c) Positive impact on certain online industries: The data from [24] are based on the analysis of 2019(positive
or butnegative)reportedintensive
on socialanalysis
media orwebsite.
Socialmedia/website
and 2020
analysis,more specificof atheuse of theinternet
during the period
information (both government official sites as well private sites) were used to draw theof 22 January 2020 to 6 February 2020. These data were used to understand the proliferation oftimeseries narrative. Word Cloud analysis was made using the key words used in social
certain online services compared to others, which is correlated to people’s interest in different
media for all the five phases mentioned in the text, and the top five most commonly
topics available
online.
used words
are picked to highlight the key discussion in the social media, as well as tounderstand citizens’ agony.

Figure 1. (a) Number of people affected, recovered, and dead in China and Hubei province; (b) New
Figure 1a. Number of people affected, recovered, and dead in China and Hubei province; Figure 1b.
confirmed
and recovered cases in China and Hubei province; (Source: these graphs were prepared by
New confirmed and recovered cases in China and Hubei province; (Source: these graphs weretheauthors
original
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News [5]).

b) Media use during/after Coronavirus spread and information types: This is mainly
derived from the analysis of [23] on February 20–21, 2020, with more than 1500 residents
from all 31 provinces in China, to understand the use of media to acquire information
related to Corona virus. The analysis used the data of CSM survey to draw originalgraphs and diagrams with its interpretation;c) Positive impact on certain online industries: The data from [24] are based on the4. Criticism, agony and depression phase: Until 14 February 2020;
5. Positive prevention and curative control phase: Until 29 February 2020.
Figure 2 shows the timeline of key events in five phases. Authors extracted the key events fromdifferent news and social media reports. In each phase, five top public concerns are highlighted,
which is prepared through word cloud analysis in each phase using the key social media data, asInt. J. Environ. Res. Public Health 2020, 17, 2309
5 of 12
specified in the methodology section.

Very early phase(~31st December 2019)

Investigation phase(~20th January 2020)

1st January 2019
Seafood market in Wuhan closed
20th January 2020
Dr. Zhong Nan Shan madeannouncement in CCTV

22nd January 2020
Hubei province announced emergency
Earlyintensification phase(~31st January 2020)

Criticism, agony anddepression phase(~14th February 2020)

30th December 2019
Dr. Li first reported the disease-

Unknown virus
Wuhan
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Observation

Dec 31-Jan 4, Jan 8-16,
Jan 18-19,2020
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CCTV new year program
Zhong Nana Shan (Doctor)-

Pneumonia
Confirmed caseCoronavirus
Epidemic
Wuhan

28th January 2020
Supreme court decision on fake news

23rd, 25th January 2020
Hospital construction started

30th January 2020
WHO announced PHEIC

2nd February 2020
Hospital completed, handed over

3rd February 2020
City sanitization started

7th February 2020
Dr. Li passed away

5th February 2020
forced door to door checking started

15th February 2020
Public life in Wuhan was publishedPositive prevention and20th February 2020
curative control phase
Death of young doctor(~29th February 2020)

Public Concern

1st December 2019
First case reproted in Wuhan

18th February 2020
QR code was introduced
26th February 2020
Overseas Chinese were prohibited

-

Wuhan
Zhong Nana Shan (Doctor)
Li Wen Liang
Confirmed case
Mask / Shuanghuang Lian

(medicine mentioned in People’s Daily)-

Pneumonia
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Zhong Nana Shan (Doctor)
Wuhan
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Figure2. Timelineof keyeventsand(Source:ThisThis
figurepreparedbyauthors
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public concern;concern; (Source:
figurewaswaspreparedby theoriginal
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4. Data
AnalysisandKey Until
Findings
4.1.1.
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31 December, 2019
As perstatistics,
the earliest
case was reported on 1 December, 2019 in Wuhan, and4.1. Narrative
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thereafter sporadic cases have been reported all through December, especially in the later part of theTodevelopas mentioned
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out here. However, the author tried to highlight the key developments in China based on the five
following phases:
1.
2.
3.
4.
5.

Very early phase: Until 31 December 2019;
Investigation phase: Until 20 January 2020;
Early intensification phase: Until 31 January 2020;
Criticism, agony and depression phase: Until 14 February 2020;
Positive prevention and curative control phase: Until 29 February 2020.

Figure 2 shows the timeline of key events in five phases. Authors extracted the key events fromdifferent news and social media reports. In each phase, five top public concerns are highlighted, which
is prepared through word cloud analysis in each phase using the key social media data, as specified in
the methodology section.
4.1.1. Very Early Phase: Until 31 December, 2019
As per the available statistics, the earliest case was reported on 1 December, 2019 in Wuhan, andthereafter sporadic cases have been reported all through December, especially in the later part of themonth. The first case was reported in a paper [26] on 1st of December 2019. The health commission of
Wuhan municipality reported the first case of Coronavirus (at the time, an unusual disease). These
were unusual cases, which took the local physicians by surprise, and it was Dr. Li Wen Liang whoreported the unusual case as a possible epidemic in WeChat social media on 30th of December 2019.
4.1.2. Investigation Phase: Until 20 January 2020
This phase was characterized by a crackdown by local government and detailed investigation.
Huanan seafood market in Wuhan city was closed on 1st of January. The city government and its

Int. J. Environ. Res. Public Health 2020, 17, 2309

6 of 12

health commission investigated the cases in December and called Dr. Li and made him apologize for
spreading a rumor on the 31st of December 2019. Three teams of experts from Beijing conducted adetailed investigation from the 31st December to 4th January, 8–16 January and 18–19 January. It was
revealed that the disease was a new type of epidemic, which had not been reported earlier. This wasannounced on 20th of January by a major and well-known doctor, Dr. Zhong Nan Shan, in a CCTV
online interview.
4.1.3. Early Intensification Phase: Until 31 January 2020
This was a critical period, when the disease spread was intensified and a relatively large numberof casualties was observed. Figure 1a shows the number of people affected, recovered and dead in
China and Hubei province, and Figure 1b shows the new confirmed and recovered cases in China andHubei province. At an early part of this phase, a few critical and wise decisions were made:22nd January: Hubei province announced a Level II public emergency;
23rd of January: Wuhan city was closed and all the entries and exits to the city were restricted.
The decision to construct Huoshenshan Hospital (new hospital) for Corona virus cases was announced
on this day (23rd January), followed the decision to construct Leishenshan Hospital (another new
hospital) decision on 25th January. Ten hospitals in Wuhan city appealed for a supply of medical andother emergency goods from all over the country;
24th January: Hubei province followed the suit, and the whole province was closed for entrance
and exit. Hubei, Beijing, Shanghai and eight other provinces declared a public emergency;
25th January: The Supreme court provided instruction on “Fake news” and the negative
consequences of this. Tencent, which is the parent company of WeChat, established a website called“Rumors exposed website,” as a platform to reduce rumors;
26th of January: The first emergency supply arrived from Sichuan to Wuhan, along with medical
and healthcare staff;
28th January: President Xi Xinping met WHO DG Dr. Tedros Adhanom Ghebreyesus and discussed
the situation. China Media administration instructed all TV channels to reduce entertainment programs,
and to increase broadcasting information and programs on Coronavirus and related news;
29th January: A countrywide emergency was declared;
30th January: The Emergency Committee on the novel coronavirus (2019-nCoV) under theInternational Health Regulations (IHR 2005) was reconvened by the World Health Organization
Director–General Dr Tedros Adhanom Ghebreyesus on 30th January (Geneva time) and a Public Health
Emergency of International Concern (PHEIC) was declared;
31st January: People’s Daily, the major Chinese newspaper’ official account, published fake news
on a possible medicine (named Shuang Huang Lian, a Chinese antibiotic, of which online orders andusers have drastically increased) for Coronavirus by mistake, which caused the panic-buying of the
medicine by the public.
4.1.4. Criticism, Agony, Depression and Control Phase: Until 14 February 2020
The next phase was a phase of panic, criticism, agony and sad news. The following events took
place that explain this phase:
31st January: Public criticism started on Chinese social media regarding the outbreak of the virus;
1st February: People’s Daily corrected their mistake regarding the fake news. A major media site,
Caixin data analysis, showed that public agony had increased and people were growing worried about
the future spread of the virus;
2nd February: The new hospital was prepared and handed over to the Army to take control;
3rd February: Sanitization of public spaces started, school entrance examinations were cancelled,
and another new hospital was ready;
4–6th February: This was a time of control, where a few major control measures were taken. like a
lockdown of villages, towns and cities (earlier, this was restricted to urban areas only). A new policy of

Int. J. Environ. Res. Public Health 2020, 17, 2309

7 of 12“no one will be spared” was started (this enabled the government to enter people’s house and checkfor virus symptoms). Dou Ban, a major media group, was shut down. Overseas news, especially the
spread of Coronavirus in a cruise ship in Japan (Diamond Princess) was broadcast in China throughInt. J. Environ. Res. Public Health 2020, 17, x FOR PEER REVIEW
7 of 12different media;
7th February:
firstSanitization
whistleblower
Dr.entrance
Li, passed
away,were
andcancelled,
this caused severe
3rdTheFebruary:of publicfrom
spacesWuhan,started, school
examinations
andanothernewhospitalwasready;
public criticism in social media. This was followed by a depression phase, where several suicides by
4–6th February: This was a time of control, where a few major control measures were taken. likethe infected people
were observed, to save their respective family members;
a lockdown of villages, towns and cities (earlier, this was restricted to urban areas only). A new policy
9th February:
ThewillCenterof Disease
Control(CDC)
gavetoan
onlineinterviewof “no one
be spared”
was started(this enabled
the headgovernment
enter
people’shouse and with Caixin
check
forthevirus
symptoms).
Dou Ban,major ofmedia
group,wasshut isdown.
Overseas
and announced
that
virus
is a totally
newa type,
which
not
much
known
yet.news,
especially the spread of Coronavirus in a cruise ship in Japan (Diamond Princess) was broadcast in
There wereseveral incidences of sacking senior administration people; the China News head
China through different media;
was sacked for spreading
wrong
information
February)
Wuhan’swasreplaced (13th
7th February:
The first
whistleblower (12thfrom Wuhan,
Dr. Li, andpassedaway, and Mayor
this caused
severepublic criticism
in socialmedia.
was followed
a depression phase, where several suicides by
February). Holidays(school
as wellasThisoffices)
were byextended.

the infected people were observed, to save their respective family members;
9th February: The Center of Disease Control (CDC) head gave an online interview with Caixin
4.1.5. Positive Prevention and Curative Control Phase: Until 29 February 2020
and announced that the virus is a totally new type, of which not much is known yet.
There were several incidences of sacking senior administration people; the China News head
The following
phase was a time of positive prevention and curative planning. Several new
was sacked for spreading wrong information (12th February) and Wuhan’s Mayor was replaced (13thinitiatives were
taken
through(schoolmedia
to address
publiccriticism as well as to lessen public agony:
February). Holidays
as wellas offices) wereextended.

15th February: A diary of public life in Wuhan was broadcast and shared through social media;
4.1.5. Positive Prevention and Curative Control Phase: Until 29 February 2020
18th February: A touching story of female nurses cutting their hair to cope with the continuous
The following phase was a time of positive prevention and curative planning. Several new initiatives
work with protective
suits was broadcast in the mass media as well as on social media. Dead bodies
were taken through media to address public criticism as well as to lessen public agony:
post-mortem had15th
startedto identify
the keyfactors
andandimpacts
on thesocialbody.
On the 18th ofFebruary:
A diary of public
life medicalin Wuhan was
broadcastshared throughmedia;
18th
February: A
femalenursescutting their
hair to copewiththe continuous
February, a uniqueapproachoftouching
using astory
QRofcodewasadoptedin Wuhanandthenspread to other parts
work with protective suits was broadcast in the mass media as well as on social media. Dead bodies
of Hubei provinceusing mobility and safety of the person (in terms of effect of Corona virus). This QR
post-mortem had started to identify the key medical factors and impacts on the body. On the 18th ofcode was usedFebruary,for public
transport,
Using
data
mobilea uniqueapproachenteringof using a public
QR codeareas.
was adopted
in big
Wuhan
andin
then
spreadphones,
to other three color
parts of
Hubei provinceusingmobilityand safetyof the(in terms ofand
effectredof Coronavirus).
coding were used
(Figure3): green(safe),
yellow(needtopersonbe cautious),(cannot
enter). PrintedThis QR code was used for public transport, entering public areas. Using big data in mobile phones,
QR codes wereused for the people who did not have mobile phones (like elderly people or children).
three color coding were used (Figure 3): green (safe), yellow (need to be cautious), and red (cannot
On 19th of February,
the “noone will
policywasenter). Printed
QR codeswere beusedspared”
for the people
who
did ended.
not have mobile phones (like elderly
people or children). On 19th of February, the “no one will be spared” policy was ended.

Figure 3. Three color codesusedfor monitoring
people’s
movement(Source: https://www.sina.com.
Figure3. Threecolor codes used
for monitoring
people’s movement(Source: https://www.sina.com.cn [5]).
cn [5]).
20th February: A newlywed young doctor passed away, which also created negative sentiment

20th February:
A newlywed
doctorpassedwhich also
in social media.
The issues youngof vulnerable
peoplelike theaway,
aged population(11 of createdthem diednegativein an old sentiment
people’shomeinWuhan,
along
with
the
caregiver,
which
came
out
in
the
news
on
20th
February),in social media. The issues of vulnerable people like the aged population (11 of them died in an old
physicallyand mentallyand theirwhich
caregivers,
receivedin the media;
people’s home
in Wuhan,alongchallenged
with thepeople,
caregiver,came
out attention
in the news
on 20th February),
physically and mentally challenged people, and their caregivers, received attention in the media;
21st and 22nd February: Data management and its authentication was re-ensured on (Jingzhoucity), and goods distribution was re-investigated to ensure a balanced distribution (after a TikTok video
which pointed out the imbalance in some areas). Punitive measures were taken for the two leaders of
Hubei province for hiding information (22nd February);Int. J. Environ. Res. Public Health 2020, 17, x FOR PEER REVIEW

8 of 12Int. J. Environ. Res. Public Health 2020, 17, 2309

8 of 12

21st and 22nd February: Data management and its authentication was re-ensured on (Jingzhoucity), and goods distribution was re-investigated to ensure a balanced distribution (after a TikTok
video
pointedimbalance
in some
Punitivemeasureswere ensuring
taken forthe
thefreetwoflow
23rdwhichFebruary:
Theoutlastthehalfof this phasewasareas).
markedby mixed
measures:leadersof
Hubei
provinceforhidinginformation(22nd
February);of emergency goods and food and punishing those prohibited them (23rd February), and the death of
23rd February: The last half of this phase was marked by mixed measures: ensuring the free flow
two additional health professionals (23rd February);of emergency goods and food and punishing those prohibited them (23rd February), and the death26th February: New infection due to the return of overseas Chinese people in someof two additional health professionals (23rd February);
selected provinces;
26th February: New infection due to the return of overseas Chinese people in some selected
28th February: The unfortunate incidence of drinking sanitization tablet by mistake by some rural
provinces;people,28th
causedhealthThe
issues,and thereincidence
was another
unfortunate
incidenceof bysuicideof abyjuniorFebruary:
unfortunateof drinking
sanitizationtabletmistakesomehighschoolwhocaused
did nothaveissues,a mobileto undertake
online classes
providedby schools.
ruralkidpeople,healthandphone
there wasanother unfortunate
incidenceof suicideof a juniorhigh school kid who did not have a mobile phone to undertake online classes provided by schools.

4.2. Media Use during/after Coronavirus Spread and Information Types

4.2.AsMedia
Use during/after
Coronavirus
and Information
TypesResearch with 1500 residents all overmentioned
above, ananalysis Spread
was doneby CSM Media

China onmobileabove,
they useto accesswas
differentshows different
usage
on four
As thementioned
an analysis
done bysites.
CSMFigureMedia 4
Researchwith 1500media
residents
all overdifferent
aspects:increased
usage
after different
Coronavirus
as before,
less
use thanbeforeChina onthe mobile
they useto accesssites. spread,
Figure 4same
showsuse
different
media
usage
on fourdifferent
increased
usage
after Coronavirus
as before,
less userolethanand
do not aspects:
use it for
6 months.
Analysisshows that spread,
WeChatsameand useTV played
a strong
inbeforeacquiringand do not after
use it Coronavirus
for 6 months. Analysis
that WeChat
and TV playeda strongrole in acquiring
information
spread. shows
The amountof applications
has also
increasedcompared to
information
after Coronavirus
spread.
The amountof applications has also increased compared toothermedia usage,
since it provides
real-time
information.
other media usage, since it provides real-time information.
Live / APP
Radio
Audio APP
Weibo
Business news (portal site and APP)
Movie / Portal site/ APP
Traditional media
Short movie / APP (TikTOK)TV
Wechat
0

20

40

60

80

100

FigureUseofofdifferent
differenttypes
types ofof mediaCoronavirus
spread;(Source:this thisfigureFigure4. 4.Use
mediabefore
beforeandandafterafterthetheCoronavirus
spread;(Source:figurewas
preparedbybythe
theauthors
authorsusing
using original
original data
Research[23]).
was
prepared
datafrom:
from:CSM
CSMMediaMedia
Research[23]).

The
surveyalso
alsopointed
pointed out
out thatthat 44%
proactively
secureinformation,
followedThe
survey44%people
peoplesought
soughttoto
proactively
secureinformation,
followed
news
and
put
their
favorites.AAtotal
totalofof33%
33%viewed
viewedthe
theinformation
information proactively,
proactively, butthethe
news
and
put
inin
their
favorites.
but did
did not
not put
put
it
into
their
favoritenews
items.
A
total
of
19%
peoplesaw
theinformation
if
it
was
in
the
news
it into their favorite news items. A total of 19% people saw the information if it was in the news oror media; 2% of people did not bother to take any additional actions for information gathering, while
media; 2% of people did not bother to take any additional actions for information gathering, while
another 2% did not want to hear the negative news on Coronavirus.
another 2% did not want to hear the negative news on Coronavirus.
Figure 5 shows the types of information accessed by different users through online platforms. It
Figure 5 shows the types of information accessed by different users through online platforms.
shows that the maximum access was to get information on medicines, followed by a set of otherIt shows
that the maximum access was to get information on medicines, followed by a set of otherinformation like food/drink, online education, in-house sports, business information andinformation
like andfood/drink,
onlineThis
education,
in-house
sports,businesswhen
informationand isolated
entertainment
entertainment
leisure goods.
shows thelifestylerequirements
people wereinandleisuregoods.
This
shows
the
lifestylerequirements
whenpeoplewereisolatedintheirhome for atheir home for a long period of time.
long period of time.

Int. J. Environ. Res. Public Health 2020, 17, 2309

9 of 12Int. J. Environ. Res. Public Health 2020, 17, x FOR PEER REVIEWOthers9 of 120.3

Accessories

4.5

Toys

5.8

Kids and pregnancy goods

8.5

Ticket (refund etc.)

8.7

Car

8.8

Electrical appliances

10.3

Cosmetics

11.7

Games (downloads)

11.9

Fashion

12.1

Digital goods

13.9
15.1

Tr avel and leisure information
Inter net application

16.1

Novel and books

18.3

Entertainment and leisure goods

25.9

Business i nformati on

28

In-house sports equipm ents

28.3

Online education

29.4

Food and drinks

29.4

Medicine and supplements

47.6
0

5

10

15

20

25

30

35

40

45

50

Figure5. Typesof informationneededneeded byby people
onlineplatforms;(Source:this figure
was wasFigure5. Typesof information
peoplethroughthrough
onlineplatforms;(Source:this figure
preparedbytheauthorsusing
original
data
from:
CSM
Media
Research[23]).
prepared by the authors using original data from: CSM Media Research [23]).

4.3. Positive
impactcertainOnline
online industries
4.3. Positive
Impactonon
CertainIndustries
As seenin Figuremedicine, food
food supply
education
were
the topitems. items.
As seenin Figure5, 5,medicine,
supplyandandonline
onlineeducation
werethesearched
top searched
Online food supply users have drastically increased by 10 million, with an increase of 10.60 million
Online food supply users have drastically increased by 10 million, with an increase of 10.60 million inin delivery capacity (by volume) when comparing the data of online food shopping of January 2019delivery capacity (by volume) when comparing the data of online food shopping of January 2019 with
with that of January 2020. A significant increase is observed in users with the age group 35 to 44 years,
that fromof January
2020. A 2019)significant
increaseis 2020).
observed
in users
withtheagenotedgroup
35 households
to 44 years, from
27.9% (January
to 45.1%(January
Specific
increase
has
been
with
27.9%
(January
2019)(January2020).
increasehas
notedwith households
withchildren
fromto0 45.1%
to 3 years
old (from
7.2Specific% of January
2019
to been25.2 %
in January2020). The withchildren
fromdata
0 toshow
3 years(from% of foodJanuary2019
to 25.2 %have
in January2020).
available
available
thatold
four
major7.2
onlinesupplycompanies
increased
their The
deliverydatacapacity
show thatmajorpercentage.
online foodsupplyhave
increased
theirdeliverycapacity byby afoursignificant
They
are ascompanies
follows: HemaFresh(up by 50%
compared
to before
the virus spread),Miss FreshcomparedJanuary2019),
Dingdong
Maicaito(upby 300%a significant
percentage.
They (uparebyas321%
follows:
HematoFresh(upby 50%
compared
beforethe virus
from Miss
DecemberandJing compareddong Daojia
by 470%compared
to January
the from
spread),Fresh2019),(up by321%
to (upJanuary2019),
Dingdong
Maicai 2019).
(up byAll300%
companies
arestruggling
with
a
lack
of
human
resourcesandsharedtheiremployees
to
help
each
December 2019), and Jing dong Daojia (up by 470% compared to January 2019). All the companies
other, which delayed delivery in several cases.
are struggling with a lack of human resources and shared their employees to help each other, which
Online education has also seen significant changes. On 27 January 2020, the Central Government
delayed delivery in several cases.
Education Ministry has declared to postpone the start of classes until after the spring vacation. There
Onlineeducation
alsoeducation
seen significant
On 27
January
Centralwasan instantrise inhas
online(Xueersi changes.
online internet
school)after2020,
that, thewhich
saw a Government
drastic
Education
Ministryhas
declaredtopostpone
the
start
of
classes
until
after
the
springincrease by twenty-fold from 0.52 million to 11.54 million users within a period of onevacation.
week (28 There
was January
an instantin online
education (Xueersi online internet school) after that, which saw a drastic
to 6riseFebruary,2020).

increase by twenty-fold from 0.52 million to 11.54 million users within a period of one week (28 January
5. Key Learning
to 6 February,2020).and Postscripts
Through the Susceptible-Exposed-Infectious-Removed (SEIR) model and AI, [27] found that the

5. KeyLearning
and Postscripts
epidemicof China
should peak by late February, showing a gradual decline by the end of April. A

five-daydelay
implementation would have increased the epidemic
in mainland
Throughthe inSusceptible-Exposed-Infectious-Removed(SEIR)size
model
and AI,China[27] threefound thatfold. Lifting the Hubei quarantine would lead to a second epidemic peak in Hubei province in midthe epidemic of China should peak by late February, showing a gradual decline by the end of
March and extend the epidemic to late April, a result corroborated by the machine learning
April.
A five-day delay in implementation would have increased the epidemic size in mainland
prediction.
China three-fold.
Lifting
thestudy
Hubei
would hasleadsummarized
to a second
epidemicpeakin HubeiWHO, in a recent
joint
withquarantine
Chinese colleagues,
four
specific key
lessons
provincein
mid-Marchandextendtheepidemic
tolateApril,aresultcorroboratedbythemachineas follows [3]:learning prediction.
WHO, in a recent joint study with Chinese colleagues, has summarized four specific key lessons
as follows [3]:Int. J. Environ. Res. Public Health 2020, 17, 2309

1.

2.

3.
4.

10 of 12China has rolled out perhaps the most ambitious, agile and aggressive disease containment effort
in history. Although initially quite aggressive, gradually, a science and risk-based approach wastaken to tailor its implementation;
Achieving China’s exceptional coverage with adherence to these containment measures has only
been possible due to the deep commitment of the Chinese people to collective action in the faceof this common threat. At a community level, this is reflected in the remarkable solidarity ofprovinces and cities in support of the most vulnerable populations and communities;
China’s bold approach to contain the rapid spread of this new respiratory pathogen has changed
the course of a rapidly escalating and deadly epidemic;
China is already, and rightfully, working to bolster its economy, reopen its schools and return
to a more normal semblance of its society, even as it works to contain the remaining chains of
COVID-19 transmission.

From our own analysis, it was observed that the success of China’s efforts in controlling thedisease was a combination of strong governance, strict regulation and spontaneous community/citizen
participation. Although it was a late response in terms of the local and provincial government at theinitial stage, once the disease was confirmed as a new one, collective responses at the community,
ward, city, province and national levels were significant. To keep this large a number of people
confined in their homes for almost two months was not an easy decision in terms of both economic
and socio-psychological aspects. China’s mobile network and big data system was able to create the
QR code-screening of people, which can be considered a significant achievement. As mentioned in
the earlier part of this paper, WHO DG has termed this virus spread as infodemic; having the rightinformation was key to the success of mitigation measures. At an early stage, The Supreme Court’s
directives on fake news were a very good step in this regard to reduce the spread of confusion andpanic. The “Rumors exposed website” created by Tencent (the parent company of WeChat) helped
to share information on fake news and rumors effectively. Whenever there was fake news publishedor some mismanagement happened with the emergency goods and food supplies, quick corrective
measures were taken by the authorities. At the village level, local communities and volunteers worked
hard to ensure the implementation of the mitigation measures to reduce the spread as well as to reportconfirmed or suspected cases. At an early stage, data management was an issue, but once the virus
was confirmed and declared by the government, strict data management measures were put into place.
In this case, strict corrective measures were ensured for the mismanagement of data. The current caseneeds a science based solutions with local action [28].
These lessons are also reflected in the WHO research roadmap [29], where eight specific researchissues have been identified with a balance of medical diagnosis and community use. It also emphasizedsocial science research in the outbreak response, where the WHO will establish a team that will be
integrated within multidisciplinary research and operational platforms and will connect with existingand expanded global networks of social sciences. As per [30], governments will not be able to minimize
deaths from coronavirus disease 2019 (COVID-19) and the economic impact of viral spread. Keeping
mortality as low as possible will be the highest priority for individuals; hence governments mustput measures in place to ameliorate the inevitable economic downturn. In our view, COVID-19 has
developed into a pandemic, with small chains of transmission in many countries and large chains
resulting in extensive spread in a few countries, such as Italy, Iran, South Korea, and Japan. Most
countries are likely to have a spread of COVID-19, at least in the early stages, before any mitigation
measures have an impact [30].
As we started the paper with two key words “humanitarian challenge” and infodemic, we would
like to once again highlight that basic humanitarian principles need to be followed in this type of
emergency. Of course, there are geo-political, economic and social consequences, which also need
to be looked at. However, humanitarian issues need to prevail over other priorities. The second
point is that Coronavirus is a non-measurable disaster, unlike other invisible disasters like radioactive
emission. Therefore, having correct and timely information is crucial for stopping its spread, as well as

Int. J. Environ. Res. Public Health 2020, 17, 2309

11 of 12in the curative prevention of this disease. These two factors, along with good governance and citizen
participation, will hold the key to success in combatting Coronavirus in future.
Author Contributions: Conceptualization and methodology was done by R.S., data collection and analysis wasdone by J.H., writing was jointly done by R.S. and J.H. All authors have read and agreed to the published versionof the manuscript.
Funding: This research received no external funding.
Conflicts of Interest: The authors declare no conflict of interest.

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Mob-Tech Research Institute. Data Insights on Mobile Internet in Epidemic. Available online: https://www.mob.com (accessed on 7 March 2020).
Huang, C. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020.
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Action in Future Earth Knowledge Action Network. Available online: www.futureearth.org (accessed on 7
March 2020).
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Switzerland, 2020.
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© 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open accessarticle distributed under the terms and conditions of the Creative Commons Attribution(CC BY) license (http://creativecommons.org/licenses/by/4.0/).

sustainability
ArticleCOVID-19 Pandemic Response in Japan: What Is
behind the Initial Flattening of the Curve?
Ai Tashiro 1
1
2*

and Rajib Shaw 2, *Graduate School of Environmental Studies, Tohoku University, 468-1 Aoba, Aramaki, Aoba-ku, Sendai,
Miyagi 980-0845, Japan; ai.tashiro.q7@dc.tohoku.ac.jp
Graduate School of Media and Governance, Faculty of Policy Management, Keio University, 5322 Endo,
Fujisawa-hi, Kanagawa 252-0882, Japan
Correspondence: shaw@sfc.keio.ac.jp

Received: 15 May 2020; Accepted: 27 June 2020; Published: 28 June 2020


Abstract: The new coronavirus disease (COVID-19) emerged in December 2019 and became a global
pandemic in March 2020. The unprecedented speed of SARS-CoV2 spread, the high infection rate
among the aged population, and the collapse of healthcare systems in several countries have madeCOVID-19 the worst “modern” pandemic. Despite its proximity to China, a large aged population, anda high urban density, Japan has mitigated successfully the initial catastrophic impacts of COVID-19.
This paper analyzed the key policy measures undertaken in Japan and suggests that Japan’s culture,
healthcare system, sanitation, immunity, and food habits, along with citizens’ behavior, are thepossible reasons for the successful flattening of the curve. Although additional disease peaks may
occur, and a consequent increase in the number of affected individuals, a combination of policy, good
governance, a healthy society, and good citizen behaviors’ should be sufficient to provide enoughtime for the health care system to cope with them. Cluster approach, science-based decision making,and scenario planning were some of the key policy decisions taken by the government. Based on thelessons from Japan, this paper suggests the importance of an ecosystem-based lifestyle as a potential
way to cope with pandemic events.
Keywords: cluster approach; scenario planning; expert advice; ecosystem approach; 3C approach(closed space; crowded space; close contact setting)

1. IntroductionMore than four months have passed since SARS-CoV2, the etiologic agent of COVID-19, wasinitially reported in Wuhan, China in the first week of December 2019. It was officially brought to thegovernment attention at the end of December, and upon evaluation by several teams of experts, it wasrecognized by the Chinese government as a new virus-borne disease in the third week of January
2020. The WHO announced it as a PHEIC (Public Health Emergency of International Concern) on
January 30, 2020, and finally a global pandemic on March 11, 2020 [1]. Hua and Shaw (2020) provided
a summary of the responses adopted in China in the first three months of the epidemic [2], while Shawet al. (2020) provided insights on the initial responses followed in East Asia, focusing on China, Korea,
and Japan [3]. The global chronologic status up to March 2020 has also been discussed [3].
The epidemiology of COVID-19 is constantly changing, and therefore, it is difficult to estimate
an accurate disease incidence. In fact, 193 out of the 195 world countries have reported COVID-19
cases, and the number of affected people has soared to more than 7.2 million with more than 407,000
deaths as of 9th of June 2020 [4]. The hotspots of the disease have constantly changed: from China,
it initially shifted to Iran, Italy, and South Korea, and then moved to other parts of Europe such as
Spain, France, and the UK. The hotspot then changed to the USA, with the largest number of infectedSustainability 2020, 12, 5250; doi:10.3390/su12135250

www.mdpi.com/journal/sustainability

Sustainability 2020, 12, 5250

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people and casualties. New hotspots are more recently found in Brazil and Russia with the second andthird highest numbers of infected people. In particular, the case of Brazil is alarming in the sense thatthe daily new cases are rising in the range of 20,000 to 30,000. Recently, the Brazilian government has
decided to change the reporting system, and exclude the accumulated counts. Russia, which currently
has the third-highest global number of infected individuals has a presumably questionable low death
rate (often termed as unreported death cases). Moreover, a new hotspot seems to be emerging in India,
a country with a large population density, especially in the informal settlements. Altogether, thismakes COVID-19 the worst pandemic in the modern age, after the Spanish flu, which occurred morethan 100 years ago.
Shaw et al. (2020) pointed out that SARS-CoV2 (and COVID-19) has the following characteristics:(1) a high spread rate (and speed), (2) affects more severely the aged and immunocompromised people(the most vulnerable), and (3) is associated with differential recovery rates in different countries andage groups [3]. Although in most countries, the vulnerable populations are those above 65 and/or 70
years of age, the younger population, including those in their 20s, 30s, and 40s, are also affected. There
are also many cases of asymptomatic infection, where an individual has not developed any COVID-19
symptoms but tested positive for the virus, potentially making COVID-19 (and its transmission) evenmore complicated. Thus, widespread testing is considered an important tool to detect affected people
in most countries, followed by quarantine, physical distancing, and lockdowns, among others.
It should be noted that while the pandemic is global, the responses are local [3]. The specificresponse against COVID-19 depends on the country’s governance system, regulations/ constitutional
provision, capacity, the robustness of its health system, and, more importantly, culture and citizens’
behavior. Therefore, every country has its own unique success/failure story, depending on its own
local conditions. Even within one country, local governments (at state, province, or prefecture levels)
have their own unique response mechanisms. Shaw et al. (2000) mentioned the importance of amulti-disciplinary approach to the COVID-19 response [3].
This study was not based on “pure epidemiological analyses”. Rather, we attempted to understandthe policy and behavioral responses in Japan, locating them in the COVID-19 timeline, as well as theimplication of the emergency announcements in the country. For a detailed analysis of government
action, we refer to earlier publications [3]. The core part of the paper provides an analysis of the inherent
socio-political system in Japan, along with its people’s behavior and immune status. An attempt
was also made to highlight the ecosystem-based approach as a potential future lifestyle. This paper
is intended for a wider audience who work in the environment, disaster, and development fields,
particularly those who study possible ways to address biological hazards. We need to emphasize thatthe results are not supposed to be compared with how the other countries flattened their curves. We allunderstand that the “pandemic is global and its responses are local”. So, keeping in mind the local
response issues, this paper demonstrates the example of Japan.
2. History of COVID-19 in Japan and Basic Policies and Measures Applied
The first case of COVID-19 was reported in Japan between January 10 and 15, 2020: a Chinese
national who traveled to Wuhan. The proximity of Japan to China, the high travel volumes between
the two countries, the high percentage of aged individuals in Japan, a high population density inurban metropolitan areas such as Tokyo and Osaka, and high volumes of commuters in these major
cities made Japan especially vulnerable to this pandemic (in theory). However, in spite of thesevulnerabilities and the expected higher exposure rates, the country has been able to suppress the initial
spread of the disease by flattening the curve and reducing the number of contagions and deaths.
Figure 1 shows the basic concept of Japan’s response to COVID-19 [5–7]. While most of thecountries experienced high increases in the number of affected people and fatalities, Japan has beenable to limit its initial outburst. As of June 7, 2020, Japan had reported more than 17,000 cases, of which
910 individuals died [5]. Although some criticize and point out that Japan has not done enough testing,and that the number of infected cases may be higher than the officially reported, the death statistics

infection, so as to provide enough time for the medical facilities to be prepared. This was done bystrengthening other countermeasures such as border control, identifying key clusters, closing schools,
promoting telework, and avoiding large public gatherings (e.g. cancel key sports events and festivals
such as the cherry blossoms’ viewing). To maximize the efforts to suppress transmission andSustainability 2020, 12, 5250
3 of 15
minimize socio-economic damage, the following three steps were taken:
1) early detection of and early response to clusters, 2) enhancement of intensive care responses
confirm themedical
initial flattening
the curve. forIn thissection, somekey countermeasures
adopted inequipmentJapan
via securingserviceof systems
severelyill patients,
including medical
arediscussed
withintherespective
timeline.
(Ventilator, ECMO, etc.), and 3) enforcement of citizens’ behavioral modification [7].

Figure1. 1.
Illustration
response(source:(source:[6,7]).
FigureIllustrationofofJapan'
Japan’ COVID-19
COVID-19 response[6,7]).

Shaw
et al. mainly(2020) [3]Wiki (2020)[8] provided
analyticalof theresponses selective
and
Japan
focusedonand
detectingand control
the clustersof overviews
infection andperformed
key approaches adopted in Japan, such as border control measures (Mizugiwa Taisaku in Japanese),testing for the virus, under the rationale that to end the epidemic quickly, it was extremely importanta cluster approach, an expert committee’s scenario planning, and overshooting challenges, among
to prevent one cluster from developing into another cluster. It was also important to curtail the rateothers. Three main potential phases were considered in these approaches: 1) prevention of domesticof increase of cases (and patients) as much as possible through these preventive measures, in orderspread, 2) prevention of the spread of infection, and 3) prevention of serious spread. It seems that Japan
to control
the epidemic
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this approach
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gradually
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provideenough time
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to bedecreased
prepared. Thisby strengthening
countermeasures
such
as border
control,
identifying
key clusters,
closingschools, promoting
telework,
emergency,
which webetterdescribein thenext section.
Meanwhile,compliancewith calls
for remoteand avoiding
large
public gatherings(e.g.
cancelsportsfestivals
as the companies
cherryworkingand social
distancing
has been
weak.
Inkey
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thatmanysuchJapaneseviewing).
Toprepared)
maximize thesuppresstransmission
and minimizesocio-economic
wereblossoms’
not equipped(andto efforts
adopt toremoteworking
schemes.
Furthermore,
the relatively
damage,thefollowing
three
steps
were
taken:
smaller houses in urban areas, where the space to work is limited was also a condition. Moreover,(1) early detection of and early response to clusters, (2) enhancement of intensive care responses
via securing medical service systems for severely ill patients, including medical equipment (Ventilator,
ECMO, etc.), and (3) enforcement of citizens’ behavioral modification [7].
Japan focused mainly on detecting and control the clusters of infection and performed selective
testing for the virus, under the rationale that to end the epidemic quickly, it was extremely importantto prevent one cluster from developing into another cluster. It was also important to curtail the rateof increase of cases (and patients) as much as possible through these preventive measures, in order
to control the epidemic in Japan [7]. This was effective at an early stage, however, in the longer run,it failed to prevent the disease spreading. One-third of Tokyo’s cases in late March and early April
were linked to sports clubs, pubs, and other night entertainment establishments, where cluster tracing
is difficult [9]. However, this gradually decreased with the announcement of a national emergency,
which we better describe in the next section. Meanwhile, compliance with calls for remote working andSustainability 2020, 12, 5250

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Sustainability
2020, 12,5250
4 of 15socialdistancing
hasbeen weak. In fact, it is argued that many Japanese companies were not equipped(and prepared) to adopt remote working schemes. Furthermore, the relatively smaller houses inpublic transportation operated as normal, although certain routes have reduced their number ofurban areas, where the space to work is limited was also a condition. Moreover, public transportation
trains or buses.
operated as normal, although certain routes have reduced their number of trains or buses.
As for immigration restrictions, Japan's response was slow. The US, the Philippines, Singapore,
As for immigration restrictions, Japan’s response was slow. The US, the Philippines, Singapore,
Indonesia, Vietnam, and Taipei adopted quarantine measures that were implemented soon afterIndonesia, Vietnam, and Taipei adopted quarantine measures that were implemented soon after Wuhan
Wuhan was locked down, from January 23, 2020 [10]. Travelers who visited Wuhan within the past
was locked down, from January 23, 2020 [10]. Travelers who visited Wuhan within the past 14 days
14 days were prohibited from entering these countries. On the opposing side, at that time, Thailand
were prohibited from entering these countries. On the opposing side, at that time, Thailand andand Cambodia did not restrict immigration. In contrast, in Japan, the government took a weak
Cambodia did not restrict immigration. In contrast, in Japan, the government took a weak measure
measure and prohibited the entry of people who had stayed in Hubei, China in the last 14 days (fromand prohibited the entry of people who had stayed in Hubei, China in the last 14 days (from February
February 1st, 2020). The government also prohibited the entry of people coming from 73
1st, 2020). The government also prohibited the entry of people coming from 73 countries/regions in the
countries/regions in the April 2nd, 2020 [11].
April Figure
2nd, 2020[11].
2 provides
a timeline analysis of Japan's response to COVID-19. Japan’s response can be
Figure2
providesatimeline
analysisof Japan’s
response
to COVID-19.
Japan’s responsecandivided into five major phases:
1) thecontainment
phase,
2) the medical
service reinforcement
phase,
beinto five phase,
major phases:(1) the containment
phase,
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5) (2)
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Each thephasecharacterized by certain policy measures. During the containment phase in January 2020,
keyis
characterized
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containment
phase
in January
2020,Wuhan.
the key
focus was to reduce
the numberof visitors Duringfrom thethe
keyaffected areas
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affectedareasinChina,
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Immediately after China declared the new virus and the WHO's announced COVID-19 as a public
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Prime
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on January
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Figure2.2. Timeline
Timeline ofof thethe COVID-19
COVID-19 response in Japan with
Figurewith thethe specificspecific policy
policy measures
measures adopted
adopted(source:authors
authorsbased
basedonondatadata fromfrom [12]).
[12]).
(source:

The analysis of the number of secondary transmissions caused by a single infected person, basedon the relevant cases, revealed that the number of secondary transmissions was significant in cases
where the root of infection was a closed space with poor ventilation [7]. During the following phase(medical service reinforcement phase), mainly in February 2020, the emphasis was placed on theSustainability 2020, 12, 5250

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The analysis of the number of secondary transmissions caused by a single infected person,
based on the relevant cases, revealed that the number of secondary transmissions was significant incases where the root of infection was a closed space with poor ventilation [7]. During the following
phase (medical service reinforcement phase), mainly in February 2020, the emphasis was placed on
the strengthening of the medical care system. Local governments were instructed to strengthen their
medical capacity and to increase the testing capacity. On February 16, 2020, the Ministry of Health,
Labor, and Welfare worked with local governments to establish 536 consultation centers that covered
every prefecture within the country to provide concerned citizens with instructions on how to get
tested for COVID-19 and receive treatment, if needed.
Not long after, Prime Minister Abe convened the government’s first Novel Coronavirus Expert
Committee Meeting at the Prime Minister’s Office to draft the national guidelines for COVID-19
testing and treatment. The expert committee brought together ten public health experts, medical
professionals, and data scientists from across Japan to coordinate a response to the virus with Abe andthe government’s coronavirus task force in a roundtable format.
The mitigation phase started with the establishment of the Basic Countermeasure Policy for
COVID-19 on 25 February 2020, based on suggestions from the expert committee. On 27 February
2020, Prime Minister Abe requested the closure of all schools from 2 March 2020 until the end of spring
break, in early April. The next day, the Japanese government announced plans to create a fund to help
companies subsidize workers who needed to take time off to look after their children. On 27 February
2020, the Japanese government announced plans to expand the national health insurance system sothat it would cover COVID-19 testing. The key characteristic of this phase was the close cooperation of
the expert committee and government decision-making. The expert committee developed detailed
scenarios with different levels of uncertainties and calculated the required percentage of physicaldistancing. Data science played an important role in these models. These scenarios were used to design
specific mitigation measures. One of the difficulties of COVID-19 response in Japan is the approximate
12–day delay between the diagnosis and its registration in the official statistics [6]. Therefore, for better
accuracy, human mobility via mobile phone data as an early indicator of confirmed cases was also
explored [13]. For instance, NTT DoCoMo data and high-resolution hourly population data of Mobile
Kukan Toukei within Tokyo were analyzed [13]. The dataset divided Tokyo into 8500 grid cells of
0.5 km × 0.5 km. The preliminary analysis suggested that the mobility levels correlated with the daily
growth rate of confirmed cases within the following 12 days. On 9 March 2020, the Health Ministry
published a disease forecast for each prefecture and instructed their local governments to prepare their
hospitals to accommodate the estimated patient numbers. Furthermore, it was predicted that the virus
peak in certain prefectures (such as Tokyo, Osaka, and Hokkaido) would occur three months after theirfirst reported case of local transmission.
In the next phase (Emergency Phase), to provide a stronger legal basis for COVID-19
countermeasures, the National Diet passed an amendment to the “Special Measures Act to Counter
New Types of Influenza of 2012” on March 13. The new act allows the Prime Minister to declare a“state of emergency” in specific areas where COVID-19 poses a grave threat to the lives (and economic
status) of residents. On 30 March 2020, the Tokyo Governor requested its residents to stay at home forthe next two weeks. The Japan Medical Association, in a press conference, expressed their concern
on the current infection spread rate and advised the Prime Minister to declare a national emergency.
On April 7, Prime Minister Abe called for a national emergency for one month in the seven mostaffected provinces effective from 8 April 2020. The national emergency was later extended to cover
all of Japan on 16 April 2020. On May 14, the emergency phase was over in most prefectures (except
in Tokyo, Kanagawa, Saitama, Hokkaido, Osaka, Hyogo, and Kyoto). Finally, on 25 May 2020, thenational emergency was lifted in the whole country.
From all of the abovementioned, the key points of Japan’s policy responses are [7]: (1) provisionand sharing of information (call for self-restraint on travel and going out), (2) surveillance andinformation gathering (identifying carriers, strengthening testing systems, and continuing to develop

Sustainability 2020, 12, 5250

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rapid test kits), (3) pandemic prevention (declaration of the state of emergency, and its extension),(4) medical care (3C approach (closed space, crowded space, closed contact setting) and PCR testing),(5) economic and employment measures (new fiscal boosting), (6) other important considerations(procurement of essential goods, give relevance to social functions, preventing core government staffs
from being infected). In the recovery phase, there has been a very strong focus by the governmenton the economy. A fiscal stimulus package, of 108.4 trillion Japanese Yen ((1.01 trillion USD), whichis equivalent to 20% of the national GDP, was approved. Furthermore, there was a supplementary
addition of 16.8 trillion JPY, which brought the total package to 117.1 trillion JPY.
3. Emergency Law in Japan and its Implications
Japan’s emergency law is unique and different from that of other countries. The law does notallow the government (national or local) to enforce lockdowns. However, the head of the government(Prime Minister and governors) can appeal to the people to stay at home and request stores and otherhigh-risk facilities to close. There is a delicate line of power between "request" (Yosei in Japanese) and"demand"’ (Kyosei in Japanese). The 3C approach (closed space: Mippei in Japanese; Crowded space:
Misshu in Japanese; Close contact setting: Misshu in Japanese) was (and is) emphasized during the
emergency period. This means that people need to follow stay at home orders, avoid crowded places,
and avoid close contacts.
During emergency periods, governors of the affected areas will receive the following powers:(1) instruct residents to avoid unnecessary outings unless they are workers in essential services suchas healthcare and public transportation; (2) restrict the use of or request the temporary closure ofbusinesses and facilities, including schools, social welfare facilities, theaters, music venues, and sports
stadiums; (3) expropriate private land and buildings for the purpose of erecting new hospitals; and(4) requisition of medical supplies and food from companies that refuse to sell them, punish thosethat hoard or do not comply, and force firms to help transport emergency goods. These powers
enable governors to take certain legislative actions. Mayors as well as town and village heads, haveless autonomy but can appeal to the prefectural governor who can then make final decisions. For
instance, in order to secure adequate supplies of medicine and other necessary goods, governors canfine uncooperative businesses involved in their distribution. Prefectures can also appropriate land andbuildings for use as temporary medical facilities without the agreement of the owners, if necessary.
Furthermore, the governors’ non-legislative initiatives can include strongly urging people to avoid
unnecessary travel as well as crowded spaces such as bars, nightclubs, restaurants, and karaoke boxes,pressing for sports and cultural events to be postponed or canceled, and asking people to refrain fromusing school facilities.
Thus, in Japan, a forced lockdown is not possible by law. Therefore, people’s behavior andself-consciousness are extremely important for the flattening of the COVID-19 curve. During an
emergency, repeated requests from governors, ministers, and the prime minister as well as experts’
advice, are conveyed through the media sources. This has a large impact on people’s behavior.
At the local level, citizen/voluntary organizations played an important role in raising awareness formaintaining “social distancing”’ and avoiding crowded areas. In addition, after the national emergency
was lifted in the third week of May, some of the local governments remained vigilant and preparedto act quickly. For instance, the Tokyo Metropolitan Government, issued Tokyo alerts whenever
the number of new affected cases reached double-digits (24, 22, 18 in three consecutive days), andinterdicted (using red-colored symbols) Tokyo venues such as the city hall and the rainbow bridge.
Additionally, other local governments such as the one from Kitakyushu city alerted its residents andrequested the care for self-restraint, whenever new cases in the range of double-digits were reported
on consecutive days in the city.
We believe that the governance and policy actions followed in Japan should be looked at and canbe adopted in other countries, especially with respect to science-based decision making.

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4. Characteristics of Japanese Lifestyles and Their Possible Implications
In this section, we argue that a combination of factors such as Japan’s basic health policy, people’s
health consciousness and basic sanitation practices, food habits, and immune statuses enabled theflattening of the COVID-19 curve, ultimately reducing the number of resulting deaths. Although Japan
has not conducted extensive coronavirus testing in comparison to other countries, we discuss thereasons for this decision, describing several hidden and unique aspects of this particular country.
4.1. Culture
Japan has a different greeting culture from other countries, and social distancing is normal.
Maintaining good social distancing, including avoiding groups of people and maintaining a physicaldistance from strangers, may help prevent infections from spreading. Unlike Western countries, theJapanese do not have the custom of kissing on the cheek or hugging as a greeting. The Japanese hardly
make any physical contact with friends or family while greeting them. Japan holds social isolation
practices, even in densely urbanized areas [14]. As for greetings, Japanese often bow and sometimes
shake hands. Thus, the country’s culture is geared around maintaining a personal space [15].
Furthermore, Japanese people who are sick with cold, flu, or allergies normally wear surgicalmasks in public to prevent others from getting sick. This behavior is based on the “Japanese collectivism”
in comparison to the “American individualism” [16]. Therefore, Japanese people do not have emotional
resistance to wearing masks, whereas people in other countries are reluctant to wear them daily.
Although recent psychological studies suggest that the theory is not applicable to young Japanesepeople [17], this tendency does not directly reflect the COVID-19 response. However, the number of
infections under 40 years of age is increasing owing to unnecessary night outings. The only approach to
tackle this issue was the closure of night clubs, bars, and restaurants enforced by prefectural governors
in the context of a national emergency. Of note, the government provided economic compensation
based on the size of the business affected. Moreover, most of the restaurants in the residential
neighborhoods started “take-out” systems instead of serving the meals in the restaurant.
In contrast, some young Japanese citizens also cooperate, but based on self-interest [18]. In thesecases, the behavior of wearing masks is based on not contracting the cold or flu virus from others.
Regardless of whether their behavior is based on collectivism or self-interest, the more importantmessage here is that wearing a mask can also signal others to keep their distance.
4.2. Healthcare System
Japan has a prominent health care system that provides universal health coverage. Japan has
introduced the National Health Insurance (NHI) system in 1961. The NHI ensures that all citizens areprovided with essential healthcare, regardless of preexisting conditions or economic status; free access,meaning patients are free to choose any hospital nationwide; and high-level care at low cost since thesystem is maintained with the use of public money [19]. In Japan, patients usually receive a plethora oftests when treated for even nonserious health problems, which are covered by the NHI. According toJapanese criteria for COVID-19 [20], if a person has any of the following symptoms they should firstcontact a coronavirus consultation center:
(1)
(2)
(3)

Cold symptoms and/or a fever above 37.5 C, which lasts for 4 days or more,
Elderly or those with preexisting health problems,
Heavy physical fatigue or trouble breathing.

As for the number of tests (and confirmed infected individuals) in Japan, Japan has run so few
tests because the Ministry of Health, Labor and Welfare initially chose PCR (polymerase chain reaction)
testing not as a “medical procedure,” but as a tool for “epidemiological investigation” to curb theoutbreak spread [20]. As per the regulation, when a condition is under epidemiological investigation,
it cannot be covered by the NHI; however, later when PCR was included as a medical procedure, it waspossible to use the NHI. The expert panel advising the government mentioned that the “overwhelming”

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shortage of personal protective equipment for sample collectors and laboratory technicians has been
one of the factors behind a slow pickup in PCR tests. However, as of 10 May 2020, the permission
process is complete to start immune-based tests, which are simpler and quicker to conduct than
PCR tests.
On the other hand, Chest CT is used for the diagnosis of COVID-19 (before PCR testing)although lung ultrasound rivals CT imaging for fast and accurate bedside diagnosis and monitoring ofcoronavirus infection. Ai et al. (2020) suggested that chest CT has a high sensitivity for the diagnosis
of COVID-19 [21]. The stocked number of CTs in Japan is 107.2. million, and the average of OECDis 25.4/million. Thus, Japan probably conducts four times more Chest CT per patient than in othercountries. As a result, the number of PCR tests related to COVID-19 was lower.
4.3. Sanitation
UNICEF highlighted the importance of handwashing as a preventive measure for COVID-19.
Japan is the world’s largest donor in the water and sanitation sector based on its experience, knowledge,
and technology [22]. In Japan, the Ministry of the Land, Infrastructures, Transport, and Tourism(MLIT) manages offsite sanitation (sewerage and wastewater management), while the Ministry of
the Environment (MOE) manages on-site sanitation (johkasou, septage management with scheduled
desludging, and sludge treatment facilities) [23]. Owing to such technical achievements in sanitation,
people can easily access clean water and drinking water. In addition, as for the individual behavioral
level, the Japanese have educated handwashing with soap habits in their homes and schools since atender age, and all people living in Japan have easy access to soap [24]. In this custom, the Japanese
wash their hands after going to the toilet, returning home, meals, etc. According to a survey ofthe MHLW, 85.6% of respondents answered that they wash hands, gargle, or use hand sanitizer forcoronavirus prevention [25]. In contrast, according to UNICEF, in the world, 40% of people (about
3 billion) do not have basic handwashing facilities at home. Moreover, over one-third of primary schools
in the world (over half in developing countries) do not have handwashing facilities for children [24].
In Japan, not only soap but also hand sanitizers, ant-bacterial sprays, and rubbing alcohol are
popular. They are set up everywhere, such as in front of the entrance of a building and near thebathrooms. Another sanitation behavior is the regular gargling of the throat. In other countries, it isconsidered a vulgar behavior, and there has never been any custom of doing it. In contrast, gargling
is commonly seen in Japan as a helpful habit to prevent sickness. The custom of gargling to prevent
sickness goes back centuries to the Heian Period, which lasted from 794 to 1185 [26]. In Japan, gargling
is considered one of the two common-sense ways of not getting sick during the winter, along withwashing hands. Satomura et al. (2005) showed that simple water gargling is effective in preventing
upper respiratory tract infections [27]. This virtually cost-free modality would appreciably benefit thegeneral population and contribute to reducing the risk of infection.
4.4. Food Habits
During meals, the Japanese do not usually eat by hand, but often use chopsticks. People inwestern countries also use knives, spoons, and forks, but they frequently use their hands, particularly
when eating junk food (hamburger, sandwich, pizza, etc.). Eating by hand without washing hands
increases the risk of infection. There are many fast-food chains in Japan, but most of the shops andrestaurants serve hot wet towels with meals, and people can easily wipe their hands. It is a unique
Japanese custom.
As for food habits, the Japanese prefer a traditional dish style of one soup and two side dishes
served in small plates, compared with meat-oriented diets in western countries. These side dishes
play an equal role as the main dish in providing sustenance and making the meal more appetizing.
For side dishes, fermented foods are often used (such as soybeans (e.g., miso, soy source, natto),
Japanese sake, and pickles). Fermented foods contribute to improved immune system function, prevent
intestinal afflictions, and promote good health via the maintenance of a well-balanced gut microbiota

Sustainability 2020, 12, 5250

9 of 15composition [28]. In this sense, many traditional Japanese foods are filled with antioxidants, vitamins,
minerals, and even beneficial bacteria. For example, miso is a fermented soybean paste that is aculinary pillar in Japanese food flavoring. Miso is a great source of probiotics or beneficial bacteria,
which increases the health of the gut and enhances the immune system by providing high protein
and mineral amounts, such as manganese zinc, vitamin E, vitamin K, various B vitamins, and folicacid [29]. Natto was also reported to contribute to healthy gut flora [29]. Furthermore, bacteria inJapanese pickles were shown to boost the immune system and prevent flu [29]. Matcha was consumed
in Japan long before it was a trending latte flavor— it was first introduced from China by a Japanese
Buddhist monk in 1191 [29]. Matcha is packed with antioxidants up to 137 times more than other typesof green tea, which helps to reduce cell damage and fight chronic diseases [29]. In addition, seaweeds(e.g., nori, wakame, and aosa) affect bacterial infections [30]. In fact, edible seaweeds were reported tohave an active principle which may help to defeat COVID-19 [31]. Drinking matcha may also help
protect against heart disease by lowering "bad" cholesterol and increasing metabolism.
The Centers for Disease Control and Prevention (CDC) mentioned that the deterioration of
the immune system by chronic health conditions, especially in the elderly, complicates coronavirus
infections [32]. Although there is no evidence that attests to the effect of fermented foods on COVID-19,
taking fermented foods impacts our guts and promotes health.
4.5. Immune System
Coronavirus has mutated into two strains, the “S-type”’ is older and appears to be milder and less
infectious, while the “L-type”, which emerged later, spreads quickly and currently accounts for around
70% of cases [33]. Japan did not strictly restrict travelers from China during the first outbreak. As aresult, the new infections caused by the “S-type” coronavirus spread first in Japan. Fortunately, thisexpansion may have been important to confer a degree of collective immunity against the “L-type”
coronavirus that emerged later [34]. Although there are controversies, this relates to inherent immunity
statuses, as per some scholars [35]. Nishijima et al. (2016) found that the composition of the Japanese
gut microbiome contains greater Actinobacteria, particularly Bifidobacterium [35]. They also foundthat while there are a large number of carbohydrate metabolism microbial functions, there are few
related to replication, repair, and cell motility. The analysis also showed that hydrogen, primarily used
for methane generation in individuals from other countries, is primarily used for acetic acid generationin Japanese individuals. The enzyme responsible for the hydrolysis of polysaccharides in nori andwakame (edible seaweeds) was found in approximately 90% of Japanese individuals as opposed to 15%
and under of individuals from other countries [35]. These findings suggest that the beneficial traits ofJapanese people’s gut microbiomes may condition potential resistance to infections. This evidence may
explain why the number of Japanese COVID-19 cases is rather low. Table 1 summarizes six aspects ofJapan’s uniqueness making a parallel to overseas contexts.

Sustainability 2020, 12, 5250

10 of 15

Table 1. Six aspects of Japanese uniqueness (versus overseas).
Aspect / Factors

Japan

Overseas

1. Government Response
Lockdown

No, but declared a state of emergency for seven
prefectures that then evolved to a nationwide
emergency state

Yes

Immigration restrictions

Yes

Yes

Remote work

AppliedAppliedAppliedApplied

Closing schools

2. Culture
Greeting

Bow, sometimes shake hands

Shake hands, hug, Cheek kissing

Social distancing

Moderate

Low

No emotional resistance
Wearing a mask-

affected personallergic person (seasonal/ spring)

Emotional resistance

3. Health Care System
National Health Insurance
Program

Universal (for all people)

Regional disparities

Medical system (guideline for
COVID-19, CT scan, etc.)

Available with detailed guidelines

Available

PCR
No. of CT [36]After CT scan
107/million

Following diagnosis
OECD: 25/million

4. Sanitation
Basic handwashing with soap

Educated since childhood
Frequent

Regional disparities
Washing hands after toilet [37]:Italy 57%, UK 75%

Gargling throat

Educated since childhood

Not common

Hot water bathing

Japanese custom
Almost all houses have a bathtubShower instead of immersion bath

Ventilating a room

Open window

Air conditioner

Disinfection gel

At the entrance of a building or in a washroom

Regional disparities

Wet towel

Served when eating out

Served rarely

Eat seaweeds

Yes (marine algae, marine plants)

RarelyEat fermented foodYes (miso, soy source, tsukemono)
something that includes lactic acid bacteria)

Few (e.g., yogurt, cheese, beer,wine) but a different type ofJapanese foods

Cutlery

Chopsticks

Folk, knife, spoon, but sometimes
use hands

5. Food Habits

6. Immune System
Spread type of COVID-19

S-type spread from China earlier than L-type,generating partial resistanceL-type spread

Intestinal environment

About 90% of Japanese have intestinal florawith genes for enzymes that disassemble
dietary fiber in seaweed

Less than 15% have genes found inJapanese population

Response measure

Individuals take action to enhance theirimmune system

Depend on immunologicalmechanisms of vaccination

5. Discussion
The COVID-19 outbreak reminds us of how an ecosystem-based lifestyle is important for modern
people. Planetary and human health are not separable. Sustainable development, even in the context

Sustainability 2020, 12, 5250

11 of 15of an outbreak requires the integrated recognition that the environment and society are closely linked.
There have been several arguments and discussions on ecosystem-based recovery, and how COVID-19
has urged us to become increasingly environmentally friendly. The economy recovery after COVID-19
should invest in nature, as a key focus. Within the framework of the Sustainable Markets Initiative
under the leadership of His Royal Highness the Prince of Wales, a 10-point action plan to create acircular bioeconomy was proposed [38]. The 10-point actions include: (1) aim at sustainable wellbeing,(2) invest in nature and biodiversity, (3) ensure an equitable distribution of prosperity, (4) rethinkholistic land, food, and health systems, (5) transform industrial sectors, (6) reimagine cities throughecological lenses, (7) create an enabling regulatory framework, (8) bring purposeful innovation to theinvestment and political agenda, (9) ensure access to finance and enhance risk-taking capacity, and (10)intensify and broaden research and education.
In Figure 3, the concept of the relationship between geo-, eco-, and socio-environment is illustrated
comparing Japan and overseas contexts. Of note, this comparison does not intend to prove thesuperiority or inferiority of any country; it rather demonstrates two different sets of cultures, customs,
habits, governance, etc. The concept of the earth has been dominated by Cartesian philosophy, where
the typical phenomena include urban structures and gardens in cities. Modernization is generally
based on the logic of logos, from Greek philosophy, whereas Asian philosophy is based on the logic of
Sustainability
2020, Buddhism
12, 5250
11 of 15
thelemma from[38]. In Asia, including Japan, unprecedented disasters occur, and people
have seen their society dominated by nature firsthand. Natural factors, as well as social factors, canecosystem services, functions, and services). The social environment refers to the rules of society
cause disasters, and these two aspects are intertwined.
govern (e.g., human wellbeing) [39,40].

FigureFigure3.3.Relationship
Relationshipofofthethegeogeoenvironment
environmentininJapan
Japanversus
versusoverseas
overseascountries.
countries.

The
geo-environment
has largerof climatechangeofandnaturaldisasters levels
such asin
Accordingto Hagihara(2008),dimensions
human wellbeing
consists
threehierarchicalearthquakes,
floods, thedroughts,
and typhoons.
The eco-environment
the law of ecology(e.g.,
ecosystem health:first level
includes income,health, and agoverns
safe environment(e.g., lifeline,
ecosystem
services,functions,andservices).
The
socialenvironment
refers
to
the
rules
of
society
infrastructure, transportation, no pollution); the second level satisfies a convenient and comfortable
govern(e.g., humanwellbeing) [39,40].
environment(e.g., comfortabletransportation, housing, green vegetation, and clean water); and theAccordingtoHagihara(2008),
wellbeing consists
threehierarchical levels
in ecosystemthird level includes the realizationhumanof a meaningful
life and of
fulfillcommunication,
enjoying
pastimehealth:
the
first
level
includesincome,health,andasafe
environment(e.g.,
lifeline,
infrastructure,
and a flourishing natural environment (e.g., rich surrounding in close contact with community ortransportation,
no pollution); the second level satisfies a convenient and comfortable environment (e.g.,
relationship) [40].
comfortabletransportation,
housing,
green
clean
water); and thehealththird level
The COVID-19 pandemic
causedan vegetation,
unexpectedandshift
in environmental[41]. includes
Owing totherealizationofameaningfullife
andfulfillcommunication,
enjoying
pastimeanda flourishingless traffic, decreased tourism, and industry shutdowns, polluted canals have transformed
intonaturalenvironment(e.g.,
rich
surroundinginclose
contact
withcommunityorrelationship)[40].
waters clear enough to see fish swimming below in many countries [42]. Global air pollution has

decreased after the outbreak owing to the lack of anthropogenic activities [42]. The International
Union for Conservation of Nature (IUCN) has reported that COVID-19 could help save endangered
species in China [43]. After the COVID-19 outbreak, many more people around the world haverealized that many animal species have been adversely affected by humans [40]. COVID-19 may not
be removed completely, it may appear again next year, and ultimately with the vaccine, it may
become similar to other seasonal diseases such as influenza.

Sustainability 2020, 12, 5250

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The COVID-19 pandemic caused an unexpected shift in environmental health [41]. Owing to lesstraffic, decreased tourism, and industry shutdowns, polluted canals have transformed into waters
clear enough to see fish swimming below in many countries [42]. Global air pollution has decreased
after the outbreak owing to the lack of anthropogenic activities [42]. The International Union forConservation of Nature (IUCN) has reported that COVID-19 could help save endangered species in
China [43]. After the COVID-19 outbreak, many more people around the world have realized thatmany animal species have been adversely affected by humans [40]. COVID-19 may not be removed
completely, it may appear again next year, and ultimately with the vaccine, it may become similar toother seasonal diseases such as influenza.
Madrodieva and Shaw (2020), in their analysis of Society 5.0 in Japan, have emphasized ahuman-centric society where technology connects people and tries to reduce the barrier of the digital
divide [44]. Japan has taken steps towards developing definitions, principles, and standards for thefocus areas of Society 5.0 and is considering proposing the devised standards to ISO to promote themin the international community. Healthcare and disaster prevention are the two key pillars of Society
5.0. It is envisaged that the futuristic society should focus on human and nature-centric approaches
and policies while leveraging new technological innovations. In the case of Japan, we reviewed thecurrent lifestyle and how actions were taken to shift from a modern lifestyle to a new optimal lifestyle,coping with the outbreak.
The successful integration of biological hazards into disaster risk reduction and response planningcan be achieved if the following two goals are reached: (1) flattening the curve and enhancing thecapacity of the healthcare system to achieve a better initial response; and (2) preventing and minimizing
negative impacts on people (lives and livelihoods), socio-economic sectors, and development goals.
Shaw et al. [45] in their recent review suggested ten steps for achieving these two goals. The ten
steps are: (1) integrated surveillance and early identification and detection, (2) identification of
hotspots/clusters at an early stage, (3) multi-disciplinary science-based decision support, (4) worst-casescenario planning, (5) inclusive (leave no one behind), human rights-based response and recovery
planning, (6) trans-boundary and regional collaboration, (7) use of new and emerging technology, (8)public-private-people collective partnerships, (9) responsible media coverage and addressing fakenews, and (10) transparency in information sharing. Japan’s experience has shown the path for most ofthese steps for the initial response and the flattening of the curve. A successful recovery will depend
on inclusiveness in recovery planning and transparency in sharing information in the future coursesof action.
6. Conclusion
Although pandemics are global events, the responses to them are always local [3]. The purpose ofthis paper was not to compare the Japan case with those of other countries, but to highlight some of
the key lessons that can be applicable to other countries where the infections are steadily growing.
Shaw et al. [3] have argued that governance, technological application, and citizen behaviors are someof the key aspects that could flatten the curves in China, Japan, and South Korea. This paper argues
that, despite the close proximity to China, the high-volume of travelers between the two countries,
a more aged population, and a high urban density, Japan has been able to flatten its curve initially.
There are possibilities of second or third waves of infection in Japan, but at least the gap between thefirst and possibly forthcoming second wave has given the health care system enough time to prepare
itself to adequately respond. From the study, it is evident that Japan has adopted a few important
policies at the government level, which are supported by strong data and evidence-based analysis.
The science-based decision/policy making was at the core of the government response. The otherimportant part was a combination of five other factors: culture, health care system, sanitation, food
habit, and immune status. Although these factors are very much Japan-related, the governance actions
can be replicated in other parts of the world to cope with the pandemic.
To cope with future pandemic risks, we need to have the following:Sustainability 2020, 12, 5250

(1)

(2)

(3)
(4)

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Robust integrated health and emergency management policy, the basic healthcare system should
be a core pillar of society. During the pandemic response, an integrated emergency response
system is required, where decisions are made based on science and expert advice, and adaptive
policy responses are ensured. Chan and Shaw (2020) provided several cases of incorporating
public health in disaster risk reduction [46] and vice versa through the health emergency disasterrisk management framework (WHO 2019) [47–49].
A healthy lifestyle is key to promote a healthy immune system. An ecosystem-based lifestylechange is essential, as exemplified above in the case of Japan. Mukherjee et al. [50] argued for an
ecosystem-based business continuity plan to recover from COVID-19.
Use of new and emerging technologies: online classes, meetings, telework, etc. Extensive use of
5G and other information-related developments is essential [3]Being responsible and risk-aware citizens, employing a civic sense, and behavioral changes arecore to any pandemic response [2,3].

Author Contributions: Conceptualization, R.S.; formal analysis, A.T., R.S.; writing—original draft, A.T. and R.S.
All authors have read and agreed to the published version of the manuscript.
Funding: The authors received no specific funding for this work.
Conflicts of Interest: The authors declare no conflicts of interest.

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Reduction (DRR) Planning, Annex Document; UNDRR: Baltimore, MD, USA, 2020; p. 71.
Chan, E.; Shaw, R. Overview of health-EDRM and health issues in DRR: Practices and challenges. In Public
Health and Disasters; Chan, E.Y.Y., Shaw, R., Eds.; Springer: Singapore, 2020; pp. 1–6.
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DeWitt, A.; Djlante, R.; Shaw, R. Building holistic resilience: Tokyo’s 2050 strategy. Asia Pac. J. 2020, 18, 1–5.
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The current issue and full text archive of this journal is available on Emerald Insight at:https://www.emerald.com/insight/1759-5908.htm

COVID-19 initial preparedness andresponse in Vietnam during theﬁrst six months of the pandemic
and the lessons for Sendai
framework implementation
Tran Nu Quy Linh

Lessons for
Sendaiframework

Received 26 July 2020
Revised 7 September 2020
11 September 2020
Accepted 21 September 2020

School of Medicine, Grifﬁth University, Brisbane, Australia andHatinh Centre for Disease Control and Prevention, Hatinh, Vietnam

Tran Thi Tuyet Hanh
Environmental Health Department, Hanoi School of Public Health,Hanoi, Vietnam, andRajib Shaw
Keio Gijuku Daigaku, Tokyo, Japan

Abstract
Purpose – This paper aims to analyze the current responses applied in Vietnam to the Coronavirus disease(COVID-19) pandemic and link these measures to priority actions highlighted in the Sendai Framework for
Disaster Risk Reduction (SFDRR). From there, strengths, limitations and recommendations on applying the
SFDRR to build the pandemic resilience in the future are discussed.

Design/methodology/approach – The authors synthesize literature on response measures to the
COVID-19 pandemic in Vietnam from January to June 2020 and compare to four priority actions of the SFDRR
including understanding risk, strengthening governance, investing in risk reduction for resilience andenhancing preparedness for effective response and resilient recovery.

Findings – Vietnam has effectively controlled the pandemic with 401 infected cases and no death so far.
Well preparation, timely policies’ implementation, risk communication and comprehensive approaches are
key strategies. These measures are same as the four priority actions in the SFDRR.
Originality/value – To the best of the authors’ knowledge, this is the ﬁrst study in Vietnam to link the
COVID-19 response and the SFDRR, which can serve as an important example for other countries in
responding to the pandemic. Some measures have surpassed SFDRR’s guidance, especially preventive
responses applied nationwide with strong political will and the community’s commitment accompanied bysanctions. Cultural factors such as the habit of using masks to prevent air pollution have contributed to thegood observance of wearing mask regulations during the pandemic. However, some areas that need more
attention include speciﬁc solutions for vulnerable groups, limiting fake news and ensuring patient privacy.

Keywords Vietnam, Preparedness, Sendai Framework for Disaster Risk Reduction, Response,
COVID-19, SFDRR
Paper type Research paper

1. Introduction
The COVID-19 pandemic caused by the Severe Acute Respiratory Syndrome (SARS)-CoV-2
virus is one of the greatest health, social, ﬁnancial and political crises of the 21st century.

International Journal of Disaster
Resilience in the Built
Environment© Emerald Publishing Limited
1759-5908
DOI 10.1108/IJDRBE-07-2020-0080

IJDRBE

Since the ﬁrst cases appeared in Wuhan, China in late 2019, seven months later, the COVID19 has hit at least 188 out of 195 countries, leading to more than 15 million cases and over
600 thousand deaths (WHO, 2020). These numbers are continuing hourly increased for the
next months and all countries are at very high risk. During the past decades, the world has
experienced many pandemics such as SARS, MERS, Inﬂuenza A(H5N1) and H1N1. Many
lessons and experiences have been achieved. However, for this COVID-19 pandemic, almost
all parts of the world, even the wealthiest countries with an advantaged health-care system,
have fallen into a severe crisis. Global Preparedness Monitoring Board (2019) concluded thatthe world still lacks preparation for the pandemic, and in fact, what have happened during
the COVID-19 pandemic showed unreadiness in many countries. The world has witnessed
many mistakes such as the ill-preparation for a pandemic of many countries, the overload of
the health system and ineffective risk communication. The pandemic has led to social
instability, fear, hoarding, panic-buying, misinformation and rumors, which can lead toinappropriate response of communities, increase racial discrimination and violent behaviors(Devakumar et al., 2020; Dinis-Oliveira, 2020).
Pandemic responses were not merely medical solutions but required a morecomprehensive and long-term strategy based on an inter-, trans- and multi-disciplinary
approach (Chan and Murray, 2017). In other words, a strategic framework needs to be
developed to improve the national and international response to epidemics, especiallygovernance and decision-making in a health crisis (Zhang and Shaw, 2020). Therefore,
applying a transnational response plan to a pandemic as well as a Potential Global Medical
Emergency has been becoming ever more important. The World Conference on Disaster
Risk Reduction in 2015 adopted The Sendai Framework (SFDRR) (2015–2030). This is theone of the most updated and comprehensive international accords on emergency response intechnological, biological and environmental hazards (Aitsi-Selmi et al., 2015). The SFDRR
with an all-hazards approach with seven targets and four priorities of actions aims tostrengthen international, national and local resilience to disasters and health emergencies
including pandemics (Djalante et al., 2020). Therefore, the idea of applying the Sendai
Framework to build a comprehensive and long-term pandemic response plan is attracting
the attention of international organizations and many public health researchers. Djalante
et al. (2020), on its analysis on Sendai Framework, made recommendations on how current
disaster resilience strategies can support to control COVID-19, including stronger science
provision on disaster and health emergency risk; mobilize existing disaster risk governancestructure to manage health emergencies; using existing disaster coordination mechanism in
the regional and local levels to inform epidemic response plans; understanding economic
effects and resilience capacity; preparing an early recovery plan; and strengthening the
emergency preparedness and response of the community. In another COVID-19 research,
Tashiro and Shaw (2020) pointed out six factors for Japan’s low death rate, despite
proximity to China, the high aged population and high urban density. These are government
response, culture, health-care system, sanitation, food habits and immunity system. These
conclusions were mostly consistent with the Sendai Framework’s goal and priorities foractions (Zhang and Shaw, 2020). Up to the present, Vietnam was one of the successful
countries in dealing with the COVID-19 pandemic. After more than six months from the ﬁrst
case (January 23), the total number of coronavirus infections update to July 22, 2020 inVietnam was only 401 cases and no death has been recorded (Ministry of Health, 2020d).
Meanwhile, up to 11.28% (22/195) and 38.97% (76/195) countries in the world had COVID-19
cases over 100,000 and 10,000, respectively (Worldometer, 2020). At the ﬁrst stage, Vietnam
was assessed as a high-risk country for spreading the epidemic because it is a densely
populated country with over 97 million people (294 people/km2), limited resources, a less

advanced health-care system, sharing a long border and a high volume of trade with China –where the disease originated (The World Bank, 2020). Also, Vietnam is one of the top tourist
destinations in Southeast Asia with over 15 million international visitors and 80 million
domestic traveler trips each year (V. T. Dinh et al., 2019). However, timely and appropriate
responses have effectively prevented and controlled the pandemic. Vietnam currently
moved to the post-pandemic recovery stage as no community transmission has beenreported since mid-April 2020 (Ministry of Health, 2020d). The government eased some
restrictions, restarting and stimulating the economy while maintaining principal preventive
measures and preparing for the next potential epidemic waves because of the rapid spreadof the virus worldwide (Ministry of Health, 2020d).
Response strategies of Vietnam were considered as one of the most cost-effective
approaches (Heath and Jin, 2020). However, these strategies seem to be based on previous
outbreak prevention experiences rather than scientiﬁc evidence because at that time there
was a lack of evidence of the spread and severity of the COVID-19 pandemic. Therefore,
some policies may not adequately consider disadvantaged groups and sensitive issues
regarding personal information security (UNDP Vietnam, 2020). Governance in a pandemic
is a big challenge; therefore, it is necessary to incorporate pandemic risks, biological anddisaster hazards in national emergency response strategies. An analysis of Vietnam’s
responses based on SFDRR’s priority actions and a discussion of the ways that the SFDRR
can be implemented in risk management will contribute to strengthening the pandemic
response capacity of Vietnam.

Lessons for
Sendaiframework

2. Key public health perspectives and decision measures
The Vietnamese Government has applied a comprehensive approach to respond to the
COVID-19 pandemic. This paper divides response measures into ﬁve main categories,
including improving the capacity of the health-care system, widely applying preventive
measures, enhancing risk communication, applying information technology and investingin science and research. These measures were well-implemented, effective and synchronizedacross the country because of clear leadership and rapid decision-making at different levels.
Moreover, the political institution, cultural characteristics and previous experiences inemerging infectious disease prevention and natural disaster adaptation were contributing
factors for the success of COVID-19 prevention and control. Figure 1 (in the supplemental
material) shows the key elements of these responses.
Clear leadership& rapid decision
making

Improving capacities ofhealthcare system
Widely applying
preventive measures

Response to
COVID-19
in Vietnam

Risk communication
Apply Information
Technology
Science and research- Political institution- Culture- The experience of disasterand pandemic management

Source: Authors’ own analysis

Figure 1.
Basic elements of
COVID-19 response
in Vietnam

IJDRBE

Improving the response capacity of the health-care system including the curative andpreventive sectors has become the ﬁrst priority of the government. The Ministry of Health(MOH) has effectively directed and collaborated agencies, the hospital network and theprovincial Centre for Disease Control and Prevention (CDC) in response to COVID-19. Whena few COVID-19 cases were reported in Wuhan, China, the Vietnamese MOH has issued
treatment guidelines and disseminated them to all health facilities across the country(Ministry of Health, 2020a). For example, MOH issued Decisions No. 181/QD-BYT, No. 237/
QD-BYT, No. 343/QD-BYT, No. 344/QD-BYT and No. 345/QD-BYT from late January toearly February about guidelines for COVID-19 monitoring and prevention, isolation
mechanisms at households and facilities. Also, the MOH issued guidelines for COVID-19
prevention and treatment for vulnerable groups such as the elderly (Decision No. 1588/QDBYT), pregnant women and infants (Decision No. 1271/QD-BYT). On January 30, 2020, theNational Steering Committee under the leadership of the Vice Prime Minister Vu Duc Dam
and 24 members of 12 related ministries were established (Decision No. 170/QD-TTg), alongwith 45 Rapid Response Teams in major hospitals across the country (Van Nguyen et al.,2020). On February 1, the Vietnamese Prime Minister ofﬁcially declared epidemic when only
six cases were reported in three provinces (Decision No. 173/QD-TTg) and the national
epidemic was declared 2 months later on April 1 when the infection reached 212 cases in 25
provinces (Decision No. 447/QD-TTg) (Tuan, 2020). The MOH and the national committee
implemented a rapid assessment of the capacity and needs of health facilities in thetreatment of COVID-19 patients and developed ﬁve different response scenarios in cases
infected people exceeded 100, 1,000, 10,000, 30,000 or more (Vietnam Finance Times, 2020).
The shortage of health-care workers, hospital beds and ventilators also were identiﬁed.
Besides, Vietnamese scientists have produced three different test kits to diagnose COVID-19
that cost less than the US$25, gave a result within 90 min and met the WHO’s standard(Vietnam Insider, 2020). The number of tests meets the domestic demand and exports to 20
other countries (VOA News, 2020). Vietnam also has increased the number of laboratories
that can test COVID-19 from 03 laboratories in January to 112 in April 2020 (Ministry of
Health, 2020c). Furthermore, temporary hospitals to quarantine and treat COVID-19 patients
have been set up since mid-February 2020 to prepare for the worse scenarios of the epidemic(La et al., 2020).
Vietnam has taken a series of strictly public health prevention to control the COVID-19.
These measures have applied a week before WHO’s declaration that the COVID-19 is an
emergency of international public health concern and more than one month before
recognized as a global pandemic (Le, 2020). At that time, these actions were above andbeyond the recommendations of WHO, but epidemiologists agreed that they were “extreme
but sensible”. Important measures included large scale quarantine and isolate all suspectedcases with a four-tier approach of identiﬁcation and isolation (Figure 2 – in the supplemental
material), visa suspension for all foreigners and restrictions on international travel. Isolating
all cases of entry into Vietnam signiﬁcantly reduced the risk of outbreaks because up to July
7th, 2020, 70.1% (249) of COVID-19 patients were passengers entering Vietnam (Ministry of
Health, 2020b).
Risk communication and applying information technology have been effectively used in
all prevention and control activities, including online consultations, online medical
declarations, risk communication and online learning. All COVID-19 information, especially
new cases (coded as the patient numbers), their epidemiological information and their
14-day-travel history, was broadcasted and updated daily by almost all channels.
Furthermore, the government and the MOH daily sent text messages to all citizens’ mobile
phones to warn the risks of infection and to promote protective behaviors. National phone

COVID-19
isolationmechanism

Tier
1

Isolated and treated all confirmed cases
and their direct contacts

In designatedhospitals

Tier
2

Quarantined people who had close
contacts with tier 1 categories

In army-run
quarantine campus

Tier
3

Self-quarantined those close contactedwith tier 2 categories

At homeTier
4lockdown of the entire community where
any infected patient lived

Entire affectedareas

Source: Adapted from Vietnamese Ministry of Health’s website(Ministry of Health, 2020b)

waiting ringtones also changed to a voice message giving notice of the COVID-19 (La et al.,2020). On 9 March, two free applications, “NCOVI” and the “Vietnam Health Declaration”
were developed to declare the medical conditions of each individual including Vietnamese
citizens and international visitors (Tuoi Tre News, 2020). The apps and the ofﬁcial website“http://ncov.moh.gov.vn” provided an update Vietnam’s epidemic map, ofﬁcial information
about new cases, policies and guidelines about the pandemic prevention (Thuy, 2020). After
just over a week of introduction, these two apps have become the most downloaded apps on
Vietnam’s Apple Store and ranked third on Vietnam’s Google Play (Khoa, 2020). The
communication strategies to help combat the COVID-19 pandemic have been developed
diversely, targeting many different groups and through different communication channels. For
example, short, catchy slogans such as “Staying at home is patriotic”, “Put on a face mask,
wash hands often” and “the virus is your enemy” were regularly displayed on television,
posters, government websites and social networks (Vietnam Times, 2020). Facebook users
were encouraged to put these slogans alongside their proﬁle pictures to show solidarity in theﬁght against the COVID-19. Also, many poems, paintings and songs have been composed tourge people to take preventive behaviors. The song “Ghen Covy – Washing hand song” hasbecome a phenomenon on social networks with millions of views, shares and downloads. The
song has been also translated into more than 20 languages, performed by many international
artists and appeared in various favorite shows in other countries (The Economic Times, 2020).
Vietnamese Government has invested in science and research to identify effective respondsolutions. Epidemiologists, sociologists, economists and scientists have worked hard to
rapidly provide scientiﬁc evidence to policymakers. Vietnam is one of the ﬁrst countries to
produce COVID-19 tests with low cost and high accuracy. Besides, numerous studies
concerning COVID-19 in Vietnam have been implemented since few infected cases reported(Giang et al., 2020). These papers focused on clinical aspects, knowledge-attitude-practice ofthe community and health-care workers, risk perception and government’s response (L.
Dinh et al., 2020; G. Huynh et al., 2020; T. L. Huynh, 2020; La et al., 2020).
2.1 Key legislative and decision measures
Regarding the epidemiological characteristics, by June 30, 2020, the COVID-19 pandemic in
Vietnam has two phases: the ﬁrst phase (from January 23 to February 26) included patientsfrom Wuhan, China and infected cases due to close contact with these patients. The second
phase (from March 16 to June 30) came with cases traveling from other countries, close
contact cases and cases of transmission in the community of unknown source. However, toLessons for
Sendaiframework

Figure 2.
Four-tier quarantine
mechanism of
COVID-19 response
in Vietnam

IJDRBE

better analyze Vietnam’s strategies, the pandemic response and recovery are divided into
ﬁve periods: Stage 1 – before the ﬁrst case was reported in Vietnam; Stage 2 – the ﬁrst phaseof the epidemic; Stage 3 – break time with no new cases were recorded; Stage 4 – the second
phase of the epidemic; and Stage 5 – the recovery period. Key legislative and decision
measures are described in Table 1 (in the supplemental material).
2.2 Factors contributing to the successOne of the factors that helps Vietnam prevent and control the COVID-19 pandemic well wasits previous experiences in emerging infectious disease prevention and natural hazards
Time

Total cases

Wave 1 (Pre- Jan 22)
Jan-030
Jan-150
Jan-160
Wave 2 (Jan 23 -Feb 26)
Jan-232
Jan-252
Jan-305
Feb-01
6
Feb-07
Feb-08
Feb-12

13
16

Wave 3 (Feb 27 -Mar 5)
Feb-27
16
16
Wave 4 (Mar 6- April 22)
Mar-0617

Table 1.
Timeline key
legislative measures

Mar-21

88

Mar-30203

Mar-30
Apr-14Apr-15
268
Wave 5 (Apr 23- June 30)
Apr-23268
Apr-28
270
May-4
271
June-30
355
Source: Authors’ own analysis

Key measures
Conducting rapid risk assessment for COVID-19
Developing different response scenarios
Establish Steering committee
Temperature screening for all passengers from Wuhan, isolating inspected cases
Providing guidelines to early prevention COVID-19
Announcing the ﬁrst two cases in Vietnam
Cancelled all ﬂights to and from Wuhan
Establishing a National Steering Committee and 45 Rapid Response Teams
Declared a national epidemic in Vietnam
Cancel all ﬂights between Vietnam and China
Quarantine and voluntary isolation suspected people at the community
Issuing National guideline on COVID-19 Prevention and Treatment
Closing schools
Lockdown 20 days in a large commune after 11 people infected
Set up temporary hospitals
All control measures were continuously maintained
Maintaining strict travel restrictions
Military-civilian drills response to COVID-19
Announcing the ﬁrst case travelled from Western countries
Compulsory wearing masks in public places
Develop low-cost tests, increase laboratories can test COVID-19
Temporary visa suspension and entry to all foreigners
Compulsory 14-day isolation at concentration facilities for all people
entering Vietnam. Cancel all foreign ﬂights
Prohibiting all entertainment activities
Declared a nationwide pandemic
Setting up testing kiosks
Enforced whole society distancing within 15 days
Extended social distancing at high-risk areas
Restricting domestic travel
Lifting COVID-19 restrictions
Declared successful in controlling COVID-19
Reopened school and businesses
Still maintain key preventive measuresresponse. Vietnam is a hot spot for natural disasters and the 6th country in the world mostaffected by climate change (Eckstein et al., 2019). Lessons from responding to healthemergencies and disasters helped Vietnam be more proactive in coping with the COVID-19
epidemic. For example, in order to deal with COVID-19, Vietnam has applied early the “Fouron-spot” Motto including leadership on-the-spot, human resources on-the-spot, logistics onthe-spot and supplies on-the-spot (Xuan Tran et al., 2020). This is a principle for natural
hazard prevention in Vietnam highlighting the role of the local community and the local
government to actively respond to a crisis (Linh and Hanh, 2020). In addition, the lessons
and experience in preventing and controlling previous epidemics such as Zika, Inﬂuenza A(H1N1), H5N1, Diarrhoea, Measle and Dengue fever have contributed to respond better to
COVID-19 (Ohara, 2004; Siembieda et al., 2015). Especially, in 2003, Vietnam became the ﬁrst
country to succeed in containing the SARS epidemic (WHO, 2003).
Vietnam is a socialist republic country with a one-party system; therefore, it was easier tomake decisions in a short time and can immediately implement interventions on a national
scale. If it was in the context of multi-party politics, such as in Western countries, these strictmeasures may not be applied in that timely manner because of disagreements about
individual privacy. Habits and cultural norms also contribute to the success of control
measures. For example, Vietnamese people especially women often wear face masks toprotect sun exposure and air pollution; therefore, the regulation of using masks to prevent
COVID-19 was well observed. Furthermore, village culture in which people in thecommunity care and know each other has supported to contact tracing of potentially
infected cases. People notiﬁed their neighbors and local authorities if there were any
suspected cases or anyone has just come back from abroad without mandatory isolation.
3. Implications to Sendai framework
Timely responses of the Vietnamese Government to control the COVID-19 have achieved
positive output indicators, and these also were the targets highlighted in the SFDRR,
including reduce mortality, morbidity, affected people, minimize economic loss, as well as
safety for the health system and health workers. The SFDRR pointed out that complianceshould be encouraged through “mechanisms and incentives” (Raju and da Costa, 2018).
However, in the context of the complicated and rapidly spreading the COVID-19 epidemic,
the promotion of preventive behaviors appears to be less likely to ensure compliance than
the application of powerful legal instruments combined with strict sanctions. For a more
understanding of the advantages and limitations of Vietnam’s responses in the COVID-19
pandemic, the following section reviews Vietnam’s responses according to four action
priorities outlined for local and national level in the SFDRR in terms of the key strengths
and limitations.
3.1 Priority 1: understanding the risk
As mention above, Vietnam has implemented many timely important actions to understandthe risk including risk and health capacity assessment, developing different response
scenarios, and mapping high-risk provinces. At a very early stage, the MOH assessed theepidemiology characteristics of each patient, the 14-day travel history, making a list ofpeople who had close contact with the patients and published information on media. Also,
information technology was effectively used to inform the risk of infection, disease
symptoms, prevention measures and high-risk areas. This information was sharedfrequently, publicly, transparently and easily accessible. From early January to April 4,
there were 14,952 news items about the COVID-19 in the media channels such as
newspapers, social networks and messages (La et al., 2020).

Lessons for
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IJDRBE

Some limitations in Vietnam’s responses compared to the priority action one in the
SFDRR should need to be improved. There was a lack of vulnerability assessment of theelders, disabilities, homeless people and foreign tourists - who are high-risk and mostaffected by COVID-19. Also, there was no evaluation on vulnerability and adaptive capacity
for other sectors in addition to health such as education, tourism, trade and services in the
pandemic, as well as a lack of risk assessment related to environmental issues. In addition,some rumors and fake news related to COVID-19 widely spread on social networks havecaused panic for the community. In the early stages of the epidemic, some personal
information of COVID-19 patients was leaked on social networks, causing negative reactions
from the community, affecting the patients’ personal lives and reputation.
3.2 Priority 2: strengthening governance to manage risk
Clear leadership and effective governance were the keys to Vietnam’s success in the COVID19 control. Strong governance and a high degree of commitment from the Prime Minister the highest political level - has promoted the participation of all sectors from central to local
levels. The responsibilities and the coordination among the ministries, government agencies,
organizations and local governments in the COVID-19 prevention and control were clearly
assigned at the beginning of the epidemic. More importantly, the government issued a set ofdecisive intervention measures such as early border control, social distancing, wearing facemasks, contact tracing all suspected cases and mass COVID-19 testing. These regulations
were accompanied by economic sanctions to ensure high levels of compliance with
communities. For example, the following acts will be punished: sharing fake news about the
pandemic on social networks (ﬁne of from 5,000,000 VND to 10,000,000 VND), not wearing amask in public (ﬁne of 100,000–300,000 VND), failure to make a medical report or makeinsufﬁcient declaration leading serious consequences for the community (ﬁne of 50,000,000200,000,000 VND or imprisonment from 1 to 5 years) (Ministry of Health, 2020e). This
penalty is relatively high compared to the average daily income per capita (VND 140,000 in2019) (Doan, 2020). Also, community initiatives in COVID-19 prevention were promoted,
such as sewing handmade face masks, making hand sanitizers, composing songs andslogans to raise the community’s awareness. The government also established online
forums and hotlines to increase coordination of stakeholders at national and local levels andpromote public scrutiny in the detection and reporting of suspected cases.
There were, however, some limitations, which included: towing to the urgent time, public
consultation has not been conducted in the process of developing laws and regulations
related to COVID-19 prevention and control. In addition, the empowerment of local
governments was emphasized in the SFDRR to enhance governance; nevertheless, in thecomplex context of an epidemic, this empowerment may need to be reconsidered as this maylead to inconsistencies in response measures. Furthermore, there was a lack of policies
related to settling accommodation, relief for homeless people and tourists during the periodof national entire lockdown.
3.3 Priority 3: investing in risk reduction for resilience
Core strengths in Priority 3 were integrating disaster and outbreak risk management into
the health system, especially CDC network in 63 provinces across the countries. This
network has been consolidated and worked effectively in previous outbreaks. Besides, thegovernment allocated the necessary resources for the health-care system in the outbreaksuch as free treatment for all COVID-19 patients, investing funds in aggressive COVID-19
testing and contact tracing all potential infected cases. Vietnam experienced the ﬁrst six
months of the pandemic with no fatalities. This was because of the strict application ofpreventive and risk reduction measures. Controlling and keeping case numbers low has
helped severe cases received full attention and were treated with the best doctors andadvantaged equipment. In the cases that risk reduction is not implemented well, the numberof people infected and fatal may signiﬁcantly increase. In addition, scientiﬁc research in theﬁeld of treatment and prevention of COVID-19, as well as minimize epidemic-related risks
has been enhanced and supported. The government also effectively applied information
technology in disaster control and prevention. This is the ﬁrst time that schools andbusinesses applied to online classrooms and online meetings. These online courses and the
E-commerce industry in Vietnam will have great opportunities to develop after the
pandemic.
There are two key limitations related to Priority 3 that need to be considered in the
future. First, the current outbreak risk management plans and policies did not fully address
the needs of vulnerable and disadvantaged groups such as the homeless, street vendors andforeign tourists. They were not supported in ﬁnding settlements when the whole country
applies lockdown within 15 days. Second, there was a lack of promoting and integrating
outbreak risk management approaches in many ﬁelds, especially the tourism industry – oneof the sectors most affected by the pandemic.
3.4 Priority 4: enhancing preparedness for eﬀective response and resilient recovery
Strengths in applying the SFDRR’s Priority 4 were good preparedness for effective response
through learning previous experiences, update new information and recommendations
about the COVID-19 pandemic. Vietnam has regular disaster preparedness, response andrecovery exercises every year. In the COVID-19 pandemic, an army simulation exercise in
response to the epidemic was implemented on March 4, 2020 when the number of COVID-19
cases were only 16. In addition, in late April, Vietnam has implemented a set of measures torecover after the pandemic, especially social stability and economic resilience while still
maintain principal preventive measures. The Government has issued ﬁnancial assistancepackages for employees and businesses affected by the COVID-19 pandemic to increase
resilience.
Compared to Priority 4 of the Sendai Framework, some key limitations should be paid
more attention. The ﬁrst, empowering for disadvantaged groups was highlighted in the
SFDRR; however, Vietnam’s policies related to COVID-19 have not yet prioritized thesegroups. Besides, the government also should focus on psychological resilience after
the pandemic for affected people such as COVID-19 patients, their family members andpeople who lost their jobs. For example, during the 2014 Ebola outbreak in West Africa, thenumber of people who died because of social service interruption and economic breakdown
was higher than from the virus infection (United Nations, 2020). Also, risk assessment andresilient ability analysis of other sectors such as education, tourism and the environment
should be implemented soon to effectively support the recovery. Regarding multi-hazards
prevention, the government should develop a comprehensive strategy and coping scenarios
to deal with multi-hazards such as natural disasters and a pandemic occurring at the sametime. Another essential lesson is that current response measures of Vietnam were mainly
based on experiences due to the lack of scientiﬁc evidence at the time of decision-making.
Therefore, it is necessary to have research on the cost-effectiveness and multi-impacts of
preventive measures such as school closing and wearing masks in public places, as well as
more studies about the quality of life, mental health, human rights and environmental
impacts during and after the pandemic.

Lessons for
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IJDRBE4. Conclusions
Although the Sendai Framework has not been mentioned in directive documents by the
Vietnamese Government related to the COVID-19 pandemic control and prevention, thecurrent analysis pointed out that the response mechanism has a strong link to the SFDRR in
terms of its four different priorities. The key success factors for the pandemic response in
Vietnam included well preparation, timely policies’ implementation, risk communicationand comprehensive approaches. In general, these measures were in line with priorities foraction in the SFDRR. However, it is necessary to develop a comprehensive plan to respond tomulti-hazards including technological, biological and environmental disasters based on the
SFDRR’s action priorities and the country’s political, economic, health and culturalcharacteristics.
Currently, there is very little early and rapid response from international institutes andorganizations related to disaster risk reduction, despite the Sendai Framework’s call forenhancing resilience from natural and biological hazards. Effective and relevant risk
management of biological hazards changes with the advancement of science, clinicalmedicine and public health practices and policy. The latest technical guidelines and researchﬁndings to support planning may be found in WHO’s Health-Emergency Disaster Risk
Management: Health-EDRM (WHO, 2019). The COVID-19 pandemic will have a lasting
impact on all aspects of development planning in the years to come. The pandemic brought
into light the need for effective risk management to safeguard development and theimplementation of the International Health Regulations, The Sustainable Development
Goals (SDGs), the Sendai Framework, Paris Agreement and New Urban Agenda, as well asother frameworks. Future detailed analysis is required to link the COVID-19 impacts on
Sendai and SDGs at the global, regional and national levels.
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Available at SSRN 3550308.
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World Bank Group (2019), “Climate change knowledge portal: country Vietnam”, available at: https://climateknowledgeportal.worldbank.org/country/vietnam/vulnerability
Corresponding author
Tran Thi Tuyet Hanh can be contacted at: tth2@huph.edu.vn

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International Journal ofEnvironmental Researchand Public Health
ArticleCOVID-19 Lockdown, Food Systems and
Urban–Rural Partnership: Case of Nagpur, India
Vibhas Sukhwani 1 , Sameer Deshkar 2 and Rajib Shaw 1, *1
2*Graduate School of Media and Governance, Keio University, Kanagawa Prefecture 252-0882, Japan;
vibhas@sfc.keio.ac.jp
Department of Architecture and Planning, Visvesvaraya National Institute of Technology (VNIT),
Maharashtra 440010, India; smdeshkar@arc.vnit.ac.in
Correspondence: shaw@sfc.keio.ac.jp


Received: 7 July 2020; Accepted: 4 August 2020; Published: 7 August 2020

Abstract: The globally fast-spreading novel coronavirus disease (COVID-19) is now testing theabilities of all countries to manage its widespread implications on public health. To effectively containits impacts, a nation-wide temporary lockdown was enforced in India. The resultant panic buying
and stockpiling incidents together with spread of misinformation created a sense of food insecurity
at local level. This paper discusses a specific case of Nagpur from the worst affected Maharashtra
state of India, wherein the urban–rural food supply chains were reportedly disrupted. Based onformal interviews with local government officials, a month-long timeline of COVID-19 outbreak in
Nagpur was studied along with the consequent government initiatives for maintaining public healthand food supply. While the city residents were confined to their homes, this study then assessed
their perceived food security at household level, along with their “Immediate Concerns” and “KeyInformation Sources”. Through online surveys at two different time intervals, the concerns of “Foodand Grocery” were found to be rising, and “Government Apps and Websites” were identified as
the most reliable source of information. Based on the research findings, the authors further suggest
specific policy recommendations for addressing the immediate and long-term concerns related tofood systems in Nagpur.
Keywords: COVID-19; lockdown; food systems; food security; supply chain; urban–rural

1. Introduction
Coronavirus disease 2019 (COVID-19) is a respiratory illness caused by the novel coronavirus,
officially referred to as Severe Acute Respiratory Syndrome coronavirus (SARS-COV-2), which was
first detected in China, in December 2019. There is currently no evidence if food is a likely source orroute of transmission of this virus, but it has been reported to originate from the world-famous Huanan
seafood market in Wuhan city. Four months later on 11 March 2020, the World Health Organization(WHO) declared the coronavirus outbreak a pandemic, after it spread over several countries affecting alarge number of people [1]. As per the global tally kept by the Johns Hopkins University [2], until
1 August 2020, the virus has already killed 675,213 people worldwide and more than 17.40 million
cases have been confirmed in 188 out of 195 countries. The resultant panic situation due to COVID-19
outbreak is also being associated with the term “Infodemic”, as huge amount of information andmisinformation is flowing through different channels, including social media (also discussed by Huaand Shaw [3]). In the wake of COVID-19 global health emergency, terms such as “Quarantine”, “Social
distancing” and “Lockdown” have today become the buzz words. A lockdown in this context mainlyrefers to the restrictions being imposed by the governments on movement of people and goods toprevent the spread of infections.
Int. J. Environ. Res. Public Health 2020, 17, 5710; doi:10.3390/ijerph17165710

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Although COVID-19 is reported to be not as deadly in comparison to past pandemics such as
Ebola virus disease, SARS and Middle East Respiratory Syndrome (MERS) [4], its high transmissibility
and rapid speed of spread have become a matter of serious concern for governments around theworld. Djalante et al. [5] and Shaw et al. [6] discussed several international response measures,
which are implemented to break the chain of virus transmission such as reduction in transportation(through all ground, ocean and air means), tightened border controls, travel bans, lockdowns, advanced
surveillance, etc. While the pandemic is still unfolding, global agencies including WHO, the World
Bank, the International Monetary Fund (IMF), the Food and Agriculture Organization of the United
Nations (FAO) and the World Trade Organization (WTO) have projected its drastic impacts on global
economy and food systems, unless fast measures are taken to contain the spread of infections.
Even before the outbreak of COVID-19, the global food systems were already at a critical juncture,as also discussed in the 2020 Global Food Policy Report [7]. As of 2018, more than 820 million people
worldwide did not have secure access to food [8] (p. 6). Other widespread concerns of climate change,
natural disasters, high population growth, poverty, malnourishment, changing consumption patterns,
obesity, etc. have also been posing serious challenges for sustainable development, particularly
in fast growing cities of Asia [9,10]. The sudden emergence of COVID-19 pandemic has currently
overshadowed or rather aggravated the already existing concerns of food insecurity. According to a
recent projection by the United Nations World Food Programme [11], COVID-19 may aggravate therisks of acute food insecurity for an additional 130 million people by the end of 2020.
Thus far, there have not been any major signs of global food shortages [1]. However, demand-side
contractions have recently been witnessed due to the largescale closure of restaurants and othercommercial food services [12]. As most countries are now under strict lockdowns or in similar
situations, Petetin [13] uncovered that the majority of the food consumption is presently concentrated
at the household level. Further, food prices are also reported to be increasing in cities around the world,
as food supply from rural areas is disrupted due to the mobility restrictions [14] (p. 6). Cities havetraditionally been dependent on areas outside their physical boundaries (mostly surrounding ruraland peri-urban areas) to meet their food demands [15–18], but the sudden transport restrictions andshortage of manpower have presently disrupted the urban–rural food supply chains (from harvesting
crops to food distribution) worldwide. While the jobs and livelihoods of food supply chain actors areat significant risk, the government mandated lockdowns are also found to be influencing the consumer
behavior towards food along with their food priorities and lifestyles [19].
In a bid to contain the impacts of COVID-19 at an early stage, the Government of India (GoI)
enforced a temporary nation-wide lockdown (the world’s largest) from 24 March 2020, by confining
more than 1.3 billion people to their homes [20]. Despite the fragile economy, the country’s timely
decision was highly appreciated by global agencies including WHO and IMF, mainly in consideration
to their huge population and limited healthcare capacities [21]. Although comprehensive protection
measures were put in place at various administrative levels [22], GoI also announced a huge stimulus
package of 20 lakh crore Indian Rupees ‘INR’ (around 265 billion United States Dollars ‘USD’) to
alleviate the economic impacts of COVID-19 [23]. Nevertheless, the negative implications of enforced
lockdown in India have surfaced in form of a serious economic slowdown, panic-stricken migrantcrisis, panic buying, etc. [24,25]. With around 195 million undernourished people, India already sharesa quarter of the global hunger burden [26] and also performs poorly on indicators of child wasting,stunting and mortality, as per the Global Hunger Index 2016 [27]. In the lockdown phase, the situationis therefore particularly critical in Indian cities, where majority of fresh food supply is dominated by
the unorganized retail market [28,29].
The wide-ranging implications of COVID-19 on local food systems are yet to be understood clearly,
as very few evidence-based studies have emerged thus far. In the context of India, the media reports
have however covered several issues. Mishra and Rampal [30] underlined that there is still a lack ofrigorous academic studies that examine the impacts of COVID-19 on food insecurity. With an aim tobridge this gap, this paper discusses a specific case of Nagpur from the worst affected Indian state of

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Maharashtra. As of 1 August 2020, the state of Maharashtra has reported more than 420,000 confirmed
cases out of the total 1.64 million cases reported in India [31]. To control the spread of coronavirus
infections in Nagpur in parallel to maintaining the local food systems, a range of government initiatives
has been taken by the local authorities. At the same time, the incidents of panic-buying, spread of
misinformation, etc. have raised food security related concerns among the city residents, as they stayed
confined to their homes under the enforced lockdown. In regards to that, the three key objectivesof this study were: (1) to firmly understand the chronology of COVID-19 outbreak in Nagpur andits implications on local food systems; (2) to understand the perceived food security of Nagpur city
residents at household level during the lockdown phase and assess their perception regarding their“Immediate Concerns” and “Key Information Sources”; and (3) to suggest feasible recommendations foraddressing the immediate and long-term concerns related to food systems in Nagpur. The food security
assessment at household level is mainly intended to assess the effectiveness of local government
initiatives in providing a secure food environment, as the city residents stayed confined to their homes
under the enforced COVID-19 lockdown.
While the food supply chains are widely disrupted due to the enforced mobility restrictions, theurban areas have adversely been affected due to their predominant dependence on rural areas formeeting their fresh food demands. In that context, the study also aimed to highlight the importance ofurban–rural partnerships for strengthening local food systems.
The paper is divided into six sections, including the Introduction (Section 1). Section 2 provides an
overview of the most prominent advances in scientific literature related to food systems and COVID-19,
which sets a broad context for the conducted research. Section 3 provides a brief introduction to thecase study area of Nagpur, before explaining the adopted research methodology. The study results andanalysis are presented in Section 4. Section 5 provides specific policy recommendations to address
the immediate concerns identified through the study and sustain the local food systems in long-term.
The key conclusions and limitations of the present research have been summarized in the last Section 6.
2. Theoretical Background2.1. Implications of COVID-19 Lockdowns on Food Systems
Food systems are basically defined as the sum of actors (farmers, traders, consumers, etc.) andtheir interactions along the various stages of food value chain such as production, storage, processing,transport, distribution, etc. [7]. As the COVID-19 pandemic continues to be a major concern for thegovernment agencies, only a handful of studies have so far been conducted to assess its impacts
on local food systems and related actors. Bene [32] synthesized the wide-ranging adverse effects of
COVID-19 on various actors involved in food systems, ranging from food producers to consumers.
The study stressed that the COVID-19 impacts on food security are further worsened by the government
mandated lockdowns and business closures, as they consequently lead to loss of income and purchasing
power. These restrictions also pose detrimental effects on the food supply, as they not only cause labor
shortage but also hinder the flow of agricultural goods and services. On the demand side, it leads topanic buying amongst the consumers and stockpiling. Further, based on a preliminary analysis of
31 European countries, Akter [33] produced reliable empirical evidence that reveals the increase in
overall food prices due to stay-at-home restrictions. Galanakis [34] also discussed the food systems in
the coronavirus era and raised an alert for global food security as billions of people are currently living
under temporary lockdown or in similar situation.
2.2. Emerging Food Security Challenges and Assessment Methods
Food security is a multidimensional concept that conventionally stresses on food availability
and accessibility at individual level, along with food quality and cultural preferences. As per thedefinition established by World Food Summit 1996 [35], “food security exists when all people, at all
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needs and food preferences for an active and healthy life”. In the present context, COVID-19 is directly
undermining the food security through disrupted supply chains, and it is also causing indirect impacts
due to lockdowns in terms of reduced household incomes, restricted physical access to food, etc. [36].
Niles et al. [37] further stressed that the ongoing COVID-19 pandemic affects all the four dimensionsof food security, defined by the United Nations [38], namely availability, accessibility, utilization andstability. The changing consumer behavior linked to the panic buying and stockpiling incidents are
already affecting the food availability in the short term, but in the long term other challenges in terms offood import–export, etc. may unfold. The relative increase in food prices due to COVID-19 lockdowns,
the shortage of preferred products, etc. are also impacting the food accessibility in the recent times.
For poor people specifically, the increased food costs and closure of informal food markets may impact
their food utilization in terms of reduced diet quality and nutrition intake. Lastly, the stability of foodsupply is also threatened by COVID-19 due to varied reasons, as already discussed [36,37].
The 2008 global food crisis had earlier mainstreamed the importance of food security in the
global policy agenda [39]. Since then, numerous efforts have been made to establish measures forunderstanding this multifaceted concept. A variety of research frameworks and indicator sets have also
been developed for the assessment of food security at different levels such as individual, household,community, national, regional and global [40]. The wide-ranging indicator sets have focused onvariety of dimensions (availability, access, utilization, consumption, stability, sustainability, etc.) andcomponents (quality, quantity, local preferences, cultural acceptability, etc.) [41–43]. Particularly at thehousehold level, various indicators are presently been employed for evaluation, monitoring, analysis,
etc. [44,45]. However, food security assessments at household level remain a challenge as the term
“household” is still subjected to varying interpretations and its composition also varies. Selecting
appropriate indicators for analyzing different dimensions of food security at different scales is also
recognized as a serious challenge [46]. Also, food insecurity has for long been viewed from theperspective of rural population only. However, in the recent years, there has been a growing recognition
for this issue in context of urban population [47].
2.3. Importance of Urban–Rural Partnerships for Enhancing Food Security in Context of India
Fostering partnerships between urban and rural areas is important for sustainable development,
as they are closely linked through a range of spatial and sectoral linkages, including food supply [48].
Urban areas have traditionally been reliant on surrounding peri-urban and rural areas to meet theirfresh food demands. However, the conventional urban–rural food linkages are increasingly stressed
due to the fast-growing urban population, rapid urbanization, industrialization, etc. [17,49]. Lately,
the industrial supply chains have started to dominate the food markets by maintaining a steady supplyof processed food with higher standards [18].
In the present context of COVID-19 in India, the GoI has assured a wide distribution of food grains
at affordable prices [50], through the established Public Distribution System (PDS) and large buffer
stocks maintained under the National Food Security Act 2013 (explained by Pillay and Kumar [51]).
However, it is important to note that the PDS system is supplemental in nature, and there are alreadysubstantial challenges related to food supply and distribution in India [52–55]. Notably, Reardon etal. [56] pointed that the PDS system caters to only 5% of all purchased food in India, and the remaining
95% of purchased food is sold by private sector. The study also indicated that 60% of the foodconsumption in India is centered in urban areas, and the growing food demands are increasingly being
met by long urban–rural supply chains. Following the enforced mobility restrictions and disrupted
food supply chains, the ongoing COVID-19 pandemic has therefore created a sense of food insecurity
in urban centers [57]. However, very limited research has thus far been done to understand the foodinsecurity issues in context of urban areas in India (e.g., [58,59]).
Recently, the importance of urban–rural partnerships has gained high prominence [60],especially after the global policy agreements, namely Sustainable Development Goals “SDG” [61]and The New Urban Agenda [62]. Goal 11 (Target 11.A) of the SDGs specifically emphasizes on

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strengthening the urban–rural linkages from a regional planning perspective. The United Nations
3. Materials
and Methods
Human
Settlement
Programme (UN-Habitat) [62] also defined key entry points to foster urban–rural
linkages for implementing The New Urban Agenda through integrated development planning.
3.1. Case Study Area of Nagpur, India
3. Materials and Methods
Nagpur, also called the Orange city, is one of the most prominent urban agglomerations ofcentralshown inFigure 1). It is the third largest city (after Mumbai and Pune) and the
3.1.
CaseIndia
Study(location
Area of Nagpur,
India
winter capital of Maharashtra state. Spread over an area of 217.56 square kilometers, the city has a
Nagpur,ofalso
called2.5
themillion
Orange[63].
city, Nagpur
is one of Municipal
the most prominent
urban
agglomerations
centralpopulation
nearlyCorporation(NMC)
serves as of
the
local
India
(location
shown
inFigure
1).
It
is
the
third
largestcity(afterMumbai
and
Pune)
and
the
wintergovernance body that administers the city area. NMC has divided the city into 10 zones, which arecapitalMaharashtrainto
state.
area
squarekilometers,location
the city has
population
furtherofsub-divided
38 Spreadwards over[64]. anDue
to of
its217.56
strategic
geographicalandarichnaturalofnearly2.5
million[63].
NagpurMunicipal
Corporation(NMC)
servesasthelocal
governancebody
resource base, Nagpur is projected to be one of the fastest growing cities in the world from 2019
tothatadministers
the
city
area.
NMC
has
divided
the
city
into
10
zones,
whicharefurther
sub-divided
2035 with an average Gross domestic product (GDP) growth rate of 8.41% [65].
into 38
wards city[64].recorded
Due to itsits
strategic
geographicaland richresourceis
Nagpurfirst confirmed
case locationof COVID-19
onnatural
12 March
2020. base,
As ofNagpur
1 August
projected
to
be
one
of
the
fastestgrowing
cities
in
the
world
from
2019
to
2035
with
an
averageGross2020, the city had recorded a total of 3645 confirmed cases [31]. Because of the steadily rising number
domestic
product(GDP)
growthrate of 8.41%
of confirmed
cases,
the city
is identified
as one[65].
of the COVID-19 hotspots in central India.

FigureFigure 1.
1. Location
Location Map
Map ofof Nagpur
Nagpur city
city in
in Maharashtra
Maharashtra State
State ofof India
India (Image(Image source:
source: Author).
Author).

Nagpur Methods
city recorded its first confirmed case of COVID-19 on 12 March 2020. As of 1 August
3.2. Research
2020, the city had recorded a total of 3645 confirmed cases [31]. Because of the steadily rising numberofconfirmed
the city
is identified
as one of the
COVID-19
hotspots in central India.
3.2.1.
Formal cases,
Interviews
withLocal Government
Officials
in Nagpur

In earlyMethods
April 2020, formal interviews were conducted with the government officials from
3.2. Research
Nagpur Municipal Corporation (NMC) and Nagpur District Collectorate Office, who are specifically
3.2.1.
FormalLocalin
Government
Officials
in Nagpur
dealingwith Interviews
COVID-19 withresponse
Nagpur city
and Nagpur
district. The secondary information
regardingthegovernanceinitiatives
that
were
taken
to
managethe COVID-19
pandemicin Nagpur
In early April 2020, formal interviews were conducted withthe government
officials
from
was gathered
based
on following
researchquestions:“WhatOffice,werewhothe arechronological
NagpurMunicipal
Corporation(NMC)threeand Nagpur
DistrictCollectorate
specifically
implicationsof COVID-19
outbreakon localfood“Are there
any specificconcerns
dealingwith COVID-19
response
in Nagpurcity
andsystems?”;
Nagpur district.
The secondary
information
pertainingthe
to governancecontinuity initiativesof urban–rural
foodtaken
supplychains thein COVID-19
Nagpur?”; pandemic
and “Whatkind ofregardingthat wereto managein Nagpur
governanceinitiatives
andmeasures
are
being
taken
for
managing
the
local
food
systems?”.
Based
was gathered based on following three research questions: “What were the chronological implications
on
their
responses,apreciseunderstandingof
ongoing
pandemicoutbreakinNagpurof COVID-19 outbreak on local food systems?”; “Are there any specific concerns pertainingwas
toestablished. Although there are limitations to the information gathered through these questions, it isimportant for understanding the ongoing state of affairs as the city residents stay confined to theirhomes due to the enforced COVID-19 lockdown. To overcome the knowledge gaps, the authors havealso referred to the NMC COVID-19 Control Room data and the daily media reports.

Int. J. Environ. Res. Public Health 2020, 17, 5710

6 of 23

continuity of urban–rural food supply chains in Nagpur?”; and “What kind of governance initiatives
and measures are being taken for managing the local food systems?”. Based on their responses,
a precise understanding of ongoing pandemic outbreak in Nagpur was established. Although there arelimitations to the information gathered through these questions, it is important for understanding theongoing state of affairs as the city residents stay confined to their homes due to the enforced COVID-19
lockdown. To overcome the knowledge gaps, the authors have also referred to the NMC COVID-19
Control Room data and the daily media reports.
3.2.2. Online Surveys to Assess the Perception of Nagpur City Residents
As the local governments in Nagpur work to manage the implication of COVID-19 under
the lockdown situation, the home-confined city residents receive extensive information about theavailability of life essentials such as food grains, vegetables and healthcare products from a wide rangeof online and media sources. However, the circulation of fake information regarding the spread of
infections or decline in market availability holds the potential to trigger any unforeseen concerns
for food security. In that regard, it becomes important to understand the perception of Nagpur
city residents for three key aspects: (1) Key Information Sources; (2) Immediate Concerns; and (3)Household Food security. While the local governments in Nagpur have reportedly taken several
measures to maintain a continued food supply, this study tried to understand their effectivenessthrough the assessment of above-mentioned three key aspects.
Table 1 highlights the main research questions that were framed for understanding the “KeyInformation Sources” and the “Immediate Concerns” of Nagpur city residents during the pandemic
situation. Acknowledging the widespread COVID-19 related concerns and the varied sources of
information, the research questions were framed to determine the overall importance of the range
of information sources (through multiple choice questions), as well as their individual significance(through single choice questions).
Table 1. Research Questions for assessment of “Key Information Sources” and “Immediate Concerns”.
Key Determinant

Key Information
Sources

Immediate Concerns

Research Question
What are your key sources of
information for ongoing
COVID-19 situation in
Nagpur? (Multiple choice)
What is the most accurate
and reliable source of
information regarding
COVID-19?
What are your immediateconcerns in the wake of
COVID-19 Pandemic
scenario? (Multiple choice)
What is your topmost
concern at the moment
under COVID-19 pandemic
situation?

Response Options

Television and Radio/Newspapers/Social
Media/Governments websites and Apps/Phone
calls and Messages/Community
Networks/Official Communications/Others

Health Services/Job Stability/Travel andTransportation/Food and Grocery/Water andEnergy/Access to banking
facility/Education/Social Interaction/Others

In reference to the range of indicators established in previous studies (as discussed in Section 2.2),
the developed framework mainly builds on four key dimensions of food security: (1) availability(in-house and market availability); (2) accessibility (physical and economic access); (3) consumption(food quality and local preferences); and (4) stability (anticipated impacts on food security). These arefurther categorized into 12 indicators. With an objective to understand the effectiveness of local
government initiatives in maintaining household food security, specific research questions were framed

Int. J. Environ. Res. Public Health 2020, 17, 5710

7 of 23

to assess the defined indicators (as shown in Table 2) at household level. These research questions
were supported with a set of predictable reactions to their experience of food insecurity, which could
later be summarized and quantified for assessing the perceived food insecurity of survey respondents
at household level.
Table 2. Indicators for assessing the perceived household food security under COVID-19 lockdown.
Food Security Determinant
and Key Indicators

Research Question

Response Options

Food Availability

1. In-house Availability

Do you grow your own fruits andvegetables in a homestead garden or
plot? Do you own any livestock, farmanimals or poultry?

Yes/No2. Market Availability

In the past few weeks, how has themarket availability of food products(including Fruits and Vegetables, Grains,
Dairy Products, Meat and Poultry,
Seafood) changed?

Highly Increased/Increased/No
Change/Decreased/Highly
Decreased

3. Current Stock

In the case of complete lockdown, for
how many days will your current foodstock be adequate?

Less than two days/Up to 1
week/Up to 2 weeks/More than 2
weeks

Food Accessibility
4. Physical Access

Presently, do you have easy access(within 2 km) to nearby markets orgrocery stores?

Yes/No5. Market Prices

Has there been any change in foodprices recently?

Highly Increased/Increased/No
Change/Decreased/Highly
Decreased

6. Institutional Support

Presently, do you have the facility to getfood delivered at you houses?

Yes/No/Maybe

Food Consumption
7. Nutritional Adequacy

Presently, do you have adequate accessto nutritious food?

Yes/No/Maybe

8. Local Preferences

Has there been any shortage of yourpreferred food products?

Yes/No9. Food Quality

In the past few weeks, has the quality offood products matched your expectedlevels?

Yes/NoFood Stability
10. Food Supply

Do you think the supply of foodproducts will be stable in coming
weeks?

Yes/No/Maybe

11. Food Prices

Do you think food products will beaffordable to you in coming weeks?

Yes/No/Maybe

12. Information AccessDo you have reliable access to
information related to availability offood products in markets?

Yes/NoTo study the perception of Nagpur city residents for the defined research questions of three key
aspects, the authors conducted online surveys (through Google Forms) at two different time intervals.
The online mode was specifically selected in consideration to the core need of maintaining social
distancing and avoiding any unintended consequences of this study. Each of the two surveys wasInt. J. Environ. Res. Public Health 2020, 17, 5710

8 of 23

conducted specifically for five days, in due consideration to the fast-changing situation of COVID-19
and related concerns. After the defined period of five days, the online survey was turned off, and thesurvey responses were downloaded as csv file. Thereafter, the collected data were analyzed by theauthors in Microsoft Excel (Microsoft; Seattle, WA, USA).
The first survey was conducted during the initial phase of COVID-19 outbreak in Nagpur(22–26 March 2020). This survey, conducted during the early phase of COVID-19 outbreak, mainly
assessed the two key aspects of “Key Information Sources” and “Immediate Concerns”. The survey
form was randomly circulated by the authors amongst the Nagpur city residents, through various
social media platforms including Facebook and Whatsapp. All the respondents in the first survey wereasked for their willingness to participate in the second (follow-up) survey.
The second survey was conducted during the peak-building phase (two weeks after complete
lockdown at National level) from 5 to 9 April 2020. To build on the results obtained through theinitial survey, the second survey was specifically conducted with the respondents of first survey who
had expressed their willingness to participate. The online questionnaire for the second survey wascirculated to the interested respondents, through emails and phone numbers received during initial
phase survey. In addition to the key aspects of “Key Information Sources” and “Immediate Concerns”,
this survey also assessed the perceived food security of the survey respondents at household level.
The initial phase survey questionnaire mainly consisted of four key research questions related
to the “Key Information Sources” and “Immediate Concerns” of Nagpur city residents (as shown in
Table 1). In addition to these, the peak-building phase survey questionnaire consisted of 13 otherresearch questions related to food security assessment at household level (as shown in Table 2).
For the aspects of “Key Information Sources” and “Immediate Concerns”, the results from two online
surveys are intended to assess the change in perception of survey respondents at two different timeintervals. Further, the food security assessment in the peak-building phase is mainly intended tounderstand the extent to which the local government initiatives have been effective to provide asecure food environment for the home-confined city residents, under the unprecedented COVID-19
lockdown situation.
Lastly, the survey respondents were also asked about some general details (age, gender, area ofresident, occupation and key food purchase areas). To create low respondent burden and ensure
wider participation from the city residents, the survey questions were specifically related to ongoing
COVID-19 pandemic, and other specific questions such as household income, etc. were excluded.
4. Results
4.1. Emergence of COVID-19 Pandemic in Nagpur and Local Government Response
Based on the formal interviews with local government officials, the initial rise in the number of
COVID-19 confirmed cases was observed as intermittent spikes (as illustrated in Figure 2). In reference
to the three spikes of COVID-19 outbreak in Nagpur that were observed between 12th March and
18 April 2020, a month-long timeline of COVID-19 pandemic outbreak was developed. Based on theinsight gained through the formal interviews, the chronological implications of COVID-19 in Nagpur,
the consequent government initiatives to control the spread of infections and maintaining the foodsupply are descriptively explained in the following three subsections.

entered into a partnership with local Chemists Association and identified 12 medical stores thatwould remain open 24 × 7, in addition to other medical stores, which operated within limited hours
during the lockdown. Likewise, NMC also tied up with 45 local merchants and shopkeepers forproviding home delivery of grocery items across majority of zones in the city. For stricter
Int.
J. Environ. Res. Public
Healthlockdown
2020, 17, 5710
9 ofkey
23
implementationof theregulations, NMC also deployed drones for surveillance of
public areas to identify the violators as well as those needing shelter assistance in the city [67].

Figure2.2.Timeline
TimelineofofCOVID-19
COVID-19outbreakoutbreakininNagpur,
Nagpur,its
itschronologicalchronologicalimplications
implicationsand
andGovernment
Government
Figureresponsemeasures
measures(prepared(preparedby
bythe
theauthors
authorsininreference
referencetotothe
theCOVID-19
COVID-19Monitoring
MonitoringDashboard
Dashboard
response
maintainedbyPublicHealthDepartment,
GovernmentofMaharashtra[31]).
maintained by Public Health Department, Government of Maharashtra [31]).

4.1.1.
Waveof Pandemic
OutbreakandandPanic
Buyingof Wholesale Markets
4.1.2.First
SecondWaveof Pandemic
OutbreakClosureAfteremergencetheof COVID-19
patients
in the city, aforpanicof healthcare
such asin
Afterthecontaining
spread of novel
coronavirus
11 buyingconsecutive
days (asproducts
also evident
handsanitizers
andwitnessed
facemasksa waswitnessed.
control that,the provisions
Epidemic
Figure2), the city
secondspike of To
COVID-19
confirmed
cases onof26theMarch,
as theDiseases
number
Act
[66]
were
extendedandtheshopping
malls
in
the
city
were
closed.
The
impositionofstricterof COVID-19 positive patients quadrupled in four days. The local authorities again sprang into action
regulations
forbidding
gatheringandof people
in public
affected
the movementsof contract
staff
in
to stop the spreadof infections
closed down
the areas
wholesalemarketareas that wereattracting
large
the
malls, daily
wagers andlaborers,
includingthose who
working in
the freighttransportation
gatheringsof farmers,
traders,
retailersand buyers.
ThewereAgriculture
Produce
MarketCommittee
andfood yard
marketsector. However,thelife essential
services
includingpharmacy,
grocery
stores,(APMC)
at Kalamna,
the biggest
wholesalemarketfor grains
and vegetablesin thecity andthat
vegetable
shops,
milk booth, daily
needsetc. closed
continued
to operate withstrict measures
distributes
the commodities
all overtheshops,
city, wasfor sanitization.
Thereafter,a sense toof
maintain“socialdistancing”prevailed
among theamongst
citizens. the farmers and traders, as there were no clearer
insecurity
for livelihoods
After aandnationwide
lockdown
from
24 authorities
March was forannouncedby theof India[20],adirections
alternatives
from thecivic
making thesale.Government
Thereafter, tomaintainall the public transportation modes including roads and railways came to a standstill. The perishable
goods that were reaching the city from adjoining states and rural areas as well as those which werebeing exported from the city through passenger trains also stopped reaching the markets. The farm
produce that reaches the markets through roadways also witnessed a temporary blockade after the
district boundaries were sealed by civic authorities. The already ongoing shortage of labor in market
and reduction in supply of commodities led to an increase in retail market prices forcing the local
government authorities to ease the freight movements of basic commodities.
To ensure continued provisioning of life saving drugs and medicines to the citizens, NMC enteredinto a partnership with local Chemists Association and identified 12 medical stores that would remain
open 24 × 7, in addition to other medical stores, which operated within limited hours during the
lockdown. Likewise, NMC also tied up with 45 local merchants and shopkeepers for providing homedelivery of grocery items across majority of zones in the city. For stricter implementation of theInt. J. Environ. Res. Public Health 2020, 17, 5710

10 of 23

lockdown regulations, NMC also deployed drones for surveillance of key public areas to identify theviolators as well as those needing shelter assistance in the city [67].
4.1.2. Second Wave of Pandemic Outbreak and Closure of Wholesale Markets
After containing the spread of novel coronavirus for 11 consecutive days (as also evident in
Figure 2), the city witnessed a second spike of COVID-19 confirmed cases on 26 March, as the numberof COVID-19 positive patients quadrupled in four days. The local authorities again sprang into action
to stop the spread of infections and closed down the wholesale market areas that were attracting large
gatherings of farmers, traders, retailers and buyers. The Agriculture Produce Market Committee(APMC) yard at Kalamna, the biggest wholesale market for grains and vegetables in the city andthat distributes the commodities all over the city, was closed for sanitization. Thereafter, a sense of
insecurity for livelihoods prevailed amongst the farmers and traders, as there were no clearer directions
and alternatives from the civic authorities for making the sale. Thereafter, to maintain a continued
supply of food produce with safety precautions, the local authorities took three key initiatives as
explained below:
1.

2.

3.

Designated open grounds to decentralize the food markets: In coordination with APMC, the city
authorities designated 24 open grounds in different parts of the city as alternative locations to carryout the sale transactions between traders and associated farmers. Such decentralization of thewholesale market was done to control overcrowding and to avert the community spread of novel
coronavirus (schematic explanation shown in Figure 3). However, reportedly, only seven of the
24 designated open grounds were occupied by the farmers and traders due to a variety of statedreasons such as lack of proper facilities, limited spaces, the long distances and transportation
costs. Resultantly, several farmers were forced to sell their produce on streets at much-reduced
prices, and many others preferred selling their produce outside the city.
Shelter camps and community kitchens for the needy people: In reference to NMC COVID-19
Control Room data, Nagpur city started witnessing panic amongst the labor class migrants from29th March onwards, as they started crossing the city by foot defying the lockdown regulations
Under the directive of the National and State Governments, the City and District authorities
set up 19 shelter homes and 177 relief camps to cater to the needs of about 5685 people (as on
8 April 2020). Furthermore, around 28 community kitchens [68] were established to meet the
food demands of 29,050 people accommodated in temporary tents, hostels and other relief camps.
Home delivery of food products: To create redundancies in food supply and provide door-to-door
service, the local authorities partnered with around 50 Food Produce Organizations (FPOs)
from the surrounding rural areas, comprised of small and medium farm holding agriculture
producers and farmers registered under various governmental schemes. The local authorities
in coordination with youth voluntary groups also launched a helpline number for vulnerable
groups (e.g., the elderly and physically challenged people), through which they can receive homedelivery of essential commodities from associated retail shops. To further promote the initiativesof home delivery and make it citizen friendly, a web-based application [69] was also launched by
the authorities.

24 designated open grounds were occupied by the farmers and traders due to avariety of stated reasons such as lack of proper facilities, limited spaces, the long
distances and transportation costs. Resultantly, several farmers were forced to sell
their produce on streets at much-reduced prices, and many others preferred selling

Int. J. Environ. Res. Public Health 2020, 17, 5710

their produce outside the city.

11 of 23

traditional
food
supplychain
in Nagpur(Imagesource:theFigure 3. Implications
ImplicationsofofCOVID-19
COVID-19onon
traditional
food
supplychain
in Nagpur(Imagesource:authors).
theauthors).

4.1.3. Third Waveof Pandemic
and Disruption
Supplypeople:
Chain In reference to NMC
2. Shelter
camps Outbreakand community
kitchens of
forFood
the needy
On 7 April, COVID-19
the city registeredfirst deathto COVID-19.
With
the informationof travelers
ControlitsRoom
data, due
Nagpurcity started
witnessing
panic amongst
thearriving from thelabor
national
capital,
one
of
the
main
hotspotsof
COVID-19,
thecity
government
gearedclass migrants from 29th March onwards, as they started crossing the city by
up for increasing their testing capacities and established four more centers on 9 April. With increasedfoot defying the lockdown regulations Under the directive of the National and Statetesting capacities, the number of COVID-19 positive patients in the city also increased and tripled overtheCityconcern
and Districtauthorities
set up 19 shelterand 177 relief
a week’s time. ItGovernments,
was a matter ofhuge
for thecity administration,
as thehomes
rapid outbreak
was
camps
to caterto theneeds ofmarket,
about 5685
people(as on8 Aprilobserved in the areas
close
to grains
wholesale
whichthen hadto besealed2020).
as perFurthermore,
the standard
operating procedures. On the other hand, just as the farmers and traders had adjusted after 10 days inthe designated open grounds for food marketing, the city government again declared that five of theseven operating make-shift markets must close on 11th April. The frequent shifting of the markets
started creating confusion amidst the retail shopkeepers, vendors, and common citizens regarding
availability of the vegetables during critical times.
4.2. Key Information Sources, Immediate Concerns and Perceived Food Security at Household Level
In total, 346 responses were received for the initial phase survey, and for the peak-building phasesurvey (follow-up survey) 88 of these respondents had expressed their willingness and participated
for the same. It is important to note that the initial survey was conducted with randomly selectedindividuals from the city, for a specific period of time. Therefore, the contacted sample does not represent
the demographic characteristics of the overall city population. The respondents for peak-building
phase survey are also comparatively fewer than those of the initial phase survey. However, it may be
due to the fixed time duration and the follow-up approach of this study.

Int. J. Environ. Res. Public Health 2020, 17, 5710

12 of 23

The results obtained through the initial phase surveys serve as a foundation over which thechange in perception of survey respondents for “Key Information sources” and “Immediate Concerns”
during the peak-building phase are assessed. In addition, the perceived food security at household
level was assessed during the peak-building phase to understand the effectiveness of food-related
governance initiatives that were taken during the lockdown situation.
Table 3 highlights the characteristics of survey respondents during both the online surveys
conducted. As is evident, a variety of respondents from different age, gender and occupation groups
from all ten zones of Nagpur city (Figure 1) participated in the online surveys. The interpretation of
study results is done in the form of percentages.
Table 3. Characteristics of survey respondents.
Respondent Characteristics

Initial Phase(22nd March to 26th March 2020)

Peak-Building Phase(5th April to 9th April 2020)

Number of Surveys

346

88

Age Group of Respondents
Under 20 Years
20s
30s
40s
50s
60 Years and Above

3.8%
34.7%
18.8%
14.5%
19.7%
8.7%

2.3%
29.5%
20.5%
23.9%
21.6%
2.3%

Gender Group of Respondents
Male
FemaleOther
Prefer Not to Answer

43.9%
56.1%
0.0%
0.0%

47.7%
52.3%
0.0%
0.0%

Area of Residence (categorized in 10 Zones of city)
Laxmi Nagar
Dharampeth
Hanuman Nagar
Dhantoli
Nehru Nagar
Gandhibagh
Satranjipura
LakadganjAshi Nagar
Mangalwari

36.1%
23.4%
11.6%
6.6%
2.9%
3.2%
1.4%
3.5%
2.9%
8.4%

40.9%
30.7%
5.7%
2.3%
2.3%
4.5%
3.4%
1.1%
2.3%
6.8%

Occupation Group of Respondents
Government Service
Private Job
Formal BusinessInformal Business
Student
Home Manager
Other

15.0%
26.0%
9.5%
2.0%
26.6%
9.8%
11.0%

26.1%
31.8%
12.5%
2.3%
15.9%
5.7%
5.7%

4.2.1. Key Information Sources Related to COVID-19 Pandemic
Figure 4 highlights the “Key Information Sources”, as identified by the survey respondents during
the initial and peak-building phase surveys. A considerable variation in community preferences fordifferent information sources was observed. The importance of “Government Apps and Websites” and“Official Communications” particularly increased during the peak-building phase. These results aremainly interpreted in the context of the enforced lockdown situation during the peak-building phase.

Int. J. Environ. Res. Public Health 2020, 17, 5710

13 of 23

While the responding city residents are confined to their homes, they appear to be primarily reliant
on the incoming information from government agencies, who are managing the overall situation atlarge scale. On the other hand, the comparative significance of “Social Media” and “Newspapers”
was observed to be declining during the peak-building phase. These results may be attributed to
the growing incidents of fake news circulation through social media platforms and the fear of print
newspapers being a potential virus carrier. Overall, “Television and Radio”, “Newspapers”, “Social
Media” and “Government websites and Apps” were identified by the survey respondents as their key
information sources (more relevant than others) during both surveys. Apart from these, other lessrecognized sources specified by the respondents under the “Others” category included informal
information
sources
medicineand pharmacists.
Int. J. Environ. Res.
Public such
Healthas
2020,
17, x FORstores
PEER REVIEW
13 of 25
Int. J. Environ. Res. Public Health 2020, 17, x FOR PEER REVIEW

13 of 25

Figure4.
4. KeyKey Information
Information Sources
Sources identified
identifiedby
bythe
thesurvey
surveyrespondents
respondentsfor
forCOVID-19.
COVID-19.
FigureFigure 4. Key Information Sources identified by the survey respondents for COVID-19.

Among thethe various
various information
information sources,
sources, Figure
Figure 55 highlights
highlights thethe most
most accurate
accurate andand reliable
reliable
Among
Among
the variousidentified
information
sources,Figure5 highlights
thethemostaccurateand reliable
sourceofinformationbythesurveyrespondents
duringinitialandpeak-building
source of information identified by the survey respondents during the initial and peak-building phasesourceinformation
identified
bywerethe conductedsurvey respondents
duringthe mode
initialdue
andtopeak-building
phase ofsurveys.
Since
thesurveys
onlyonline
through
onlinetherestrictions,
lockdown
surveys.
Since thesurveyswere conducted
only throughmode
due tothe lockdown
phasesurveys.
Since
thesurveys
were
conducted
only
through
onlinemode
due
to thelockdown
restrictions,
there
is
a
possibilityof
these
results
tobemore
relevant
for
those
who
use
onlinesources.
there is a possibility of these results to be more relevant for those who use online sources. Withintherestrictions,
there
is a possibilityofthesesurvey
results respondents,
to be more relevant
for those whowebsites
use online
sources.
Withintheselectedsubsetofonlinethe“Government
and
Apps”
selected subset of online survey respondents, the “Government websites and Apps” followedbyWithinthebyselected
subsetonlinewere
surveyrespondents,
the reliable“Government
and Apps”
followed“Television
andofidentified
Radio”
identified
as the mostsourceswebsites
for
COVID-19
related“Television
andRadio” wereas themost reliable
sourcesfor COVID-19
relatedinformation,
followedby “Television
andforRadio”
were identified
asthelife-essential
most reliable services
sources for
COVID-19
relatedinformation,theincludingfood.
specificallyforspecificallythe availability
ofthe
theavailability
life-essentialof
services
including food. The comparative
declineTheininformation,
specificallyfor importancethe availabilityof themedia”
life-essential
services including
food.
The
comparativein theof “Social
andpeak-building“Newspapers”
duringtheispeakthe
importancedeclineof “Social
media” and “Newspapers”
during thephasesurveyalso
comparative
declinein istheof “Social
buildinginphasesurveyalsoimportanceevident in thisfigure. media” and “Newspapers” during the peakevident
this figure.
building phase survey is also evident in this figure.

Figure 5. Most reliable source of information identified by the survey respondents for COVID-19.
Figure 5. Most reliable source of information identified by the survey respondents for COVID-19.
Figure 5. Most reliable source of information identified by the survey respondents for COVID-19.

4.2.2. Immediate Concerns Due to COVID-19 Pandemic
4.2.2. Immediate Concerns Due to COVID-19 Pandemic
Figure 6 highlights the “Immediate Concerns” identified by the survey respondents during the
Figurehighlights thephase“Immediate
identified
by thesurveyrespondents
during theto
initial and 6peak-building
surveys.Concerns”
During boththe stages,“Healthservices”
was identified
initialandpeak-buildingphasesurveys.
Duringboth
thestages,“Healthservices”
wasidentified
tobe the most immediate concern for majority of the respondents. The concern was particularly higher
beintheimmediatephase,
concern
for majorityof thedue
respondents.
The
concern
was particularly
higherthemostpeak-building
which
is supposedly
to the rising
cases
of COVID-19
infectionsin theincity.
the Further,peak-building
phase,
whichissupposedly
due
to
the
risingcases
of
COVID-19
infectionsin the“Food and Grocery” was identified to be the second immediate concern. Noticeably,
its
city.
Further, “FoodGrocery” during
was identified
to be the second
immediate
importancegrew andsignificantly
the peak-buildingphasesurvey,concern.
as moreNoticeably,
than 60%itsof

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4.2.2. Immediate Concerns Due to COVID-19 Pandemic
Figure 6 highlights the “Immediate Concerns” identified by the survey respondents during theinitial and peak-building phase surveys. During both the stages, “Health services” was identified to be
the most immediate concern for majority of the respondents. The concern was particularly higher inthe peak-building phase, which is supposedly due to the rising cases of COVID-19 infections in thecity. Further, “Food and Grocery” was identified to be the second immediate concern. Noticeably, its
importance grew significantly during the peak-building phase survey, as more than 60% of respondents
highlighted it to be an immediate concern. This result is presumed to be associated with the abrupt
closing and shifting of vegetable wholesale markets, disruption of supply chain of food grains
and grocery, etc. that were also being reported in the news media. Although less significant, thesurvey respondents also identified other immediate concerns such as “Social interaction”, “Travel andtransportation”, “Job stability”, “Education”, etc.
Int. J. Environ. Res. Public Health 2020, 17, x FOR PEER REVIEW
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Figure 6. Immediate
Immediate concernsidentified
identified bythe
the survey respondents
respondents during COVID-19
COVID-19 lockdown.
FigureFigure 6.
6. Immediate concerns
concerns identified byby the survey
survey respondents during
during COVID-19 lockdown.
lockdown.

Among the range
range of Immediate
Immediate concerns, Figure
Figure 7 highlights thethe topmost concern
concern identified by
by
Among
Among thethe range ofof Immediate concerns,
concerns, Figure 77 highlights
highlights the topmost
topmost concern identified
identified bythesurveyrespondents
duringtheinitialandpeak-building
phaseof
COVID-19.
The
comparative
thethe survey
survey respondents
respondents during
during thethe initial
initial andand peak-building
peak-building phase
phase ofof COVID-19.
COVID-19. The
The comparative
comparative
significanceof
of“Food“Foodand
and
Grocery”
relatedconcernwas
found
to haverisensignificantlyin thesignificance
Grocery”
relatedconcern
was
found
to
have
risen
significantly
significance of “Food and Grocery” related concern was found to have risen significantly inin thethe peakpeakpeak-buildingphasesurvey,inparallelto“Jobstability”
and“Education”.
Notably,theconcernsofbuildingbuilding phase
phase survey,
survey, inin parallel
parallel toto “Job“Job stability”
stability” andand “Education”.
“Education”. Notably,
Notably, thethe concerns
concerns ofof “Social“Social“SocialInteraction”
and“TravelandTransportation”
were
less
significant
duringthepeak-building
Interaction”
Interaction” andand “Travel“Travel andand Transportation”
Transportation” were
were lessless significant
significant during
during thethe peak-building
peak-building phase.
phase.
phase.
This
comparative
decreaseinsignificancemaypossiblybetheresultofstrictlockdown
situation
This
comparative
decreaseinsignificancemaypossiblybetheresultofstrictlockdown
situation
This comparative decrease in significance may possibly be the result of strict lockdown situation andandand growing awarenessfor maintaining social
distancing preventto prevent the
spread of
COVID-19 pandemic.
growinggrowing awarenessawareness forfor maintaining
maintaining socialsocial distancing
distancing toto prevent thethe spreadspread ofof COVID-19
COVID-19 pandemic.
pandemic.

Figure7. Topmost
concerns identified
by the survey respondents during COVID-19 lockdown.
FigureFigure 7.
7. Topmost
Topmost concerns
concerns identified
identified by the survey respondents during COVID-19 lockdown.

4.2.3.
4.2.3. Perceived
Perceived Food
Food Security
Security atat Household
Household Level
Level
At
At thethe outset,
outset, it
it is
is important
important toto highlighthighlight thatthat 86.4%
86.4% ofof thethe survey
survey respondents
respondents statedstated their
theirdependenceontheretailmarket(supermarket,
streetmarkets,
vendors,etc.)
formeeting
dependence on the retail market (supermarket, street markets, vendors, etc.) for meeting their
their foodfood
demands,
which
is
very
high
comparedtoothersourcessuchaswholesalemarket
(5.7%),
demands, which is very high compared to other sources such as wholesale market (5.7%),
intermediaries
intermediaries (5.7%)(5.7%) andand farmers
farmers (2.3%).
(2.3%). These
These results
results particularly
particularly highlighthighlight thethe highhigh dependence
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4.2.3. Perceived Food Security at Household Level
At the outset, it is important to highlight that 86.4% of the survey respondents stated theirdependence on the retail market (supermarket, street markets, vendors, etc.) for meeting their fooddemands, which is very high compared to other sources such as wholesale market (5.7%), intermediaries(5.7%) and farmers (2.3%). These results particularly highlight the high dependence of Nagpur city
residents on food purchased from the formal and informal markets, which despite creating redundancy
for food supply at local level are highly dependent on centralized wholesale markets. Table 4 further
highlights the survey results for defined indicators of perceived food security at household level during
the peak-building phase surveys (under the lockdown situation).
Table 4. Perceived household food security of survey respondents during the peak-building phase.
Food Security Determinant
and Key Indicators

Research Question

Response Options—Response
Percentage

Food Availability

In-House Availability

Do you grow your own fruits and vegetables in ahomestead garden or plot?
Do you own any livestock, farm animals or poultry?

Yes—19.3%
No—80.7%
Yes—1.1%
No—98.9%

Market Availability

In the past few weeks, how has the market
availability of food products (including Fruits andVegetables, Grains, Dairy Products, Meat and Poultry,
Seafood) changed?

Highly Increased—4.5%
Increased—9.1%
No Change—36.4%
Decreased—43.2%
Highly Decreased—6.8%

Current Stock

In the case of complete lockdown, for how manydays will your current food stock be adequate?

Less than two days—5.7%
Up to One week—31.8%
Up to Two weeks—33%
More than 2 weeks—29.5%

Food Accessibility
Presently, do you have easy access (within 2 km) to
nearby markets or grocery stores?

Yes—98.9%
No—1.1%Market Prices

Has there been any change in food prices recently?

Highly Increased—9.1%
Increased—61.4%
No Change—28.4%
Decreased—1.1%
Highly Decreased—0%

Institutional Support

Presently, do you have the facility to get fooddelivered at you houses?

Yes—39.8%
No—25%
Maybe—35.2%

Nutritional Adequacy

Presently, do you have adequate access to nutritious
food?

Yes—87.5%
No—12.5%

Local Preferences

Has there been any shortage of your preferred foodproducts?

Yes—38.6%
No—61.4%

Food Quality

In the past few weeks, has the quality of foodproducts matched your expected levels?

Yes—69.3%
No—30.7%

Physical AccessFood Consumption

Food Stability
Food Supply

Do you think the supply of food products will bestable in coming weeks?

Yes—38.6%
No—19.3%
Maybe—42%

Food Prices

Do you think food products will be affordable to you
in coming weeks?

Yes—46.6%
No—18.2%
Maybe—35.2%

Information AccessDo you have reliable access to information related toavailability of food products in markets?

Yes—68.2%
No—31.8%

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2.

3.

4.

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Food Availability: The city residents were found to be highly dependent on food markets, as very
low percentages of respondents stated growing their own fruits and vegetables (19.3%) or own
any livestock, farm animals or poultry (1.1%). Against the growing disruptions in food supply
and relocation of food markets, around 50% of the survey respondents have witnessed a decreasein market availability of food products (mainly “Food and Vegetables” and “Meat and Poultry”).
Although the survey respondents were found to have maintained adequate stock of food grains
and grocery, most (around 70.5%) could satisfy their needs up to only two weeks in the case of acomplete lockdown.
Food Accessibility: Most survey respondents (98.9%) were found to have easy access to nearby
markets or grocery stores. However, due to the strict containment measures, the markets
and grocery stores were opening only for stipulated hours every day. While 39.8% of survey
respondents were stated to have access to food delivery services, the majority of respondents
were still required to compulsorily visit the markets for purchasing their food products. Notably,
35.2% of respondents were not aware if they even have any access to home delivery services
for food. Against the frequent disruptions in food supply chains that resulted in a limited stockwith the retailers and vendors, more than 70% respondents reported an increase in food prices(particularly for fruits and vegetables) in the wake of COVID-19 outbreak. These results also
substantiate the earlier finding of declining market availability of food products.
Food Consumption: Overall, 87.5% of respondents were found to have adequate access tonutritious foods. However, 38.6% of the survey respondents reportedly experienced shortageof their preferred food products in the market. While most food products are sourced from therural areas around the city, it is important to note that the “Fruits and Vegetables” are perishable
food commodities, which need adequate storage and processing. It was also found that the
food quality has recently not matched the expected levels of 30.7% respondents. This may be
associated with the shortage created due to panic buying phenomenon observed in the initial
phase of the outbreak and also the shopkeepers opening up their reserved stock of the goods.
Food Stability: While Nagpur city residents usually depend on the informal food markets, theemergence of COVID-19 pandemic has led to a sense of uncertainty about the stability of foodsupply. It was found that only 38.6% respondents think that the food supply will be stable, while
only 46.6% of respondents think they can afford the food products in the coming weeks. Even
more concerning is the fact that a significant proportion of people are not sure about the stabilityof food supply (42%) or their ability to afford the food products (35.2%) in the coming weeks.
Further, 31.8% of the respondents believe that they do not have reliable access to information
related to availability of food products in markets.

5. Discussion
Similar to most cities around the world, Nagpur has also presently become a living laboratory.
Unlike normal times, the management and governance of food systems is currently been coordinated by
the local governments. With the aim to decongest the wholesale markets, various initiatives have beentaken from closing down the wholesale market itself to designating city open grounds for wholesale
vegetable trade, app-based home delivery, community kitchens, etc. However, the traditional foodsupply chains that connect Nagpur city to surrounding rural areas have been disrupted due to theclosure of wholesale markets. The traders and farmers associated with the wholesale markets are also
facing extreme difficulties in terms of limited spaces, financial constraints, manpower shortages, etc.
As the pandemic continues to unfold, findings suggest that Nagpur city residents are also witnessing
uncertainties in food supply along with the decline in market availability and increase in food prices.
Based on the established understanding of pandemic situation in Nagpur (Section 4.1) and the resultsof online surveys (Section 4.2), the authors suggest specific policy recommendations for addressing theuncovered immediate concerns, as well as to strengthen the local food systems in the long-term.

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5.1. Short-Term Policy Recommendations
5.1.1. Efficient Information Sharing Mechanisms to Avoid Panic among the Citizens
Reliable access to accurate information can play an important role in effectively managing theongoing COVID-19 health emergency. As discussed in Section 4.1, the local government authorities in
Nagpur have already put in operation several advanced technologies such as mobile apps, websites,
helpline numbers, drones, etc. for various purposes including surveillance, food delivery, relief
operations, etc. However, through the online surveys, the immediate concerns of “Food and Grocery”
were found to be rising (Section 4.2.2) among the local citizens. Although there is a lack of supporting
evidence, the rising concerns of “Food and Grocery” may inadvertently lead to changed consumer
behaviors in terms of panic buying and stockpiling. To reduce any such uncertainties, it is important
for the city residents to have reliable access to real-time information regarding the market availabilityof life essential services such as food commodities and healthcare products.
Based on the assessment of people’s perception in Nagpur, “Government websites and apps” were
found to be highly reliable and accurate source of information. While the local government are alreadymaking use of mobile apps and web-portals for COVID-19 related information sharing, the study results
show that 31.8% of survey respondents (refer to Table 4) did not have reliable access to information
related to market availability of food products. In view of the already existing online platforms and theoutreach shortcomings identified through the study, the authors stress on strengthening these existing
online platforms through effective information sharing and wider community outreach. In that manner,
the local governments can timely reach out to citizens for tackling or avoiding any panic-driven
response by the citizens.
5.1.2. Enhancing the Household Food Security through Robust Food Supply Chains
Several global research agencies including the UN, FAO, WHO, etc. have put forward specificguidelines to manage the wide-ranging implications of COVID-19, including those on food systems [70].
The steadiness of food supply chains has been recognized as the core need to avoid any potential
food shortages or price hikes [71]. In the case of Nagpur, the closure of wholesale markets reportedly
disrupted the urban–rural supply chains and raised serious concerns for various supply chain actors
including the farmers and traders (discussed in Section 4.1.2). Based on the primary surveys, it has
also been found that urban residents have recently witnessed food insecurity concerns such as
declining market availability and increased food prices (refer to Table 4). It is therefore apparent thatthe robustness of traditional food supply chains in Nagpur needs to be strengthened for ensuring
household food security, specifically as the food consumption is presently concentrated in the household.
To achieve that, the local authorities should consider the development of a “business continuity plan”
in close coordination with all the related actors including the farmers, traders, etc. As explained in
Section 4.1.2, the local governments in Nagpur have already partnered with around 50 local FPOs forenhancing home delivery of food products. These partnerships should further be mobilized to create
short and reliable food supply chains for long term.
5.2. Long-Term Policy Recommendations
Although COVID-19 pandemic continues to proliferate, cities around India (including Nagpur)
are now easing the lockdown restrictions to alleviate the economic impacts. The local authorities
in Nagpur have undeniably taken extraordinary steps to manage the local food systems during the
lockdown situation. However, at the same time, there is a need for adopting certain long-term actions
to mitigate the anticipated impacts of COVID-19 as well to prepare for the future pandemics. Based on
the research findings and interaction with the local government officials, the authors postulate three
specific policy recommendations for strengthening the local food systems.

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5.2.1. Boosting Urban Agriculture and Local Food Production
As with most cities, Nagpur considerably depends on surrounding rural areas to meet their fooddemands, specifically for perishable products such as fruits and vegetables. Through the study results,
only 19.3% of the survey respondents were found to grow their own fruits and vegetables (refer toTable 4). In the wake of COVID-19, a genuine need for enhancing urban agriculture and encouraging
local food production has therefore been realized around the world to supplement the traditional
food supply from rural areas [57,72,73]. To ensure sustainable food production and consumption
at city level, the city governments should encourage the local residents to practice agriculture atneighborhood level. Several forms and practices of urban agriculture such as community gardens,
farmer’s market, green roofs, etc. were highlighted by Burton et al. [74]. Nicholls et al. [75] also
underlined the importance of enhancing urban and peri-urban agriculture to achieve sustainable
development. The many benefits of enhancing urban agriculture also include improved household
food security [76] and urban resilience [77].
5.2.2. Integrated Governance of Food Systems at Regional Level
While Nagpur city provides the market for food supply, the bulk of it is produced in surrounding
rural areas. It is therefore important to understand that food systems connect Nagpur city with therural areas in wider metropolitan area. The importance of multi-level food system governance hasfor long been advocated to bring together a wide range of supply chain actors from producers to
consumers [78]. Dubbeling et al. [16] also highlighted the importance of city-region perspective forbuilding more resilient, fair, and sustainable food systems. However, the integrated governance offood systems is still not recognized at policy levels in Nagpur. Although the local governments in
Nagpur are now coordinating with The Agriculture Produce Market Committee for managing the foodsystems in the wake of COVID-19 outbreak (discussed in Section 4.1.2), the study recommends for theircontinued engagement to leverage the urban–rural interdependencies and promote policy coherence
at regional level. For the long-term sustainable development of Nagpur, the city essentially needs tobe underpinned by strong urban–rural linkages, the importance of which has also been recognizedthrough global policy frameworks such as SDGs and The New Urban Agenda.
5.2.3. Bridging the Urban–Rural Gaps through Improved Producer-Consumer RelationshipThe closure of wholesale markets in Nagpur and the disruption of supply chains have brought
forward the vulnerabilities of food systems in Nagpur. While rural farmers are reportedly experiencing
increasing marginalization (Section 4.1.2), the high dependence of city residents on retail markets
also makes them vulnerable to the concerns of food shortages and price hikes (as shown in Table 4).
As such, there is a need for redundancies in the local food systems. Sukhwani et al. [17] explained how
improved producer–consumer relationships can serve for narrowing the food supply demand gaps
between urban and rural areas at regional level. In reference to the existing best practices, the local
governments should adopt locally-relevant strategies for strengthening the food systems in long-term.
6. Conclusions
This paper presents an early assessment of COVID-19 implications on local food systems,with reference to the specific case of Nagpur in central India. The key purpose of the study was
to understand the chronological implications of pandemic outbreak on local food systems and to
determine the effectiveness of counteractive governance measures by examining the perception ofhome-confined Nagpur city residents. The study covered an important issue of perceived food security
at the household level, as the city residents stay confined to their homes under the strict lockdown
situation. It, therefore, provides an original contribution as only a few studies have so far addressed
this issue in the context of a pandemic situation.

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Through a descriptive analysis of city resident’s “Key Information Sources” and “Immediate
Concerns” in different time intervals of COVID-19 outbreak, a considerable variation in people’s
perception was observed. While the concerns of “Food and Grocery” were found to significantly
increase in the lockdown phase (along with the concerns of health services), the survey respondents
were found to prefer authentic sources of information such as “Government apps and websites” and“Official Communication”. The assessment of perceived food security at household level also brought
forward the key vulnerabilities in the local food systems, which could not be adequately addressed by
the local governments in the lockdown phase.
Moreover, the dynamics of COVID-19 is still very complex, and the situation is constantly evolving
by the day. It is therefore very hard to determine the significance of the study findings in long run.
However, this study is hoped to serve as a strong foundation for effectively managing the local foodsystems against future pandemics. The paper describes the grassroot level situation based on formalinterviews (with local government officials) and primary surveys (with city residents) at defined timeintervals (March–April 2020). However, the statistics related to spread COVID-19 are already very
different four months later in August 2020. The small sample size and the online mode of survey,
necessitated by the strict lockdown situation in Nagpur, is one of the key limitations of this study.
Due to the random sampling method, the study also could not incorporate the concerns of variedsocioeconomic groups.
Towards the end, it is important to underline that the suggested policy recommendations are
based on a precise understanding of the ongoing pandemic situation and the research findings derived
through online surveys. The authors also acknowledge that the perceived household food security,
immediate concerns and key information sources are bound to vary significantly between different
socioeconomic groups, and there is need for further research to precisely understand the effectivenessof food-related governance initiatives in pandemic situation.
Author Contributions: Conceptualization, visualization and methodology, all authors; investigation, formal
analysis, writing—original draft preparation and writing—review and editing, V.S. and S.D.; resources, supervision,validation and project administration, R.S. and S.D.; and funding acquisition, R.S. All authors have read andagreed to the published version of the manuscript.
Funding: This research received no external funding.
Acknowledgments: All the authors sincerely acknowledge the valuable support received from the office of
Additional Commissioner, Nagpur Municipal Corporation and Nagpur District Collectorate Office. The firstauthor (V.S.) is also thankful to the Ministry of Education, Culture, Sports, Science and Technology (MEXT), Japanfor the scholarship.
Conflicts of Interest: The authors declare no conflict of interest.

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Article

COVID‐19 Response in Thailand and Its Implications on
Future Preparedness
Wijitbusaba Marome 1 and Rajib Shaw 2,*
Research Unit in Urban Futures and Policy and Faculty of Architecture and Planning,
Thammasat University, 99, Khlong Nueng, Khlong Luang District, Pathum Thani 12120, Thailand;
wijitbusaba@ap.tu.ac.th
2 Graduate School of Media and Governance, Keio University, Endo 5322, Fujisawa 252‐0882, Japan* Correspondence: shaw@sfc.keio.ac.jp
1

Citation: Marome, W.; Shaw, R.
COVID‐19 Response in Thailand and
Its Implications on Future
Preparedness. Int. J. Environ. Res.
Public Health 2021, 18, 1089.
https://doi.org/10.3390/ijerph18031089

Abstract: Thailand has been affected by COVID‐19, like other countries in the Asian region at an
early stage, and the first case was reported as early as mid‐January 2020. Thailand’s response to the
COVID‐19 pandemic has been guided by the “Integrated Plan for Multilateral Cooperation for
Safety and Mitigation of COVID‐19”. This paper analyses the health resources in the country andfocuses on the response through community‐level public health system and legislative measures.
The paper draws some lessons on future preparedness, especially with respect to the four priorities
of Sendai Framework for Disaster Risk Reduction. At the end, the paper puts some key learning for
future preparedness. While Thailand’s response to COVID‐19 has been effective in limiting the
spread of the disease, it falls short at being able to address the multiple dimensions of the crisis
such as the economic and social impacts. The socioeconomic sectors have been hardest hit, withsignificant impact on tourism sectors. Sociopolitical system also plays an important role in gov‐
ernance and decision‐making for pandemic responses. The analysis suggests that one opportunity
for enhancing resilience in Thailand is to strive for more multilevel governance that engages withvarious stakeholders and to support grassroots and community‐level networks. The COVID‐19
pandemic recovery is a chance to recover better while leaving no one behind. An inclusive
long‐term recovery plan for the various impacted countries needs to take a holistic approach toaddress existing gaps and work towards a sustainable society. Furthering the Health Emergency
Disaster Risk Management (HEDRM) Framework may support a coordinated response acrossvarious linked sectors rather than straining one particular sector.

Academic Editor: Nicola Luigi

Keywords: COVID‐19; Thailand health response; Sendai framework; inclusive recovery; HEDRM

Bragazzi
Received: 27 December 2020
Accepted: 22 January 2021
Published: 26 January 2021

1. Introduction
Publisher’s Note: MDPI stays neu‐
tral with regard to jurisdictional
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tutional affiliations.

Copyright: © 2021 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms andconditions of the Creative Commons
Attribution

(CC

BY)

license(http://creativecommons.org/licenses/by/4.0/).

The COVID‐19 pandemic is a public health crisis without precedent in living
memory, which is testing our collective capacity to respond” (OECD, 2020 [1]). Caused
by SARS‐CoV‐2 (Severe acute respiratory syndrome coronavirus 2), the infectious
COVID‐19 (Coronavirus disease 2019) was first identified in Wuhan, China December
2019 and spread across the globe. At the time of writing, the pandemic is ongoing andhas affected over 227 countries and territories [2]. The impact of COVID‐19 in different
countries has varied significantly due to factors including but not limited to govern‐
mental response, demographics, and healthcare infrastructure.
This paper focuses on the experience of COVID‐19 pandemic in Thailand. As a
popular destination for Chinese tourists, it was in Thailand that the first COVID‐19 pa‐
tient outside of China was identified on 13 January 2020. At the end of the same month,
the first case of domestic transmission and the 16th patient in Thailand was identified.
The number of COVID‐19 patients remained relatively low until there was a rise in do‐
mestic infections in mid‐March. A key event was a boxing match at the Lumpinee Boxing

Int. J. Environ. Res. Public Health 2021, 18, 1089. https://doi.org/10.3390/ijerph18031089

www.mdpi.com/journal/ijerph

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Stadium, which took place on 6 March 2020 despite a ban on large gatherings that was
put in place days before. It is estimated that 143 COVID‐19 cases were directly linked tothe boxing match [3]. In the days following the event, the number of new infections shot
up to over a hundred per day.
Thailand’s response to the COVID‐19 pandemic has been guided by the “Integrated
Plan for Multilateral Cooperation for Safety and Mitigation of COVID‐19”, which wasdrafted by the Ministry of Public Health for the following objectives: (1) Reducing thechances of the virus transmission into Thailand, (2) Everyone in Thailand and Thai peo‐
ple abroad are safe from COVID‐19, (3) Mitigating the health, economic, social impacts
and increasing national security. The Thai government provided daily updates on
COVID‐19 infections in Thailand via television and used the media to inform the citizensof new restrictions, safety precautions, and any other official news regarding the pan‐demic. As of September 2020, the number of COVID‐19 cases and new domestic infec‐
tions in Thailand remains relatively low. Thailand’s ability to contain the spread of
COVID‐19 thus far has been attributed to factors such as the country’s past experienceswith similar epidemics, the citizen’s readiness to wear face masks, a culture of hygiene,
and successful public health campaigns [4].
Thailand is often considered as a good practice to reduce the infection rate at an
early stage [4]. However, there are little holistic analysis on this. Therefore, this paper
aims to provide a short yet comprehensive overview of the responses to COVID‐19 inThailand and to examine the extent to which the measures taken are in line with theguiding principles of Sendai Framework for Disaster Risk Reduction 2015–2030 of theUnited Nations Office for Disaster Risk Reduction (UNDRR). The Sendai Framework is alandmark document in the domain of disaster risk reduction, which also addresses thechallenges brought about by COVID‐19, as the framework categorizes epidemics andpandemics as a biological hazard. The case study presented by this paper can be used forcomparative analysis of national responses to COVID‐19. The findings of this paper bringto light how Thailand can become more resilient to public health crises such as COVID‐19
and can therefore be useful not only for academics but also for policymakers and civilsociety actors. Here, resilience is to be understood as “the ability of a system, community
or society exposed to hazards to resist, absorb, accommodate to and recover from the ef‐
fects of a hazard in a timely and efficient manner, including through the preservation andrestoration of its essential basic structures and functions.” [5]. It is argued that the resili‐ence of the country and communities depend on the inherent governance and stake‐holder participation, which is linked to four priorities of Sendai Framework.
2. Methods
This paper examines how Thailand responded to the COVID‐19 pandemic, specificallyfocusing on the public health and legislative measures. The core of the current analysis lieson the national government policy analysis, supplemented by document reviews and analy‐
sis. Information about the measures taken is derived mainly a thorough review of daily gov‐
ernmental announcements about COVID‐19, which happen via national television as well as
through governmental websites and social media accounts, most notably the website of the
Department of Disease Control of the Ministry of Public Health. News articles reporting
about COVID‐19 were selected from Google searches made with relevant keywords andthen analyzed to establish a better understanding of how COVID‐19 and the response
measures have impacted the public. While governmental announcements and decrees are
rarely translated from Thai, English‐language articles published by were prioritized to makethe cited sources accessible to non‐Thai speakers.
The relevant plans and measures taken are critically analyzed through the lens of the
Sendai Framework for Disaster Risk Reduction to highlight the robustness and short‐comings of Thailand’s approach with regards to resilience. The analysis is mainly basedon: (1) public health capacity and response, and (2) legislative measures. Public healthcapacities are mainly evaluated based on three issues: (1) health resources in the country,

Int. J. Environ. Res. Public Health 2021, 18, 1089

3 of 11(2) COVID‐19 testing, and (3) community based public health initiatives. On the other
hand, the legislative measures are analyzed based on Emergency Decree and Disaster
Mitigation and Prevention Act. Both the analyses then linked to the four priority areas of
Sendai Framework. Sendai Framework.
Sendai framework has four priority areas: (1) understanding disaster risks, (2)strengthen disaster risk governance, (3) investing in disaster risk reduction, and (4) en‐
hancing disaster preparedness for effective response. The Sendai Framework reinforces
the scope of disaster risk management by expanding beyond natural hazards to include
biological hazards such as epidemic‐ and pandemic diseases. The Sendai Framework also
places strong emphasis on the need to build resilient health systems through the integra‐
tion of disaster risk management into the provision of health care at all levels and, inparticular, “to enhance cooperation between health authorities and other relevant
stakeholders to strengthen country capacity for disaster risk management for health.”
3. Results
3.1. Public Health Capacity and Response
3.1.1. Health Resources in Thailand
While 80% of COVID‐19 patients are able to recover without medical treatments [6],many patients develop severe symptoms and may require hospitalization and even in‐tensive care. Patients with lung damage may require the use of non‐invasive mechanicalventilators, depending on the severity of the symptoms, to help them breathe. Addition‐
ally, hospitals need to have negative pressure isolation rooms and a sufficient amount of
personal protective equipment (PPE) to help prevent the spread of the virus within thehospital. Health resources, which refers to “the means available for the operation ofhealth systems, including human resources, facilities, equipment and supplies, financial
funds, and knowledge” [7] are therefore critical to the mitigation of the impacts of
COVID‐19 and prevention of loss of life.
Hospitals in Thailand are divided into three categories, namely (1) public hospitals
operated by the Ministry of Public Health, (2) public hospitals operated by other entities(e.g., Medical Service Department of Bangkok Metropolitan Administration, Ministry of
Education, Royal Thai Army, Thai Red Cross) and (3) private hospitals. The majority of
hospitals in Thailand are public hospitals operated by the Ministry of Public Health,which can be further categorized into central, regional, and community hospitals. Ac‐
cording to the Strategy and Planning Division of the Thai Ministry of Health [8], in 2019
there was a total of 158,026 hospital beds at 1370 hospitals across Thailand. This meansthat Thailand has 2.2 hospital beds per 1000 citizens. To put things into perspective theOECD data shows that the average number of beds per 1000 citizens of its member
countries in 2017 was 4.7, with the highest rates being 13.1 and 12.3 beds per 1000 people
in Japan and South Korea, respectively [9].
Since 2002, Thailand offers a comprehensive insurance scheme to all its citizens. This
scheme was first introduced in 2001 and originally required beneficiaries to contribute a
co‐payment of 30 baht for medical treatments. The co‐pay has since been abolished, andthe scheme is now colloquially known as the “gold card” scheme. Universal healthcare isalso made available via a civil servant insurance scheme and a private sector employeesocial security scheme. Under these schemes, 99.5% of the population of Thailand is eli‐gible for healthcare coverage [10].
3.1.2. COVID‐19 Testing and Treatment
On 21 March 2020, Thai citizens were told by the government that they should callthe hotline of the Department of Disease Control or to go to the hospital that they are
registered at to get tested for COVID‐19 if they fall under the following criteria:

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1.

4 of 11

Having had a fever of over 37.5 °C with one or more respiratory symptoms (cough,runny nose, sore throat, rapid breathing or breathing difficulties), in addition to one
or more risk factors14 days before the onset of the symptoms.
(a) Travelling to or from a country or residing in an area with an ongoing
COVID‐19 outbreak;(b) Professional who have had close contact with tourists from areas with ongoing
COVID‐19 outbreaks;(c) Having had close contact or high‐risk exposure to confirmed COVID‐19 pa‐
tients in accordance with surveillance and investigation guidelines;(d) Being a medical or public health personnel who has come into contact with asuspected or confirmed COVID‐19 patient or to the bodily fluids of a suspected
or confirmed COVID‐19 patient without appropriate protective equipment;(e) Having been to a densely populated area at the same time as a confirmed
COVID‐19 patient, in accordance with the announcement of the provincial in‐
fectious disease committee.

2.

Pneumonia patients who:(a) Has had of close contact with a confirmed COVID‐19 patient;(b) Is a medical personnel;(c) Is experiencing pneumonia without an identifiable cause and who is not re‐covering within 48–72 h of treatment;(d) Exhibits pneumonia characteristics that are consistent with COVID‐19.

3.

Persons who are suspected to be part of an infection cluster, which is defined as:(a) Three or more medical personnel of the same department testing positive for
COVID‐19 within one week. For smaller establishments e.g., clinics, the criteria
used is 3 or more personnel of the establishment;(b) For those who are not healthcare workers, five or more infections from the sameplace within one week with an epidemiological link [11].

Those who fall under any of these criteria can get tested for COVID‐19 for free. Ifthey have been infected with the virus, they will also receive free treatments. Those who
do not fall under any of these criteria may nevertheless get tested for COVID‐19 but attheir own cost. In public hospitals, COVID‐19 tests cost 2500 to 9900 THB. In private
hospitals, the test costs 5000 to 10,500 THB. Under the universal healthcare scheme, con‐firmed COVID‐19 patients will receive free medical treatments according to the proce‐dures of the Ministry of Public Health. Table 1 shows the country data of COVID‐19 in‐fection.
Table 1. COVID‐19 data in Thailand as 27th December 2020.

Cumulative cases
Recovered patients
DeathsNumber of People
6123
4161
60

Data from the Department of Disease Control, Ministry of Health, Government of Thailand.

3.1.3. Community‐Level Public Health Initiatives
In Thailand, the village health volunteers (VHVs) scheme is central to the National
Primary Health Care program’s effort to be able to reach more people at a low cost [12].
VHVs are individuals chosen by villagers to receive basic medical training according to
the requirements of the Ministry of Public Health in order to help inform and support
public health in their community. The initiative started in 1978, and there are now over a
million VHVs all over the country. Tasked with the goal of controlling and preventing
the spread of diseases, VHVs were influential in mitigating the impacts of the SARS andavian flu outbreaks in Thailand [13]. During the COVID‐19 pandemic, VHVs played an

Int. J. Environ. Res. Public Health 2021, 18, 1089

5 of 11

important role in preventing the spread of the diseases by going door to door to inform
people about COVID‐19 symptoms and to screen the residents’ COVID‐19 risks by ask‐
ing them about their travel history and symptoms. They also reported COVID‐19 related
data to the provincial health office. The VHVs enabled the public to be informed about
COVID‐19 as well as collected data that are essential for public health decision‐making.
This is essential to effective COVID‐19 response, as demonstrated by a study on how of
how China responded to the epidemic [14].
3.2. Legislative Measures
On 25 March 2020, the Thai government announced a state of emergency. This al‐lows them to operate according to the Emergency Decree on Public Administration in
Emergency Situation, B.E. 2548 (2005) which grants the Prime Minister more deci‐sion‐making power as well as the ability to impose certain restrictions. The most im‐
portant clause of the Emergency Decree is Section 9, which explicitly grants the Prime
Minister the power to issue regulations to prohibit or restrict personal movements, as‐semblies, fear‐mongering or misleading communications, usage of routes and buildings,
as well as to implement evacuations or preventing entry to designated areas. These
measures allow the Thai Government to implement restrictions that go beyond what ispermitted under the Disaster Prevention and Mitigation Act B.E. 2550, which includes
the power to quarantine individuals, to inspect residences, and to restrict the use ofroutes and vehicles. As of September 2020, the Emergency decree has been extended 5
times and remains active. This has raised some criticisms from those who believe that it isunnecessary for the government to maintain a state of emergency due to a very low rateof domestic COVID‐19 infections in Thailand.
One of the first actions of the Prime Minister was the creation of the Center for
COVID‐19 Situation Administration (CCSA) and an executive committee comprising ofministers and heads of departments that will report directly to the Office of the Prime
Minister. They are tasked with implementing policies according to the Communicable
Diseases Act B.E. 2558, Disaster Prevention and Mitigation Act B.E. 2550, and the State
Administration Act B.E. 2534 (Office of the Prime Minister, 2020). The Thai government
has issued numerous announcements of different restrictions such as the closure of cer‐tain places and halting some services in order to prevent the spread of COVID‐19. Eachprovince also had their own set of restrictions that are issued by the provincial governors.
The provincial‐level restrictions follow the provisions of the Communicable Diseases Act
B.E. 2558 [15].
3.3. Analyzing Thailand’s Response to COVID‐19 through Sendai Framework
Adopted by UN member states in 2015, the Sendai Framework for Disaster Risk
Reduction (2015–2030) is a document that provides guidance on disaster risk reduction.
The Thai Department of Disaster Prevention and Mitigation includes epidemics as one ofthe disasters that they handle, which is appropriate considering the definition of a dis‐
aster being “A serious disruption of the functioning of a community or a society at any
scale due to hazardous events interacting with conditions of exposure, vulnerability andcapacity, leading to one or more of the following: human, material, economic and envi‐
ronmental losses and impacts” [16].
Thailand’s response to the COVID‐19 pandemic can be analyzed through the fourpriorities of the Sendai Framework, which serve as guiding principles for robust andcomprehensive disaster risk reduction. Effective and relevant risk management of bio‐
logical hazards changes with the advancement of science, clinical medicine and publichealth practices and policy. The latest technical guidelines and research findings to
support planning may be found in WHO’s Health‐Emergency Disaster Risk Management(Health‐EDRM). Although the Sendai Framework strongly focuses on biological hazards
and its risk mitigation approaches, there is hardly any country analysis on this.

Int. J. Environ. Res. Public Health 2021, 18, 1089

6 of 113.3.1. Understanding Disaster Risk
The Sendai Framework highlights how policies and actions should be based on athorough understanding of disaster risk. The Thai Disaster Prevention and Mitigation
Act B.E. 2550 recognizes epidemics as disasters, so the Department of Disaster Prevention
and Mitigation has been involved in the handling of the COVID‐19 pandemic. Thailand’s
understanding of COVID‐19′s various risks is supported by how the country’s previous
experiences with respiratory diseases outbreaks such as SARS, avian flu, and MERS. The
Ministry of Public Health was at the forefront of the country’s COVID‐19 related deci‐sion‐making and planning. The Ministry oversaw measures such as helping medical fa‐
cilities around the country prepare for COVID‐19 testing and treatment as well as in‐volving VHVs to help the authorities to have a better understanding of the spread of
COVID‐19, which allows science‐based decisions to be made. The Thai government also
introduced the contact tracing applications that provide information to the Department
of Disease control. However, the applications have been criticized for privacy issues [17].
On the other hand, socioeconomic risks of the pandemic seemed to have been
overlooked, as suggested by the government’s limited capacity for providing assistanceto vulnerable populations. The Thai government has also been criticized for its insistence
to maintain the emergency situation and closed borders despite having had zero cases ofdomestic infections for over 100 days up until 4 September 2020. Indeed, it is a challenge
for governments to determine the optimal stringency of their pandemic measures thatwould allow them to effectively contain the outbreak without inflicting too much eco‐nomic damage. Ashraf (2020a) [18] found that “announcements regarding the imple‐
mentation of social distancing measures by governments have dual, a direct negative andan indirect positive, effect on stock market returns.” While the announcements of social
distancing measures “result in negative stock market returns due to their expected ad‐verse impact on economic activity”, they also “lead to positive market returns throughthe channel of reduction in COVID‐19 confirmed cases.” As a country that relies heavily
on tourism and from exporting goods, Thailand suffered severe economic impacts due to
COVID‐19. The Asian Development Bank (ADB) estimated a contraction of −8.0% in theThai GDP, and that Thai exports of goods and services contracted by 17.6% (in US dollars
terms) [19]. Many businesses suffered directly and indirectly from government measures
such as border closure and COVID‐19 restrictions on restaurants and other services thatwere introduced during the first and second wave of infections in Thailand. As a result,many people in Thailand lost their income completely or partially. This was especiallydevastating for day laborer, informal workers, and the urban poor, who also struggled toreceive government assistance for reasons such as the lack of access to digital services ordifficulties in fulfilling bureaucratic requirements.
For biological hazards, a comprehensive multi‐hazard and multi‐sectoral National
Risk Assessment (NRA) needs to be conducted. The assessment should include exposure,vulnerability, and capacity analyses as part of an integrated policy approach. The cas‐cading effect of different disasters should also be considered, keeping in mind a systemicrisk approach. A health risk assessment needs to be an integral component of the risk
assessment whenever risk informed public health management is required. For re‐
sponding to an epidemic or pandemic, an early stage risk assessment and scenario plan‐ning incorporating the impacts on different sectors would be required. Real time loca‐
tion‐based risk maps should be maintained for enhanced coordination among the dif‐ferent actors. Data sharing and big data analysis also becomes crucial for this step.
Capacity and systems development for integrated risk assessment at the national toa local level is important. Disciplinary divergence (wherever possible) and mul‐ti‐disciplinary collaboration are key to producing an integrated risk assessment. Higher
education/research capacities need to be strengthened, and trans‐disciplinary to mul‐ti‐disciplinary innovative research should be promoted.

Int. J. Environ. Res. Public Health 2021, 18, 1089

7 of 113.3.2. Strengthening Disaster Risk Governance to Manage Disaster Risk
For disasters to be managed effectively and efficiently, there should be “Clear vision,plans, competence, guidance and coordination within and across sectors, as well as par‐ticipation of relevant stakeholders” [19]. Thailand’s COVID‐19 response has been guided
by the Emergency Situation Decree and was largely led by the Prime Minister via theCenter for COVID‐19 Situation Administration. However, there is a degree of decentral‐
ization as provincial governors were responsible for introducing restrictions against the
spread of COVID‐19. On 25 January 2020, the Department of Disaster Prevention and
Mitigation, which falls under the Ministry of Interior, issued an announcement to allprovincial governors to prepare and plan for the spread of COVID‐19 in their jurisdic‐
tion. The announcement urged the governors to be alert, to make COVID‐19 containment
plans as well as necessary preparations, and to report any confirmed cases to the De‐partment. On 20 March, the “Integrated Plan for Multilateral Cooperation for Safety and
Mitigation of COVID‐19” was published. This plan is comprehensive and assigns keys
responsibilities to the relevant ministries and departments. The provincial governors
were also told to align the local COVID‐19 strategies with this plan.
It is important to identify synergies between the health emergency and disaster risk
management regulations, and where applicable, review laws specific to epidemics andpandemics to determine implications for disaster risk management. The revision of reg‐ulations or legislation related to disaster risk management should be considered to en‐
hance the scope to include biological hazards. The relevant policies and plans also need
to be customized.
Science‐based, data‐centric decision‐making is considered important for early iden‐tification of hotspots, to provide policy makers with the appropriate advice, and to ad‐
dress collateral hazards. Inclusion of a multi‐disciplinary scientific community in na‐
tional platforms for DRR is important to ensure different perspectives are brought in for
decision‐making. This will aid in the development of an integrated risk assessment, sce‐nario planning, forecasts of the spread of the epidemic, etc.
3.3.3. Investing in Disaster Risk Reduction for Resilience
Effective disaster risk reduction requires investments for enhancing the resilience ofpeople, their assets, and their environment. Investments include financial andnon‐financial resources, which can be used for both structural and non‐structural
measures. In the context of COVID‐19, a country’s response is heavily influenced by theinvestments that have been made both before and during the pandemic not only in pub‐lic health but also in other domains such as social welfare. Thailand’s experience with
COVID‐19 highlights the importance of the country’s past investments into the national
public health system and to the VHV scheme. The experience also showed how the lackof social safety nets undermines Thailand’s resilience, especially in times of crisis. The
government initially struggled to provide the 5000 THB relief to low‐income citizens
whose livelihood were affected by the pandemic, which contributed to a spike in finan‐cially driven suicide attempts in May [20].
As a response to the COVID‐19 pandemic, the Thai government unlocked a 2.2 tril‐lion THB (USD 61 billion) relief package that is primarily aimed at providing financial
assistance to individuals and SMEs [21,22]. This includes providing financial aid to vul‐
nerable populations, reducing the cost of living by subsidizing natural gas costs and in‐troducing tax reduction, exemption, and delays. However, there is a lack of clarity in how
this budget will be spent exactly and there is currently no mention of using it for in‐vestments for disaster risk reduction. Through their case study of Japan where govern‐
mental financial stimulus was also directed to resilience planning and development,
DeWit et al. [23] highlight the importance of a holistic approach to disaster risk reduction
by emphasizing that responses to the COVID‐19 pandemic should also promote resili‐ence and sustainability in a wider sense.

Int. J. Environ. Res. Public Health 2021, 18, 1089

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Investment varies based on the socioeconomic nature of the country. In recent
analysis of more than 80 countries socio economic data, Ashraf (2020b) [24] concluded
that a stringent lockdown at initial stage, a better social distancing policy and generous
economic/fiscal boosting helps the middle to lower income countries to address the so‐
cioeconomic issues in pandemic, as well as reduce the number of deaths. In Thailand, thetourism sector plays an important role, which is hardly hit by the pandemic. Farzanegan
et al., (2020) [25] concluded that international tourism is highly impacted, which is thesame case as Thailand. Thus, investing in boosting domestic travel and tourism to copewith the immediate impact becomes very important. This is also the case of “Go To
Travel” campaign in Japan.
Epidemics and pandemics affect wide sectors of society and put both lives and live‐
lihoods at risk, which also impedes development. Fiscal boosting is an important tool forenhancing not only economic recovery, but through a proper social protection measures,
can also enhance social safety nets. Existing tools and methods for registering the mostvulnerable groups should be adapted to be quickly adjusted and used to identify priority
groups for support.
Keeping with a whole‐of‐society approach, public‐private partnerships and busi‐
ness‐to‐business cooperation are important elements to ensure the continuity of supply
chains. This assumes higher significance in the context of supporting small and medium
enterprises (SMEs), including those which operate in the informal sector and hence areoften left out of social and economic assistance packages.
3.3.4. Enhancing Disaster Preparedness for Effective Response and to “Build Back Better”
in Recovery, Rehabilitation, and Reconstruction
According to the Sendai Framework, “Disasters have demonstrated that the recov‐
ery, rehabilitation, and reconstruction phase, which needs to be prepared ahead of adisaster, is a critical opportunity to “Build Back Better”, including through integrating
disaster risk reduction into development measures, making nations and communities
resilient to disasters” [18]. It is unclear whether the Thai government has started planningfor post‐pandemic actions, and no recovery plan or business continuity plan has beenannounced as of September 2020. There has also been no announcements business con‐tinuity planning. As such, there is currently no known plans for the Thai government to
use the COVID‐19 budget for sustainable development or for enhancing resilienceagainst public health or environmental hazards.
Early warning is key to responding to any type of hazard, and biological hazards are
no exception. A proper early warning system for biological hazards can be developed
only when there is a robust public health system in place, which detects any biologicalhazards before outbreaks occur. This issue needs to be incorporated in development
planning as well. Like with natural hazards, a key to early warning is end‐to‐end com‐munication, where last mile communication is crucial. It is also important that the bio‐
logical hazard early warning system be integrated into the existing multi‐hazard early
warning system, which usually focus on natural hazards.
Since epidemics and pandemics are often long lasting, proper business continuity plan‐ning for core impacted sectors/ministries is critical. These plans should be developed in ad‐vance or at an early stage of the event. Moreover, emergency operation centers should be
optimized. Where possible, protocols should be adapted based on lessons from previous
disasters while integrating the particularities of the biohazard. Crisis leadership in both the
public and private sectors are important. As the situation changes over time, it will be im‐portant have an adaptive strategy that can synchronize with the scenario planning.
While most epidemic and pandemic responses focus on impact management, it isequally important to look at root causes and enhance impact reduction. Risk reduction ap‐
proaches need to be the core of the response mechanism, as well preventative risk reduction
in non‐emergency decision‐making and investment. Volunteers, civil society organizations,and structures at the decentralized level that are working directly on awareness raising andInt. J. Environ. Res. Public Health 2021, 18, 1089

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response should be trained regularly to work under the conditions of epidemics and pan‐demics to ensure their safety and continuity of operations. Lessons from past biological haz‐ards are needed to be taken into account and capacity might need to be strengthened to in‐
troduce new institutional arrangements to transform the risk profile.
4. Conclusions
While Thailand’s response to COVID‐19 has been quite effective in limiting the
spread of the disease, it falls short at being able to address the multiple dimensions of thecrisis, such as the economic and social impacts. The Sendai Framework for Disaster Re‐
duction helps highlight how Thailand’s approach to COVID‐19 does not comprehen‐sively address the issue of resilience—there are limited considerations given to building
resilience against climate change or other epidemics. Thailand’s success in containing
COVID‐19 can be partly attributed to its public health system and to VHVs. VHVs, inturn, benefitted from collaboration with local community leaders and civil society or‐
ganizations. This suggests that one opportunity for enhancing resilience in Thailand is to
strive for more multilevel governance that engages with various stakeholders and tosupport grassroots and community‐level networks.
It can be noted that the Thai approach to COVID‐19 response is not very holistic as
little consideration has been given to enhancing the country’s resilience to such pan‐demics as well as to ‘build back better’ in a more environmentally or socially sustainable
way. The economic cost of border and business closures and strict restrictions in Thailand
has been immense. Businesses in the service and tourism sector were hit the hardest.
They are also the sector that employs a large portion of the workforce, who are now fi‐
nancially insecure: Before the COVID‐19 pandemic, tourism accounts for 22% of the Thai
GDP, and in 2018, one in six jobs in Thailand were in the tourism sector [26]. This sector ishighly impacted, along with its link to other formal and informal sectors. The scale of theeconomic impact of the pandemic as a result of Thailand’s reliance on its tourism sector
also highlights the importance of a diversified economy for more resilience. The gov‐
ernment’s initial failure to effectively assist low‐income and vulnerable populations
during the pandemic suggests that they are not included or appropriately prioritized by
the government’s COVID‐19 risk assessment and planning. However, this seems to havebeen improved overtime with better governance and decision‐making. Although Thai‐
land has been relatively successful at mitigating the public health risks of the COVID‐19
pandemic, the impact of the subsequent economic risks and the lack of consideration forbuilding resilience in a broader sense may lead to further vulnerability in the future.
The recovery from past outbreaks, epidemics, and pandemics have shown that an
overburdening of the ecosystem services occurred due to increased production for eco‐nomic gain to make up for losses. Ecosystem services have a more or less constant re‐generation cycle, which is disrupted by this sudden surge in demand, thus tipping thethreshold of regeneration. Issues of overfishing and clearing of forests could disturb life
under water and on land. The increase in production and travel in the aftermath of thehealth emergency may also increase air and water pollution levels, which might impact
the health and wellbeing of people with pre‐existing respiratory comorbidities. Further,changes in climatic conditions (temperature, humidity, precipitation, sea level sensitivi‐ty) will act as a risk multiplier to other non‐communicable and infectious diseases andbiological hazards, based on their seasonality and return period. For instance, a decreasein public utility services, like solid waste collection and cleaning of drains may lead to anincrease in breading of mosquitoes putting countries identified as dengue hotspots at ahigher risk of an outbreak.
The COVID‐19 pandemic recovery is a chance to recover better while leaving no one
behind. An inclusive long‐term recovery plan for the various impacted countries needs totake a holistic approach to address existing gaps and work towards a sustainable society.
A biological hazard like the COVID‐10 pandemic is an opportunity to strengthen Part‐
nerships under Goal 17 of Sustainable Development Goals (SDGs) to develop warning

Int. J. Environ. Res. Public Health 2021, 18, 1089

10 of 11mechanisms and to reduce gaps in data sharing and accuracy for effective evi‐
dence‐based policy and decision‐making. The role of science and technology and mul‐ti‐stakeholder partnerships are of importance in such a case. Better global partnerships
and effective risk governance need to be brought into the core of preparedness and re‐sponse for future health emergencies. Furthering the Health Emergency Disaster Risk
Management (HEDRM) Framework may support a coordinated response across various
linked sectors rather than straining one particular sector.
Author Contributions: W.M.: Contributed on Investigation, Data curation, funding acquisition,
Writing, while R.S.: contributed on supervision and review & editing. All authors have read andagreed to the published version of the manuscript.
Funding: This work was supported by Thammasat University Research Unit in Urban Futures andPolicy.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Acknowledgments: The authors acknowledge the support from Thammasat University Research
Unit in Urban Futures and Policy and Keio University respectively.
Conflicts of Interest: The authors declare no conflict of interest and the funders had no role in thedesign of the study; in the collection, analyses, or interpretation of data; in the writing of the man‐uscript, or in the decision to publish the results.

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Article

COVID-19 Impact on SDGs and the Fiscal Measures:
Case of Indonesia
Yulida Safitri, Reni Diah Ningsih, Dwi Putri Agustianingsih, Vibhas Sukhwani, Akiko Kato and Rajib Shaw *Graduate School of Media and Governance, Keio University, 5322 Endo, Fujisawa,
Kanagawa Prefecture 252-0882, Japan; yulida89@sfc.keio.ac.jp (Y.S.); renidiah@sfc.keio.ac.jp (R.D.N.);
agustia@sfc.keio.ac.jp (D.P.A.); vibhas@sfc.keio.ac.jp (V.S.); katoakiko1012@gmail.com (A.K.)* Correspondence: shaw@sfc.keio.ac.jp

Citation: Safitri, Y.; Ningsih, R.D.;
Agustianingsih, D.P.; Sukhwani, V.;
Kato, A.; Shaw, R. COVID-19 Impact
on SDGs and the Fiscal Measures:
Case of Indonesia. Int. J. Environ.
Res. Public Health 2021, 18, 2911.
https://doi.org/

Abstract: The implications of the ongoing COVID-19 pandemic have stretched far beyond humanhealth and wellbeing, causing serious setbacks for the achievement of the Sustainable Development
Goals (SDGs). Although governments worldwide have implemented different fiscal stimulus
measures to mitigate the implications of COVID-19, it is important to develop a precise understanding of their focus areas to ensure if the progress of SDGs is on track. For a specific case of Indonesia,
this study establishes a thorough understanding of the COVID-19 implications on SDGs, and its
fiscal stimulus package through a literature review and semi-formal interviews with the core stakeholders in Indonesia. The study results highlighted that COVID-19 has varyingly affected the progress of all SDGs in Indonesia. Amongst the four pillars of sustainable development in Indonesia,
the SDGs on the social and economic development pillars are stated to be the most impacted. As forthe fiscal stimulus, it is perceived that it can help maintain the SDGs’ attainment progress to a certain extent, although there are several concerns on its implementation. Deriving lessons from theconducted research, the study puts forward key suggestions for the effective implementation of
SDGs in the post-COVID-19 era.
Keywords: COVID-19; sustainable development goals; fiscal stimulus; Indonesia

10.3390/ijerph18062911
Academic Editor: Paul B.
Tchounwou
Received: 21 January 2021
Accepted: 9 March 2021
Published: 12 March 2021
Publisher’s Note: MDPI stays neutral with regard to jurisdictional
claims in published maps and institutional affiliations.

Copyright: © 2021 by the authors. Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).

1. Introduction
The first cases of coronavirus disease 2019 (COVID-19), a respiratory illness causedby the novel form of coronavirus called severe acute respiratory syndrome coronavirus 2(SARS-CoV-2), were reported in China towards the end of 2019. It was later declared apandemic by the World Health Organization (WHO) on 11 March 2020, after the virus
spread to more than 110 countries and there were 118,000 confirmed cases worldwide [1].
By 5 March 2021, the global confirmed cases for COVID-19 had surpassed the staggering
figure of 114 million, with over 2.5 million deaths [2].
Despite the fact that the COVID-19 pandemic is still unfolding, countries all over theworld have distinctly executed a range of countermeasures to control and manage thespread of the virus, including the closure of educational, commercial, sports, and religious
institutions [3]. In that manner, the impact of the COVID-19 pandemic has extended far
beyond the global health sector, affecting the social and economic sectors as well. Bordercontrols have been strengthened, as have lockdowns and travel bans, resulting in widespread economic closures and job losses. According to the WHO [4], over 10 million people are at risk of falling into severe poverty, and malnutrition is predicted to increase by
up to 130 million people. Furthermore, the COVID-19 pandemic has also posed major
challenges for achieving sustainable development in the context of increasing food insecurity, hunger, and unemployment.

Int. J. Environ. Res. Public Health 2021, 18, 2911. https://doi.org/10.3390/ijerph18062911

www.mdpi.com/journal/ijerph

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Initially, 2020 was supposed to be the marking point of the Decade of Action to keep
track on the 2030 Sustainable Development Agenda, and the 17 defined Sustainable Development Goals (SDGs) [5]. Having been already behind, the progress of SDG attainment
worldwide has been further pushed back due to the emergency of the COVID-19 pandemic. Specifically, in the developing nations of South-East Asia—although all the member states of the Association of South East Asian Nations (ASEAN) have geared towards
achieving SDGs by 2030—none of the 17 SDGs have been met [6]. It is projected that the
COVID-19 pandemic will further delay the progress of SDGs in the region [7].
Indonesia—like all other nations—is also struggling through the pandemic’s emergency consequences. Early in March 2020, the first confirmed case in Indonesia was recorded, and COVID-19 was then declared a national non-natural disaster by the Indonesian
government on 13 April 2020 [8]. By 5 March 2021, there were more than 1.36 million
confirmed cases, and 26,897 deaths [9]. The Indonesian government’s numerous countermeasures, such as large-scale social restriction, physical distancing, massive rapid testing,
and work and study from home policies, have all resulted in considerable economic
downturn [10]. To this extent, COVID-19’s impacts have hampered Indonesia’s progress
toward the SDGs [11,12].
Referring to the Sustainable Development Report in 2020 [13], some SDGs are on
track and moderately improving, while other SDGs are posing major challenges andshowing a stagnant progress pattern. In the backdrop of COVID-19, Indonesia faces
greater challenges in achieving the SDGs by 2030, as the economic downturn has affectedhouseholds, Small and Medium Enterprises (SMEs), corporations, and the financial sector[14]. As a result, the Indonesian government implemented the fiscal stimulus to offset themultisector effects of the COVID-19 pandemic [11,14].
The fiscal stimulus and/or state budget instruments are stated to be driving the economic improvements in handling the COVID-19 pandemic and the national economic recovery program [15]. Although Indonesia’s economy grew in the third quarter (Q3) of2020 [16], there is no clear information as to what extent the fiscal stimulus is intended forachieving SDGs during the COVID-19 outbreak, although they have been defined as critical [17]. As such, the implications of COVID-19 for SDGs’ progress in Indonesia are yet
to be understood, let alone the role of fiscal measures towards the SDGs’ implementation.
While extensive research studies have been conducted so far to study the implications of the COVID-19 pandemic, there have been very few empirical studies seeking tounderstand their consequences on the progress of SDGs and the relative role of fiscal stimulus measures. Furthermore, since COVID-19 economic recovery packages must be designed to not only mitigate the pandemic’s short-term repercussions, but also to “build
back better” towards a more sustainable and resilient future [18,19], it becomes more imperative to understand how the fiscal stimulus initiatives have addressed the SDGs’ attainment so far.
With an aim to bridge this gap, a qualitative research design (combination of a literature review and semi-formal interviews with key stakeholders) has been adopted in thisstudy to methodically understand the impacts of COVID-19 on the progress of SDGs in
Indonesia, as well as the role of fiscal measures for keeping SDGs on track. The three key
objectives of this study are: (1) to establish a wider understanding about the impacts of
the COVID-19 pandemic on the progress of SDGs in Indonesia; (2) to study the stakeholders’ perception about the impact of the COVID-19 pandemic and the impact of stimulus
measures towards the SDGs’ progress; and (3) to suggest feasible directions for enhancing
and strengthening the implementation of fiscal measures and SDGs in Indonesia. In doing
so, the study addresses two key research questions: (1) How has the COVID-19 pandemic
impacted the progress of SDGs? (2) What are the perceived direct and indirect impacts offiscal policies in Indonesia towards the progress of SDGs’ implementation?
For the study context, it is important to highlight that the “direct impacts” refer tothe immediate impacts of the fiscal measures on the SDGs, while the “indirect impacts”

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refer to the relatively predictable effects of the stimulus on the SDGs that could arise laterin time or in the cause-and-effect relationship chain.
Overall, this paper is divided into seven sections, the first of which is the Introduction(Section 1). Section 2 provides an overview of the current scientific literature on the SDGs,
as well as the implications of the COVID-19 pandemic on SDGs worldwide, and the fiscal
measures. The third section introduces the case study area of Indonesia, and Section 4
explains the research methods adopted in this study. In Section 5, the research findings
and analysis are presented. The following section (Section 6) provides the relevant policy
recommendations to resolve the immediate issues identified through this study. The final
section (Section 7) outlines the key findings, contributions, and constraints of this research.
2. Literature Review
This section is mainly intended to establish a foundational view of the study’s topic,
based on the review of state-of-the-art scientific literature. It is divided into three subsections. The first sub-section provides an overview of the SDGs and their global progress.
The second sub-section highlights the implications of the ongoing COVID-19 pandemic
towards SDGs. The final sub-section discusses the fiscal stimulus programs implemented
by governments around the world to overcome the repercussions of the COVID-19 pandemic.
2.1. Importance of the Sustainable Development Goals
On 25 September 2015, the 2030 Development Agenda (titled “Transforming ourworld: the 2030 Agenda for Sustainable Development”) was adopted by 193 countries of
the United Nations (UN) General Assembly, which serves as a framework for achieving
peace and prosperity around the world. As the continuation of the Millennium Development Goals (MDGs), the 2030 Development Agenda outlines 17 SDGs and 169 associatedtargets, which frame the integrated plan of action in a global partnership for people, theplanet, and prosperity [18,20,21]. The SDGs are primarily designed to provide policy guidance and to evaluate government performance in key areas that affect the people’s andthe planet’s well-being [22].
Having been implemented for five years, the global progress on achieving the SDGs
appears to be lagging behind in fulfilling the targets [5,23,24]. Barbier [25] stated that whilesome goals have made strides, they have come at the detriment of other goals. Poverty
eradication, child and maternal health improvement, school and drop-out reduction, andwomen’s participation are among the goals that have made some progress. However, thenatural environment is still in grave danger, and inequality remains profound [5]. Now,
the attainment of the 2030 Agenda for Sustainable Development faces unprecedented
challenges due to the COVID-19 global pandemic [5,26].
2.2. Implications of COVID-19 on SDGs Worldwide
The progress of SDGs worldwide was already behind the target, and the COVID-19
pandemic brings tremendous challenges in realizing all the goals [23,27]. The pandemic
has not only overshadowed the focus on SDGs, but it has also overturned the years ofprogress made so far [13,28]. COVID-19’s effect on SDG 1 (No Poverty), SDG 2 (Zero Hunger), SDG 3 (Good Health and Wellbeing), SDG 4 (Quality Education), SDG 8 (Decent
Work and Economic Growth), and SDG 17 (Partnership for the Goals) has been the subjectof extensive discussion [14,23,27,29–32]. However, the pandemic’s impacts on other SDGs
have not received considerable coverage yet.
Based on the Sustainable Development Report in 2020 [13], the short-term impacts of
COVID-19 on SDGs have been classified into three levels: High, Mixed or Moderate, andUnclear (refer to Figure 1). The “high level” category indicates that COVID-19 has had amajor negative effect on the achievement of the SDGs, in which they become the key focus
on SDG progress worldwide. The “mixed” or “mild” level comprise the SDGs that areInt. J. Environ. Res. Public Health 2021, 18, 2911

4 of 22experiencing moderately negative impacts through the pandemic, or both positive andnegative impact on the progress of SDGs. The “unclear level” indicates that the impact of
COVID-19 on the SDGs’ progress is yet to be observed.

Figure 1. Short-term impacts of COVID-19 on the Sustainable Development Goals (SDGs) (Modified from Sachs [13]).

2.3. Fiscal Stimulus Measures around the World
Governments all over the world implemented fiscal stimulus initiatives to counteract
multi-sector effects of the COVID-19 pandemic [33]. Herein, the fiscal policies primarilyrefer to the changes in government expenditures and taxation structures to affect a nation’s economic conditions, and the fiscal stimulus specifically refers to the increase ingovernment spending and tax cuts to stimulate public demand for goods and services[34]. Shortly after COVID-19 was declared a pandemic, the Governments of Japan, theUnited States (US), Canada, India, and South Africa all initiated massive fiscal stimulus
programs, far exceeding the amount of stimulus implemented during the 2008 financial
crisis. Likewise, Western European countries have already set aside up to four trillion
USD for fiscal stimulus measures [35].
It is evident that the components of fiscal stimulus (to mitigate the impacts of COVID19) differed from country to country. The ASEAN member states’ fiscal stimulus packages
were designed to assist people, households, and businesses in all sizes to survive the impacts of the pandemic and to improve the healthcare system [36]. Other nations such as
Canada, Australia, and Japan used wage subsidies to distribute stimulus to workers andemployers. France has increased its fiscal stimulus package, which includes funding for
research and training. Germany, South Korea, and Japan have all initiated fiscal stimulus
programs aimed at green growth and digital infrastructure [37].
The International Monetary Fund (IMF) [37] stressed that the fiscal stimulus (public
investment) is essential to strengthen economic resilience, promote long-term economic
development, and to support SDGs. As such, the stimulus packages with the primary objective of improving public health infrastructure have the ability to build resilience in addition to promoting the goal of SDG 3 (Good Health and Wellbeing) [38]. Furthermore,
the social protection measures may contribute to addressing the pandemic’s immediate
issues while also building on long-term SDG commitments [39]. According to Zhang [40],the scope of social security policies has both direct and indirect effects in terms of preventing individuals from losing their jobs and properties, as well as indirect effects in terms ofproviding opportunities for the vulnerable to rise out of poverty, resulting in a more prosperous and resilient economy.

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3. Case Study Area—Indonesia
Indonesia is one of the world’s largest archipelagic countries with over 17,000 islands.
It is located south of Malaysia and the Philippines, between the Asian and Australian continents, and between the Indian and Pacific oceans [41]. The central government, regional
governments (34 provinces), regencies and towns (514 cities and regencies), districts (7071
districts), and villages (81,936 villages) make up Indonesia’s governmental structure[42,43]. Regencies and cities as the sub-provincial level or local governments have greater
responsibilities of management affairs and regional interests [44]. The current populationof Indonesia is estimated to be 269 million [45]. More than half of the population resideon the island of Java, which has the highest rate of COVID-19 cases in the country (refer
to Figure 2).

Figure 2. Indonesia’s confirmed COVID-19 cases by province (Image source: author).

Like all nations worldwide, Indonesia has faced the widespread repercussions of
COVID-19 not only in its public health but also in its economy. The COVID-19 pandemic
has slowed the economic growth in Indonesia, as observed from the country’s Gross Domestic Product (GDP) growth contracting in the first and second quarters of 2020 [10,46].
In 2021, the economy of Indonesia is expected to grow at a rate of 4.9–5.1% [47]. Morenotably, the economic recovery after COVID-19 in Indonesia is projected to be faster due
to domestic demand-oriented economic growth that makes Indonesia less vulnerable toglobal economic downturns [47].
For the effective implementation of SDGs, Indonesia has taken considerable efforts
to integrate the goals into its development strategies and policies, and to assure that thesegoals are implemented at the ground level. As a form of commitment to SDG implementation, the President of Indonesia signed the Presidential Regulation (Perpres) Number 59
Year 2017 (on July 4) on Achieving Sustainable Development Goals (SDGs) [48]. The decree regulates the structure of the National Coordination Committee, the engagement ofrepresentatives of the implementation team, and the task force of government agencies
and non-government agencies, as well as the roles and responsibilities of the stakeholders.
The regulation also assigned 17 goals and 169 indicators, aligning them with Indonesia’s
Long-Term National Development Plan (RPJPN) and Medium-Term National Development Plan (RPJMN). To support the SDGs’ attainments, the Indonesian government has
also developed a number of additional documents including the SDGs Road Map, National Action Plan (RAN) and Regional Action Plan (RAD), and SDGs metadata indicators
which serve as guidelines for SDG implementation [48].

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As the coordinator of SDG implementation in Indonesia, the Ministry of National
Development Planning (BAPPENAS) has categorized the 17 SDGs into four development
pillars [49], which are illustrated in Figure 3.

Figure 3. Four Sustainable Development Pillars in Indonesia (Modified from BAPPENAS [49]).

While the COVID-19 pandemic has caused significant disruptions to the progress ofthe 2030 Agenda, the deceleration is apparently concentrated in the social and economic
development pillars of SDGs in Indonesia. The virus has taken a huge toll on public healthservices around the nation, and education has shifted from traditional classrooms toonline platforms. As the poverty rate is expected to increase, there are also growing concerns about food insecurity. The pandemic is also likely to curtail the progress in achieving
gender equality [11,49].
Under the cornerstone of economic development, the success of the SDGs has had
significant ramifications. As explained earlier, Indonesia’s economic growth has plummeted after the onset of COVID-19, and so has inequality. The advancement of clean andaffordable energy has slipped down the priority list [32]. Reportedly, the environmental
development pillar has experienced a positive impact of the pandemic, although it is more
likely to be temporary [50]. Furthermore, the effects of COVID-19 on the law and governance development pillar have not yet been discussed widely.
Altogether, the COVID-19 pandemic has had a wide-ranging effect on the people aswell as the economy in Indonesia. To overcome the economic meltdown, the Indonesian
government has taken several efforts and established fiscal policy measures under the
National Economic Recovery (PEN) program. The economic recovery package of Indonesia (PEN) comprised of around 4.2% of the nation’s GDP, and its implementation is being
performed in four phases [11], as illustrated in Figure 4. Phases 1 to 3 are currently ongoing and will continue until the COVID-19 pandemic is handled. The main focus of thesephases is to implement fiscal stimulus measures that are delivered directly to a variety oftarget groups, including individuals, paramedics, corporations, SMEs, etc. The main aim
is to boost Indonesia’s economic growth out of recession. Phase 4 has not yet been implemented, and it will be executed only after the COVID-19 pandemic has been completely
handled. The dedicated amounts of fiscal stimulus in Indonesia are shown in Table 1.

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Figure 4. The timeline of COVID-19 mitigation policies (Modified from BAPPENAS [11]).
Table 1. Indonesia’s fiscal stimulus against COVID-19 pandemic (Modified from Ministry of Finance [51]).

Fiscal Stimulus
HealthSocial Protection
Business Incentives
SMEs
Corporate Financing
Sectoral and Regional Government
Total

Amount (IDR)
87.55 Trillion
203.9 Trillion
120.61 Trillion
123.46 Trillion
53.57 Trillion
106.11 Trillion
695.2 Trillion

Amount (USD)
6.28 Billion
14.62 Billion
8.65 Billion
8.85 Billion
3.84 Billion
7.61 Billion
49.85 Billion

In order to fund the COVID-19 mitigation and the PEN, the Indonesian President has
issued the Indonesian President Instruction (Inpres) No. 4 year 2020 on government programs’ refocusing, budget reallocating, and procurement of goods and services to accelerate COVID-19 mitigation [52]. The Inpres instructed all ministries, institutions, provincial governments, and local governments to reallocate their annual expenditures for
COVID-19 mitigation and PEN [52,53]. Within Indonesian PEN, the largest amount of fiscal stimulus is allocated towards the social protection category, followed by SMEs, business incentives, sectoral and regional government, health, and corporate financing.
4. Research Methods
To study the impact of COVID-19 on SDGs in Indonesia, two steps of research wereconducted in this study. Firstly, a methodical literature review was conducted to establish
a basic understanding of the research subject. Relevant documents were identified fromthe selected research databases of Scopus, Science Direct, ResearchGate, and Springer byexecuting search queries for keywords such as “COVID-19”, “SDGs”, “COVID-19 fiscal
stimulus” and “Indonesia”. While the research documents related to COVID-19 and SDGs
are still very few, a total of 83 research documents were identified (as of December 2020)
through keyword search queries in all defined research databases. These documents werethen sorted by their title and abstract to meet the relevance for this study, after which 16of these documents were taken into consideration. In addition, an online search was also
conducted to find relevant policies, official reports, and statistics from the government,international organizations, (Non-Governmental Organizations) NGOs, media releases,
and academic research.

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8 of 22In the second step, semi-formal interviews (through online meeting platforms) wereconducted with key stakeholders in Indonesia to substantiate the literature findings. The
online mode was explicitly chosen with respect to the core need to maintain social distancing and to avoid any unintended consequences of this study. The key stakeholders
were identified in consideration of their roles and responsibilities in SDG implementationand fiscal stimulus policy in Indonesia, which are mostly conducted by Indonesian government agencies. Thus, representatives from three different Indonesian government
agencies were approached to be interviewed in this research: (1) SDGs Secretariat of BAPPENAS: the coordinating agency for SDGs Implementation in Indonesia; (2) Ministry of
Finance: the agency that is responsible for fiscal policy; (3) Statistics Indonesia: the SDGs
database coordinating agency. To further widen the range of stakeholders interviewed inthis study, academic experts, NGOs, community groups, and the private sector were also
identified based on their work on the field of SDG implementation in Indonesia.
During November–December 2020, a total of 11 interviews were conducted with arange of stakeholders from Indonesia as follows: one expert form the SDGs Secretariat of
BAPPENAS, two experts from the Ministry of Finance Indonesia, two experts from Statistics Indonesia, one expert from SDGs Research Centre, two academic experts, one expert
from an NGO, one expert from a community group, and one expert from the private sector.
Three broad research topics were prepared for guiding these interviews: (1) The impact of COVID-19 on SDG attainment in Indonesia; (2) The role of fiscal stimulus to keep
SDG progress on track; (3) The impact of fiscal stimulus on SDG progress in Indonesia.
Based on these topics, the authors prepared specific research questions to initiate the discussions during the semi-formal interviews as follows: (1) Describe the impact of the
COVID-19 pandemic on SDG progress in Indonesia; (2) Which SDGs are the most affectedby the pandemic?; (3) Do you think the fiscal stimulus will help to keep SDG progress on
track?; (4) Which SDGs will be directly impacted by the fiscal stimulus?; (5) Which SDGs
will be indirectly impacted by the fiscal stimulus?
The average duration for each of the interviews was around 60 min and all the interviews were documented. In order to effectively keep track of all interview responses, theauthors also prepared matrices to list down the direct and indirect impacts on all 17 SDGs
and the fiscal stimulus. These matrices were later brought to Microsoft Excel for analysis
and data display. Based on the responses from the interviews, a deeper understanding
regarding the impact of the COVID-19 pandemic on SDG implementation in Indonesia
and the impact of fiscal stimulus towards SDG progress was established, and the literaturefindings were accordingly substantiated.
5. Results
5.1. Impacts of COVID-19 on SDGs in Indonesia
Based on the insights gained through the literature research and semi-formal interviews, it has been inferred that the progress of SDGs’ realization in Indonesia was lagging
even before the pandemic. The interviewees even raised specific concerns on the progressof SDG attainment in Indonesia before COVID-19, which are explained as follows:1.

Insufficient SDG knowledge dissemination
As a new development concept adopted from an international agreement, SDG
knowledge was first disseminated at the national government level, from where theknowledge was transferred to provincial and city/regional governments. However, somestakeholders argued that the knowledge transfer had not been well implemented. A familiarity gap persists between the national government and other tiers of governments
below it. The knowledge on SDGs and their implementation is primarily possessed bythose in the national government, whereas the other government levels have inadequate
knowledge of SDGs, let alone the ability to translate them into their development programs.

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2.

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SDGs are not yet mainstreamed into the development programs in provincial andlocal government levels

Although it has been instructed by the national government of Indonesia to mainstream SDGs into development programs in all government levels, some stakeholders
claimed that many provincial and local governments have not yet been able to do so.
Through the interviews, it was discovered that certain government programs are not yetaligned with the SDGs, which hinders their progress. In addition, several programs arealigned with SDG attainment but are not yet synchronized on the programs’ report.
Herein, the interviewees highlighted that the SDG roadmap set by BAPPENAS is yet to
be translated into development programs by all government levels and institutions, particularly provincial and city/regional governments.
The interviewees perceived that COVID-19 would delay Indonesia’s progress towards achieving the SDGs. Further, some SDGs are perceived to be more impacted thanothers, especially those under the social and economic development pillars.
Derived through the stakeholder perception, Figure 5 below depicts the impact of the
COVID-19 pandemic on the attainment of SDGs in Indonesia. The top three most impacted goals by COVID-19, according to stakeholders, are Goal 1 (No Poverty), Goal 8(Decent Work and Economic Growth), and Goal 3 (Good Health and Well-being), while
Goal 11 (Sustainable Cities and Communities), Goal 14 (Life Below Water), and Goal 15(Life on Land) are perceived to have experienced little impact from COVID-19. The more
specific impacts of COVID-19 on different SDGs in Indonesia are discussed in the following sub-sections, which are organized in accordance with the four pillars of sustainable
development (explained in Section 3) defined by BAPPENAS, the coordinator of SDG implementation in Indonesia. The overall summary of the impacts of COVID-19 pandemic
is depicted in Figure 6.

Figure 5. The impact of COVID-19 on SDGs identified by the stakeholders’ interviews.

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Figure 6. The summary of COVID-19 pandemic towards SDG progress in Indonesia.

5.1.1. Impacts on Social Development Pillar
In the wake of the COVID-19 pandemic, achieving SDG 1 (No Poverty) would be
extremely challenging in Indonesia. The poverty rate is expected to rise as a result of largescale social restriction policies which have been implemented by provincial, city, and regional governments all around Indonesia. Many people have lost their jobs and enterprises as a result of enforced social restrictions. The vulnerable groups of society are expected to fall into poverty, and those who are poor are expected to fall into deeper poverty. As per BAPPENAS [11], the poverty level is projected to reach 9.7–10.2% of the population. Additionally, according to the World Bank [54] survey, lower-middle-income
households will face income shocks as a result of pandemic, with job losses in urban areas
being more prevalent. These literature findings have also been corroborated with thestakeholder interviews, wherein it was pointed out that COVID-19 will likely exacerbate
the poverty in Indonesia.
The disruption of the food system due to COVID-19 restrictions has raised concerns
for SDG 2 (Zero Hunger). BAPPENAS [11] underlined that the people who experienced a
reduction in income levels would see a decrease in the quality and quantity of food available, and the most disadvantaged members of the community may even experience hunger. Through the semi-formal interviews, it was reviewed that the number of stunting
cases would likely worsen in the long run as a result of a decline in food nutrition. In thatmanner, COVID-19 may reverse the moderately growing development of SDG 2 (Zero
Hunger).
The pandemic also has a major effect on SDG 3 (Good Health and Well-being) according to the stakeholders interviewed. While the disruption in public health is apparent,

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11 of 22the public healthcare services are presently more focused on controlling the pandemic,
which is likely to disrupt the whole public service.
The reallocation of the education budget for COVID-19 mitigation measures has impacted the national education program [55], as well as constrained the attainment of SDG
4 (Quality Education). To suppress the pandemic, the government has also implemented
the school from home scheme, wherein the efficacy of online learning remains to be determined in the long run. Additionally, some students have been unable to access theonline classes due to remote locations, a lack of sufficient devices, book and supplies, andfinancial constraints for internet access [56]. Through the semi-formal interviews, the potential issue of an increase in the school dropout number also came to light, as more students are projected to leave school to support the falling family incomes.
The achievement of SDG 5 (Gender Equality) is also affected by COVID-19. Several
reports have highlighted the rise in physical assault cases within the first six weeks of thelarge-scale social restriction in Indonesia. From March to April 2020, the number of domestic violence cases was reported to be doubled [57]. The insights obtained from thesemi-formal interviews further revealed that women are at greater risk due to the declining economy because they lack decision-making capacity, their basic needs are not met,
and access to health reproduction services is restricted. Furthermore, working women
now have more domestic responsibilities as well as the additional burden of childcare.
5.1.2. Impacts on Economic Development Pillar
SDG 7 (Affordable and Clean Energy) was perceived as hard to accomplish even before COVID-19. Since the pandemic, the progress has become much more hampered as
the energy demands have plunged due to the closure of offices and shopping centers, anda drop in flight frequency. This has brought the fossil fuel price down significantly [11].
As a result, fossil fuel has once again outshone renewable energy sources [58]. Throughthe semi-formal interviews, it was highlighted that the research and development of clean
and affordable energy will now be much less prioritized than before COVID-19, since thebudget of renewable energy has been reallocated for COVID-19 mitigation.
The economic impact of the COVID-19 pandemic in Indonesia is highly prominent,
making SDG 8 (Decent Work and Economic Growth) harder to attain. Indonesian economic growth contracted to minus 5.32% in the second quarter of 2020 [10]. The country
has not experienced such a severe economic downturn since the 1998 Asian financial crisis[59]. Due to declining demand, the number of workers in the sub-sectors of trade, processing, transportation and warehousing, as well as accommodation, has decreased. Many
workers in the tourism industry (cafes and restaurants) do not even have access to social
security [11]. The economic growth contraction thus increases unemployment, especiallyfor those in urban settings [59]. Further, through the stakeholder interviews, it was discovered that the rural area economy is less impacted because it is mainly supported by
the agricultural sector. Additionally, new tourism sites have opened in rural areas that
introduce COVID-19 spread prevention measures.
BAPPENAS [11] reported that the progress of SDG 9 (Industry, Innovation, and Infrastructure) has been affected by COVID-19 due to a range of its implications on various
sectors, for example, the growth of the food and beverage industry has slowed down due
to the fall in foreign demand. Because of the decline in tourism and air-travel, the aviationand tourism industries are also struggling to stay afloat. Aside from tourism, the Purchasing Manager Indexes (PMI) for manufacturing and the fiscal of imports to Indonesia haveboth been stated to be on the decline [11]. Through the semi-formal interviews, it was
revealed that the impact of COVID-19 is dependent on the type of industry. Some industries, such as the tourism and manufacturing industries, experience harder impacts dueto the large-scale social and mobility restriction. Other industries that involve export andimport activities are disrupted by the lockdown policies worldwide which restrict the
global trade.

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While COVID-19 has widened the inequalities, the attainment of SDG 10 (Reduced
Inequalities) has become far more challenging. Inequality has risen primarily due to thedisproportionate impacts of COVID-19 on different social groups, such as on the informal
sector. While the urban society has been shown to be more vulnerable to poverty, they arealso at a higher risk of virus exposure due to high population density, slum living, andlimited access to health services. Furthermore, the rural economy is less affected by the
COVID-19 pandemic, at least in the early stages of the pandemic. Recently, the economy
in rural areas has returned to normal, and in some cases has even grown because of the
new opening for tourism with COVID-19 prevention measures.
While no scientific study has discussed the implication of COVID-19 on SDG 17 (Partnerships for The Goals), it is perceived to be impacted based on the semi-formal interviews. Many multi-stakeholder initiatives have been put on hold due to COVID-19, which
will hamper the progress toward this goal. Multinational collaborations on various development projects have been postponed due to the fact that all countries are presently focusing on themselves.
5.1.3. Impacts on Environmental Development Pillar
SDG 6 (Clean Water and Sanitation) achievement was on track before COVID-19 [25];however, in the semi-formal interviews, it was revealed that the sanitation and clean water infrastructure development budget has been reallocated for COVID-19 pandemic mitigation, which may slow down its progress.
SDG 11 (Sustainable Cities and Communities) is also impacted by COVID-19 in varying ways. According to BAPPENAS [24], the use of public transportation is declining
due to the large-scale social restriction. While the means of public transportation havebeen constrained, people tend to commute more in their private vehicles to avoid crowds.
During the pandemic, the rise in medical waste and plastic packaging has been amajor concern for the environment as people use disposable packaging to prevent the
spread of the virus [11]. Without an intervention scenario, approximately 6250 tons ofdangerous and hazardous waste are expected to be generated [60], posing a threat to theachievement of SDG 12 (Responsible Consumption and Production).
In relation to SDG 13 (Climate Action), the pandemic reduced the commitment to
Climate Action [61]. According to the semi-informal interviews, the large-scale social restrictions to mitigate COVID-19 impacts have resulted in a reduction in carbon emissions;however, after the pandemic ends, these emissions could significantly increase. While theenvironment is undoubtedly improving in the meantime due to reduced economic activities, BAPPENAS [11] highlighted that the air quality in many major cities in Indonesia
has improved due to the large-scale social restriction. However, the stakeholder interviews perceived that this positive impact will only be temporary because post-pandemic
economic recovery policies will most likely be introduced with Business-as-Usual (BAU)
orientation instead of a green-economy approach.
The data availability for SDG 14 (Life Below Water) was limited even before the pandemic, and the pandemic has further exacerbated the situation, making it difficult to understand the impacts of COVID-19 on the attainment of this goal [12]. Regardless, there
has been a growing concern regarding this goal’s progress during the pandemic. The
number of illegal fishing incidents increased during the pandemic due to fewer patrols on
Indonesian water [12,62].
For Goal 15 of Life on Land, the extent of deforestation is found to be increasing during the pandemic [63]. While the pandemic has affected many households due to job loss,
deforestation has become one of the solutions to feed the family. Moreover, the patrol
teams in forest areas are not fully operational due to the pandemic. Thus, illegal activities
are easier to be executed [64]. What is more concerning is that once the pandemic is controlled, the economic recovery will almost certainly be accompanied by increased deforestation due to loosening regulations and patrols [65].

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13 of 225.1.4. Impacts on Law and Governance Development Pillar
Goal 16 (Peace, Justice, and Strong Institutions) is affected by the pandemic as the
restriction on public services on court processes disrupts the stability in the legal and judicial fields [66]. Further, during the semi-informal interview, the key stakeholders disclosed that the tax revenue will likely experience a significant contraction due to the economic slowdown and stimulus provision.
Herein, the impacts of COVID-19 towards SDGs attainment in Indonesia have beenpresented, combining both literature review and stakeholder interviews as depicted in
Figure 6 below.
5.2. Role of Fiscal Measures to Keep SDGs on Track
Based on the understanding obtained through the semi-formal interviews, fiscal
measures under the national economic recovery of Indonesia were initiated as emergency
measures to alleviate the impact of the COVID-19 pandemic. They were launched withthe primarily goal of addressing the health fallout of the pandemic, while simultaneously
mitigating social and economic impacts. Along the way, the Indonesian government has
pledged to align the economic recovery measures with the SDG framework. The purpose
was to expand the impact of fiscal stimulus measures to not only respond quickly to therepercussions of the COVID-19 pandemic but also to keep the 2030 sustainable development agenda on track [67]. Broadly, the fiscal measures are perceived to contribute tomaintaining the SDGs’ progress in Indonesia in three core development pillars (explainedin Table 2), and limited contribution is expected towards the pillar of law and governancedevelopment.
Table 2. Role of fiscal measures in SDG progress in Indonesia.

Goals

Role of Fiscal Measures in SDG Progress in Indonesia•

SocialDevelopment Pillar

•

•

•
•
•
Economic
Development Pillar•

Fiscal measures act as an intervention which can prevent the poverty rate worsening. Without the social
protection relief measures, The World Bank’s Indonesia
COVID-19 Observatory [67] estimated that potentially
5.5 to 8 million Indonesian people may fall into poverty.
In addition, government emergency packages assist thepeople in supplementing the reduced non-food andfood expenditure [59,68].
Fiscal measures will help in ensuring food security, accessibility and food quality for the civilians and maintain the infants’ stunting rate.
Fiscal measures under the health category amounting
to USD 6.2 billion will contribute to ensuring the accessibility of health services for more people by widening
national health insurance coverage.
Fiscal measures will contribute to ensuring the qualityof education by providing aid for cellular data.
Fiscal measures targeting SMEs will help women to
keep their business afloat.
Electricity subsidies will assist people to ensure that
their households have access to energy during the economic downturns [69].
Pre-working scheme enables the unemployed to gain
access to career training to develop their skills. TheyInt. J. Environ. Res. Public Health 2021, 18, 2911

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•

•

•

•
Environmental
Development Pillar•

will also obtain an extra cash transfer after finishing thetraining.
Business and corporate incentives are aimed at laborintensive programs in order to increase multiplier effects.
Although economic growth is still contracting, fiscal
measures are perceived to prevent the Indonesian economy from worsening.
Sectoral and regional government stimulus contributeto achieving the goal of Sustainable Cities and Communities.
Some programs under the sectoral and regional category are geared toward fighting climate change.
However, Hadi et al. [70] argued that the stimulus provided by the National Economic Recovery Plan of Indonesia is primarily targeted at sectors which contributesignificantly to Green House Gas (GHG) emissions. The
orientation of the National Economic Recovery Program (PEN) remains based on business as usual, withno long-term green economy orientation [71].

Although it is perceived that fiscal measures may help to keep the attainment of Indonesian SDGs on track, several concerns were highlighted by the stakeholders interviewed in regard to the implementation of fiscal measures:
1.

The possibility of misconduct in stimulus implementation

The key interviewees argued that although the amount allocated for fiscal stimulus
is not as large as expected, it will at least benefit vulnerable people, if well implemented
without any misconduct such as corruption and fraud. However, the possibility of misconduct is rather high owing to the lack of accountability in the stimulus delivery process.
Clean, transparent, and accountable tender mechanisms may be overlooked for the sakeof ensuring a speedy stimulus implementation. This concern is also highlighted by The
United Nations Office on Drugs and Crime (UNODC) [72], which stated that, under theIndonesian Government Regulation (Perpu) No. 1 Year 2020 on State Financial Systems
for the Management of Corona Virus Disease 2019 (COVID-19) and/or Encounter the
Threat to National Economy and/or Financial Stability, the government officials are exempted from civil and criminal liability during the implementation of this regulation if it
is based on “goodwill and according to the law”. However, the definition and criteria of“goodwill” have yet to be established. Thus, it can open up a chance of misconduct.
2.

Unsynchronized database at all government institutions

The semi-formal interviews revealed that the social protection fiscal measures may
be beneficial only if they are delivered to the accurate beneficiaries. However, some interviewees highlighted that the database used for fiscal measure distribution is poorly maintained and updated. Each ministry has its own database, and so have the provincial andcity/regional governments. These databases have not yet been integrated across government institutions and at all levels. As the accuracy of the beneficiary data is still inadequate, the distribution of social protection packages is often disrupted. For instance, during the ongoing COVID-19 crisis, some households received the social protection packages despite not meeting the eligibility criteria, while there have been cases where qualifying recipients were overlooked.
3.

Lack of resources and capacity in fiscal measures’ implementation

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15 of 22A large number of fiscal measures are distributed by the local governments in Indonesia. However, some interviewees argued that the local governments have not yet obtained sufficient capacity in managing a huge amount of emergency budget which must
be distributed in a short period of time. This could lead to further implementation problems such as delayed delivery and a chaotic distribution process. The new work-fromhome setting caused by COVID-19 has also hampered the fiscal measures’ implementation. The stakeholders perceived that the Indonesian government is not yet able to adopt
a work-from-home setting both in terms of the manpower capacity and infrastructure.
5.3. Perceived Direct and Indirect Impact of Fiscal Measures on SDGs’ Progress
Figure 7 illustrates the perceived direct impact of fiscal measures on SDGs’ progressin Indonesia based on the stakeholders’ semi-formal interviews. The bar illustrates theperceived direct impact of each fiscal stimulus category towards all 17 SDGs. The number
in each colored bar represents the number of stakeholders (out of 11 stakeholders interviewed) who perceived the direct impact of each stimulus to corresponding SDGs.

Figure 7. Perceived direct impact of fiscal measures on SDG progress in Indonesia.

Noticeably, the goals within the “economic” and “social development” categories areperceived to be the most directly impacted goals by the fiscal measures. However, goals
under the environmental and law and governance development categories do not experience as much direct impact. Most stakeholders regarded that SDG 8 (Decent Work andEconomic Growth) will be mostly impacted directly by the stimulus, followed by SDG 3(Good Health and Well-being), and SDG 9 (Industry, Innovation, and Infrastructure), respectively. The reason is that the stimulus is largely allocated towards economic recovery,
whether through SMEs financing, business incentives, sectoral and regional governments,
and corporate financing.
The stimulus on the sectoral and regional government category is recognized as being able to give a direct impact to all 17 SDGs, although the amount of the budget allocation is not as high as other economy related stimulus categories. It is because the stimulus
aimed for the sectoral and regional government will be spent by ministries and local governments all over Indonesia for a variety of purposes. This stimulus enables the Indonesian government in all levels to execute a broad range of programs that may cover all

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SDGs, unlike other stimulus categories which are specifically addressing only thosewithin their field.
Figure 8 highlights the indirect impacts of fiscal measures towards SDGs obtained
from the stakeholders’ interviews. Although the “social” and “economic development”
pillars are perceived to remain dominant in experiencing indirect impacts of the stimulus,
the goals under the “environmental development” pillar are expected to be impacted aswell in the future. Notably, the stakeholders perceived that none of the fiscal measures
will address SDG 7 of Affordable and Clean Energy. They argued that achieving clean
and affordable energy will be even less prioritized during economic recovery. The SDGs
under the environmental development pillar, SDG 6 (Clean Water and Sanitation), SDG
11 (Sustainable Cities and Communities), SDG 12 (Responsible Consumption and Production), SDG 13 (Climate Action), SDG 14 (Life Below Water), and SDG 15 (Life on Land),would thus be impacted in the future as a prolonged impact of the stimulus.

Figure 8. Perceived indirect impact of fiscal measures on SDG progress in Indonesia.

6. Discussion
Evident through the research findings, the attainment of SDGs in Indonesia has been
impacted by the pandemic (as also discussed in Section 5.1), although there are some gaps
in comparison to the UN assessment of the short-term impacts of COVID-19 on SDGs
(highlighted in Section 2.2). Based on semi-formal interviews, the stakeholders perceived
that COVID-19 has a significant effect on SDG 1 (No Poverty), SDG 3 (Good Health andWell-being), and SDG 8 (Decent Work and Economic Growth). Meanwhile, based on the
UN assessment, SDG 2 (Zero Hunger) and SDG 10 (Reduced Inequality) are also assessedas highly negatively impacted by COVID-19.
Further, like many other nations around the world, the Government of Indonesia has
also taken fiscal measures to mitigate the multisector fallouts from the COVID-19 pandemic. The economic packages launched by the Indonesian government are aimed to support domestic consumption and prevent rapid poverty and rising unemployment. Although the fiscal measures do not explicitly seek to minimize the impacts of COVID-19 on
SDGs, it can be concluded based on the semi-formal interviews that the fiscal measureswould have a direct impact on SDG 8 (Decent Work and Economic Growth) and SDG 3

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(Good Health and Well-being) (explained in Section 5.3), in which these goals are perceived as highly impacted by COVID-19 based on the UN assessment of COVID-19’s shortterm impacts on SDGs (refer to Section 2.2).
Based on the understanding gained through the existing literature and semi-formalinterviews, the authors suggest specific policy recommendations (in the following threesubsections) to address the identified concerns on fiscal measures and SDG implementation in Indonesia (presented in Section 5.1).
6.1. Ensuring Good Governance Practice
As discussed in Section 5.2, fiscal measures for COVID-19 mitigation require the Indonesian government to administer a significant amount of money intended to benefit thepeople and the economy. However, the government is under pressure to complete everything within a short period of time. Executing fiscal measures in such a tight timeframe
necessitates more resources and capacity, which some stakeholders perceived that the
government is lacking (refer to Section 5.2). Additional havoc on government bureaucracies came from the work-from-home and mobility restrictions policy. An online setting indoing government jobs adds more challenges in orchestrating fiscal measure implementation. To compensate such shortcomings, it is important for the government to be agile
in facing the crisis and to come up with innovations that are data-driven and sciencebased to compensate the shortcomings on resources and capacity. Moreover, good andstrong coordination among government institutions and across government levels are essential to ensure the effectivity in fiscal package distribution, which is also emphasized by
Antara News [73].
As highlighted in Section 5.2, there is a risk of misconduct in the implementation of
emergency packages to mitigate the COVID-19 pandemic. These emergency packages
may possibly have been implemented with the absence of necessary inspection procedures and mechanisms with an aim to expedite packages’ distribution to those in need.
Therefore, potential fraud, misuse, and corruption are increasing [72]. As discussed in
Section 5.2, the stakeholder interviews highlighted that good governance practice is required to ensure there is no leakage and fraud in the process of implementing and distributing the fiscal measures from the government to the people. Although some have argued
that the amount of the stimulus is insufficient to prevent poverty from worsening, at least
it can help even a little bit. Therefore, it is important to implement clean and transparent
governance of the fiscal stimulus packages.
6.2. Integrating Beneficiaries’ Database to Improve Accuracy of Targeted Groups
The allocation of the economy packages for social protection has brought forth concerns from the key stakeholder perception (explained in Section 5.2). Some interviewees
stated that the budget allocated for social protection is not sufficient to overcome the economic repercussions of the COVID-19 pandemic. Sparrow et al. [62] also highlighted thatthe method of distribution for the social protection stimulus was based on pre-COVID-19
schemes, such as direct fund transfer (BLT), the Hopeful Families Program (PKH), thefood assistance program, and the village cash support program. These existing schemes
mostly target rural areas and the poor. However, based on the insights gained from thesemi-formal interviews, the pandemic hits people in urban areas harder due to reduced
income and job loss (Section 5.1). It is the lower-middle-income households which areprone to economic shocks due to the pandemic. Many are likely to fall into poverty for the
first time, and others may fall back into poverty. Therefore, the current schemes of social
protection package distribution may not address those newly poor households.
As the schemes are organized by different ministries, the beneficiaries’ database is
not integrated across ministries and each ministry has its own database (Section 5.2). Thishas caused overlap and outdated data in emergency package distribution. Some households who are not in poverty accepted the emergency packages, while some poor families
have not been identified as beneficiaries. Thus, integrating databases across ministries andInt. J. Environ. Res. Public Health 2021, 18, 2911

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governmental levels is essential to improve the accuracy of the targeted beneficiaries inthe distribution of emergency packages. The COVID-19 pandemic amplifies the importance of an innovative information system which is well integrated and can accommodate a rapid data change.
6.3. Mainstreaming SDGs at Different Government Levels
As the Indonesian government is committed to mainstream SDGs in its economic
recovery program, it is imperative to ensure the mainstreaming of SDGs in all government
institutions and across all government levels. The stakeholders interviewed in this study
also highlighted that one of the key challenges of attaining SDGs in Indonesia is the gapof knowledge of the SDGs themselves existing within the government institutions, as discussed in Section 5.1. The stakeholders’ perception is also highlighted, which stated thatmany local governments have not yet synchronized their programs to SDGs, although
they have been instructed to by the central government. The reason is that they do not yet
have comprehensive knowledge about SDGs; therefore, they cannot identify whether or
not their programs are aligned or could be aligned with SDGs. As sectoral and regional
governments are included as the fiscal stimulus beneficiaries under PEN, it is importantto allocate this stimulus to programs that are aligned with SDGs.
7. Conclusions
While the wide-ranging implications of COVID-19 on SDGs worldwide are yet to be
fully understood, this study presented a specific overview of COVID-19 implications on
SDGs for the context of Indonesia. Building over the foundation of the existing literature,semi-formal interviews were conducted with the key stakeholders in Indonesia that are
directly involved in the implementation of SDGs. In addition to identifying the most affected SDGs through specifically defined interview questions, this study has also derived
the perceived direct and indirect impacts of the fiscal stimulus measures on different
SDGs. In the backdrop of the limited research conducted so far on the implications of
COVID-19, it is hoped that this research will provide useful insights and directions to thedecision makers for enhancing the implementation of SDGs in the post COVID-19 era.
The findings highlighted that COVID-19 impacts all 17 SDGs, although disproportionately. Based on the four pillars of sustainable development defined in Indonesia, theSDGs in the social and economic development pillars are seen to be most impacted by
COVID-19, while the pillars of environmental and law and governance development are
not as highly impacted. The semi-formal interviews also helped to identify the role of fiscal measures in maintaining SDG progress, wherein the fiscal stimulus is perceived to beable to help in maintaining the SDG progress to some extent, except in the law and governance development pillar. The direct and indirect impacts of the stimulus towards each
SDG were also identified. Further, the semi-formal interviews, as the key strength of thisstudy, have also brought forward the stakeholders’ concerns on the progress of SDG implementation and fiscal stimulus implementation.
This study contributes to the existing knowledge of COVID-19, SDGs, and fiscal stimulus by providing a precise overview of COVID-19’s impacts on SDG attainment in thespecific case of Indonesia. Building over the country’s governance profile and fiscal stimulus measures against the COVID-19 pandemic, the study methodically presented the research findings based on a literature review and stakeholder interviews. Through thisstudy, specific policy recommendations were derived, in which they were establishedbased on the stakeholders’ concerns on the COVID-19 fiscal measure implementation. Deriving specific lessons from the case of Indonesia, the study also highlighted the core needfor aligning the COVID-19 fiscal stimulus with SDG attainment in order to keep the local
level progress of SDGs on track, which is now is highlighted as necessary to be done.
Towards the end, it is important to acknowledge the following limitations of this research. The study has been conducted in reference to the existing literature on COVID-

Int. J. Environ. Res. Public Health 2021, 18, 2911

19 of 2219’s impacts on Indonesia and semi-formal interviews with the key stakeholders. However, the implications of the COVID-19 pandemic for SDGs may further transform, until
the pandemic is fully controlled. As such, the future scope of this study necessitates afurther detailed literature analysis and stakeholder perception study. It is also important
to note that this research was mainly conducted through the online mode, but there is afurther need for primary surveys in the field, and analysis of the secondary data. The future scope of this study also includes the mapping of the before and after COVID-19 progress of SDGs to determine the development gaps based on both primary and secondary
data, and accordingly, to work for the timely attainment of SDGs. Another possible areaof future research would be to investigate the impact of the COVID-19 pandemic on theenvironmental related goals with more data availability.
Author Contributions: All authors were involved in conceptualization, visualization, investigation,
methodology, writing, review and editing. Data management, validation, formal analysis, Y.S.,
R.D.N., D.P.A.; writing—original draft preparation, Y.S., R.D.N., D.P.A., V.S., A.K.; resources, supervision, project administration, funding acquisition, R.S. Moreover, all authors have substantiallycontributed to the development of this paper. All authors have read and agreed to the publishedversion of the manuscript.
Funding: This research received no external funding. The APC was funded by the Keio University
research fund.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Acknowledgments: All the authors sincerely acknowledge the valuable support received from Indonesia Ministry of Finance, Ministry of National Development Planning (BAPPENAS), Statistics
Indonesia, and all the stakeholders interviewed in this study. The first, second, and third authors(Y.S., R.D.N., and D.P.A) are thankful to the BAPPENAS and Japan International Cooperation
Agency (JICA) for the scholarship. The fourth author (V.S.) is also thankful to the Ministry of Education, Culture, Sports, Science and Technology (MEXT) Japan for the scholarship. The authors
acknowledge support from Keio University to conduct this research.
Conflicts of Interest: The authors declare no conflict of interest. The funders had no role in thedesign of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.

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Int J Disaster Risk Sci
https://doi.org/10.1007/s13753-021-00337-7

www.ijdrs.com
www.springer.com/13753

ARTICLENew Realization of Disaster Risk Reduction Educationin the Context of a Global Pandemic: Lessons from Japan
Rajib Shaw1 • Aiko Sakurai2,3 • Yukihiko Oikawa4

Accepted: 12 March 2021
Ó The Author(s) 2021

Abstract The global COVID-19 pandemic has challenged
different development sectors, including education. In thisarticle, two main analyses are provided: one on the biological hazards of the pandemic in the context of the
Sendai Framework for Disaster Risk Reduction
2015-2030, which analyzes the overall impacts on the
education sector. Then we discuss the overall impact on
education sectors, with specific focus on disaster risk
reduction (DRR) education and education for sustainable
development (ESD). Disaster risk reduction education and
ESD are analyzed from the perspective of school-community-family linkages. Specific case analysis of COVID19 response in the education sector is presented from
Omuta City, Japan, which is considered as a champion city
for ESD. Four phases of response in Omuta City arecharacterized with three specific foci: (1) mitigating covid
impacts on educational program and participants; (2) preventing exacerbation of covid transmission within andoutside schools; and (3) maintaining educational program
integrity despite covid. Key lessons are summarized in the
concluding section, which explore the importance of (1)educational governance (on critical decision making) during the pandemic as well as with cascading risks; (2)& Rajib Shaw
shaw@sfc.keio.ac.jp
1

Graduate School of Media and Governance, Keio University,
Fujisawa 252-0882, Japan2

Department of Social Sciences, Toyo Eiwa University,
Yokohama 226-0015, Japan

3

International Research Institute of Disaster Science, Tohoku
University, Sendai 980-0845, Japan

4

Center for Ocean Literacy and Education, University ofTokyo, Tokyo 113-0032, Japanenhancement of school-community-family linkages as
pandemic response commonalities between ESD and DRR
education; (3) risk communication and citizen behavior;and (4) use of technology. We argue that integration ofhealth and DRR education is important, that resilienceneeds to be redefined in terms of sustainable development
goals (SDGs), and that education plays a vital role inachieving these ends.
Keywords Citizen behavior  Disaster risk reduction
education  Education for sustainable development 
Global COVID-19 pandemic  Japan 
School-community-family linkage

1 Introduction
Disaster risk reduction (DRR) has evolved over timethrough the painful experiences of different disasters, bothin Japan and abroad. Living with a diverse society andcoexistence with nature has been part of human history. In
our ever-changing lifestyles, we have termed the co-existence as education for sustainable development (ESD) or
environment education. Similarly, living with disasters andliving with risk have always been part of human history,
and experiential learning has been the core to educational
process. We have renamed this experiential process as
disaster risk reduction education, henceforth called DRR
education. As many authors have argued (Shiwaku andShaw 2008; Shaw, Takeuchi, et al. 2011; Shaw, Shiwaku,
et al. 2011; Thi et al. 2012; Shiwaku et al. 2016), DRR
education links school, community, and home. The ultimate goal of DRR education is to internalize risk perception and enhance preventive/preparedness actions. This has
always been an evolving process. Shaw, Takeuchi, et al.

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Shaw et al. New Realization of Disaster Risk Reduction Education Japan(2009) proposed the KIDA (Knowledge Interest Desire
Action) model as the example of process-based DRR
education.
School safety has been a strong pillar of DRR education,
which includes a physical part, management components,and education components (ASEAN 2016; UNISDR andGlobal Alliance for Disaster Risk Reduction and Resiliencein the Education Sector 2017). Japan has been in theforefront of DRR education, be it in the formal sectors likeschools or informal sectors such as communities. After the2011 Great East Japan Earthquake and Tsunami, theJapanese government has started focusing on DRR education related to the importance of life. It is often said that
DRR education is a lifelong education and is focused on
behavioral changes (UNICEF and UNESCO 2009; Shawand Oikawa 2014). In DRR education, the traditional focus
has been on ‘‘how to evacuate’’ as exemplified in emergency drills. But several disasters have taught the authorsthat it is not just sufficient to have an education on ‘‘howto.’’ Rather, we need to focus more on ‘‘what to.’’ In that
more proactive space, risk information, risk understanding,and risk perception have a critical role to play. We need tothink of a more holistic perspective within which toencourage resilience in the human, natural, and socioeconomic/governance systems.
The COVID-19 pandemic is the worst biological hazard-induced disaster observed in recent memory. Its
unprecedented speed and spread have affected most partsof the world. The year 2020, which was supposed to be an
important milestone year for the Sustainable Development
Goals (SDGs) (UN 2015), the Sendai Framework for
Disaster Risk Reduction 2015-2030, and the Paris Climate
Agreement, is now under the shadow of the pandemic. The
pandemic has not only impacted economies at every level,but it has also hindered the achievement of the SDGs.
Moreover, the cumulative effect of COVID-19 has strongly
impacted national and local development. The education
sector is no exception to that adverse result. In the formal
education sector, all levels, including primary, secondary,and tertiary (higher education), are affected. COVID-19
has also negatively influenced nonformal and informal
education through lock downs or emergency regulation
announcements in most countries, and thereby prohibited
direct contact between people.
The United Nations, in a recent estimate, has pointed outthat the pandemic has potentially affected 1.6 billion
learners worldwide, impacting 94% of the student population (UN 2020). The impact is more prominent in poorand vulnerable communities, although several developed
countries have also felt the disruption with a certain
amount of increased dropout rate in the schools. Educational disruptions have impacted the mid-day, in school
meal, which is often considered to be the only nutritious

123

food for school-age children in poor neighborhoods. The
prolonged pandemic has also increased violence againstchildren, especially girls. Financing education seems to bea challenge in many countries, and gaps with pre-COVID19 education funding are increasing with a staggering
estimated figure of USD 148 billion globally as per theUnited Nations (UN 2020) report. This report also advocated establishing resilient education systems that can belinked to sustainable development of communities andnations.
The past few months of pandemic experiences have not
only changed the course of education as a whole, they havealso impacted the meaning and realization of DRR education. Cascading disasters have been common in many
parts of the world. We have seen several cyclonic storms
hit coastal communities in which the ongoing pandemic
has posed a key challenge to the evacuation process. Strong
heat waves and flooding during the pandemic have posed
new health-related challenges. In many countries, education related to the pandemic is considered as a ‘‘healtheducation.’’ The pandemic impact goes beyond health,however, and is strongly related to the Sendai Frameworkfor Disaster Risk Reduction 2015-2030 (Djlante et al.
2020; Shaw, Kim et al. 2020).
Within this context, this article analyzes the biologicalhazards perspectives of the Sendai Framework and draws a
few key lessons. An analysis of DRR education in the newrisk landscape follows, as well as analysis of ESD, DRR
education, and the link to SDGs. Key issues of DRR education and COVID-19 impacts in Japan are also described.
A specific case from Japan illustrates the need for anew
realization of DRR education, linked to education forsustainable development. Finally, the article proposes key
learning for DRR education in the ‘‘new normal’’ condition
by analyzing the case of Omuta City, Japan. In this article,
we argue that the new perspective of integrated DRR
education can implement the lessons learned from thepandemic as well as enhance reduction of systemic, cascading risks.

2 Biological Hazards and Impacts on Education
Sectors
The Sendai Framework reinforces the scope of disaster risk
management by expanding beyond natural hazards toinclude biological hazards such as epidemic and pandemic
diseases. The Sendai Framework also places strongemphasis on the need to build resilient health systems
through the integration of disaster risk management into
the provision of healthcare at all levels and, in particular,‘‘to enhance cooperation between health authorities andother relevant stakeholders to strengthen country capacity

Int J Disaster Risk Sci

for disaster risk management for health’’ (UNISDR 2015,
p. 19). The purpose of this section is to highlight that apandemic response is not just a health response, but rather
is an integrated development sector’s response to a disaster,which is caused by biological hazards.
United Nations Office for Disaster Risk Reduction(UNDRR) terminology defines biological hazards as follow(UNDRR 2017a, 2017b):
Biological hazards are of organic origin or conveyed
by biological vectors, including pathogenic microorganisms, toxins and bioactive substances. Examples
are bacteria, viruses or parasites, as well as venomous
wildlife and insects, poisonous plants and mosquitoes
carrying disease-causing agents.
In a recent study, Shaw, Chatterjee, et al. (2020a, 2020b)
have identified 10 basic principles that need to be incorporated into future risk preparedness (Fig. 1). These principles define the key aspects of biological hazards: (1) risk
assessment (integrated surveillance and early detection,
identification of hotspots/clusters); (2) risk planning (multidisciplinary science-based support, worst case scenario
planning); (3) recovery planning (with regional collaboration); and (4) use of technologies and stakeholder participation in order to address fake news and infodemics(information as the key of epidemic, mentioned by WHO
Director General in January 2020) by means of information
sharing, which is an important component of risk communication. Risk communication is also an essential element of disaster risk management (DRM) because it shapes
people’s perceptions of risk and influences their actions
with respect to disaster preparedness and disaster response.
Priority Four of the Sendai Framework (UNISDR 2015)
specifies the importance of investing in disaster risk communication along with multi-hazard forecasting and early
warning systems, developing these systems with participatory process, tailoring them to the needs of users, andbroadening release channels for disaster early warning
information. These principles can be adopted for thedisaster risk reduction process, and the education sector canalso learn and adopt some of these goals and practices.
The education sector is differentially affected by
COVID-19. The sector needs to provide a unified response
with: (1) mitigating disease impacts on students, staff, andsupport personnel within its direct purview; (2) adopting
practices that do not exacerbate disease transmission in thelocal community; and (3) maintaining its educational
mission in creative and innovative ways, despite being
seriously impacted, based on its unique knowledge
resources. The education sector can help reduce local
impacts by generating health education that increases student and community awareness of disease ecology andpreventive public health practices. In this way the education sector plays a critical role in risk communication aboutoutbreaks, epidemics, and pandemics.
Education also supports development of rich humanresources by imparting required training and skills. Higher
education institutions (HEIs) are resourceful in conducting
research on various aspects linked to an outbreak and inincreasing risk awareness. During the COVID-19 outbreak,the HEIs can play an important role in response to thedisease outbreak, spread, and status. This has been highlighted by examples such as the role of Johns Hopkins
University in developing an online dashboard that documents the spread of the infection or the role played by
students at the Indian Institute of Technology, Roorkee indeveloping low-cost ventilators (Izumi et al. 2020).
The education sector is one of the most frequently
impacted service sectors. The main reason is the closure ofschools and absenteeism of teachers. The propensity ofchildren to become infected with particular virus infections
has led to the closure of schools in the past. This disturbs
the academic calendar and adds stress to parents and students alike. The education sector has embraced online
tools, redefining how learning takes place by opening up
the traditional classroom. The effectiveness of online
education in student learning and its impact on care providers’ regular responsibilities (for example, work duties

Fig. 1 Basic steps and learning for biological hazard integration into disaster risk reduction (DRR). Source Shaw, Chatterjee, et al. (2020a)

123

Shaw et al. New Realization of Disaster Risk Reduction Education Japanand care responsibilities) should not be neglected. Issues ofundernutrition in low income groups in developing countries and obesity globally not only put the children at highrisk of infection but also may expose them to long-term
developmental, psychological, physical, and emotional
complications (Dunn et al. 2020). A pandemic may expose
children to higher risks of abuse, neglect, and other issues
around child protection (UNICEF 2020). A biologicalhazard also may often be an opportunity for higher education institutions and research organizations to engage indeveloping new tools, encourage research and innovation,and find new funding opportunities.

December 2020. In Japan, schools were faced with sudden
closures in the beginning of March and then again in June
2020, just as the country was at the phase of safe school
resumption. Although people tried to return to their normal
daily life, it was not possible to resume the same life as
before the pandemic. To turn the COVID-19 pandemiccrisis into opportunities in the education sector, the international community started to discuss how educational
systems could be built back stronger and more
equitable than before (UN 2020; World Bank 2020). Since
disaster education is one of learning activities, it isworthwhile examining what disaster risk reduction education could learn from the COVID-19 pandemic in the newrisk landscape.

3 Disaster Education in the New Risk Landscape
3.2 Living with COVID-19 Risk
COVID-19 has brought new challenges as well as opportunities in the education sector, similar to other sectors likehealth, livelihoods, and so on. In the new risk landscape,where the biological hazards continue over a period oftime, and there are risks of cascading hazards, education
sector’s role becomes more important for formal, informal,
and nonformal education.
3.1 Implication of COVID-19 Pandemic
to Education
Early resumption and continuity of educational services
after a disaster is listed as one of the global targets in the
Sendai Framework for Disaster Risk Reduction
2015-2030. The COVID-19 pandemic gave enormous
global shocks to children’s education. Different from anatural hazard and disaster, the pandemic affects children’s
education all over the world almost simultaneously. The
impact of educational services disruption by the COVID-19
pandemic extends from lost learning opportunities tochildren’s learning outcomes, increasing dropouts, anddisruption of school nutrition programs. Isolation of children from schools could also affect their mental health. In
addition, economic shock puts pressures on households that
could decrease educational expenses. Fiscal pressure maylead to reduction in education investments, impacting
learning environments and quality of education (WorldBank 2020; UN 2020).
With the COVID-19 virus pandemic, each country hastaken all possible actions to prevent disease spread, andinternational cooperation has been explored to overcome
the crisis. Lockdown measures were utilized in cities inmany countries. In mid-June of 2020, lockdowns started tobe lifted gradually in some countries although the spread of
the coronavirus and emergence of new varieties continue.
New lockdowns were imposed in many countries, whichwere undergoing a third wave between November and123

Risk communication has been playing a vital role inmanagement of the COVID-19 pandemic. Governments
and public health agencies in each country have been
informing the public about what the COVID-19 virus is,what the symptoms of the virus are, how to avoid catching
the virus, what measures to take when the suspicion of
infection arises, and so on. Public health education also
involves multiple messages, not strictly about risk, that
express concerns, opinions, or reactions to risk messages or
to legal and institutional arrangements for risk management(Natural Research Council 1989). The goals of risk communication in public health are to share information vitalfor saving life, protecting health, and minimizing harm toself and others throughout a society. Regarding the
COVID-19 virus, each individual needs to change their
behavior to avoid personal risk of infection, but also thewhole society needs to take actions against societal risk toprevent disease spread in the society. To respond to asocietal risk requires all citizens, each of whom has adifferent level of risk perception, to participate in discussions to reach a social agreement on appropriate response
to a societal risk. Risk communication is recognized as
multidirectional communication and engagement withaffected populations so that they can take informed decisions to protect themselves and their loved ones. This canand should utilize the most appropriate and trusted ofchannels of communication and engagement (WHO 2014).
It could be said that infectious risk of COVID-19 is a newrisk, which people perceive as ‘‘dread’’ and ‘‘unknown.’’
The higher the dread factor levels and the higher the perceived unknown risks, the more people want to see suchcurrent risks reduced, and the more they want to see strict
regulation employed to achieve the desired reduction inrisk (Slovic 1987).

Int J Disaster Risk Sci

4 Education for Sustainable Development,
Disaster Risk Reduction Education,and Sustainable Development Goals
ESD, DRR education, and SDGs are inter-connected, andoften considered as the part of the same coin. Oikawa(2016) has demonstrated the linkages among the three
types of education, and the connectivity goes to the schoolcommunity linkages. This section provides a brief overview of these three types of education process.
4.1 Improving Disaster Risk Reduction Education
through Education for Sustainable Development
Faced with the global COVID-19 infection, social systems
and lifestyles need to adjust to extreme change. Disasterrisk reduction education should also change its concept andmethod towards achieving a sustainable society. Education
for sustainable development brings new perspectives to
DRR education. As a lesson learnt from the 2011 Great
East Japan Earthquake and Tsunami and ESD practice in
Kesennuma City, Miyagi Prefecture, Japan, ESD brought
new innovations to DRR education from the perspective of
the sustainable development concept. This achievement
was attained by improving the quality of DRR education,
fostering DRR ability and attitude, and building networks
and partnerships for DRR (Oikawa 2014c). In the context
of DRR and ESD values, such concepts as respect for lives,
human security, life together (coexistence), and building asustainable society (Build Back Better) emerged. Education for sustainable development also transforms learning
styles of DRR education. Education for sustainable
development recommends learning that is inquiry-based,
problem-solving, experience-based, project-oriented, community-based, and integrated. Adoption of those ESD
learning methods into DRR education should further
improve the quality of DRR education. As a result, throughthe improvement based on ESD, DRR education can foster
DRR abilities and attitudes that become the building blocks
of disaster management (Oikawa 2014b).
4.2 Education Achieving the Sustainable
Development Goals
Sustainable development goals ensure inclusive andequitable quality education and promote lifelong learning
opportunities for all at Goal 4. Education is at the heart ofthe 2030 Agenda for Sustainable Development and isessential for the success of all SDGs (Fig. 2). Especially,
ESD is a key enabler of all the other SDGs, so that theoverall objective of ESD for 2030 is to build a more justand sustainable world through the achievement of the 17

SDGs. Pursuant to the achievement of SDGs, the United
Nations Educational, Scientific and Cultural Organization(UNESCO) submitted a proposal for a framework, entitled
Education for Sustainable Development: Towards
Achieving the SDGs (ESD for 2030),1 as a 10-year followup to the Global Action Programme on Education for
Sustainable Development (2015-2019),2 and this proposal
was adopted at the UN General Assembly in December
2019. The ESD for 2030 therefore proposes to strengthen
ESD’s contribution to all SDGs, with particular focus on
helping attain Goal 4. The UNESCO document alsostresses that future education—the Education 2030
agenda—should place emphasis on the contribution oflearning content to the survival and prosperity of humanity(UNESCO 2019). In this context, the COVID-19 pandemic
is an unprecedented disaster that threatens human existence, and a common issue to be solved by all humans.
Therefore, the response to prevent the COVID-19 pandemic should be implemented in the context of SDGs, andas result, its process leads to the achievement of SDGs. To
realize this, education, especially DRR education based on
ESD, should make a great contribution through capacity
development.
4.3 Overview of Disaster Risk Reduction Educationand Sustainable Development Goals
Sustainable development goals mention DRR at Goal 1, 11,
and 13. In the SDGs context, it is possible to promote DRR
education targeting DRR-related goals above, mainly Goal
11, and combining with SDG 4 focused on education. Yet
DRR education should not be limited to SDGs 4 and 11.
Disasters have serious impacts on other issues such as
poverty (Goal 1), food and hunger (Goal 2), clean waterand sanitation (Goal 6), energy (Goal 7), infrastructure(Goal 9), and so on. Many disasters, such as storm, flood,
drought, tsunami, and landslide, occur from climate change(Goal 13), rising seawater temperature and tsunami (Goal
14), and deforestation and desertification (Goal 15).
Therefore, promoting DRR education centered on DRR(Goal 11) and education (Goal 4) in relation to other goals
can contribute to achieving all SDGs. The COVID-19
pandemic is also related to many other SDG goals, such as
poverty, food, health, sanitation, economic growth, among
others. Thus responses to prevention of infection are congruous with the aims of DRR education. This perspective iscrucial for education of COVID-19 pandemic.

1https://en.unesco.org/news/esd-2030-whats-next-education-sustain
able-development.
2
https://www.mext.go.jp/unesco/004/1339970.htm.

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Shaw et al. New Realization of Disaster Risk Reduction Education Japan

Fig. 2 Education for sustainable development (ESD) towards
achieving sustainable development goals (SDGs). Source Left:Japanese National Commission for UNESCO (https://www.unesco.

emb-japan.go.jp/htm/jpcommissionunesco.htm); right:(https://en.unesco.org/sustainabledevelopmentgoals)

5 Japan’s Disaster Risk Reduction Education
and COVID-19 Response

the participants, regardless of their age, to build trustfulrelationships among themselves, and to understand theirown community’s society and nature holistically. These
educational efforts could energize participatory disasterrisk management by any local community trying to find,through discussion, solutions that reduce disaster risk.
From the experience of the 2011 Great East Japan
Earthquake and Tsunami disaster, participatory disasterrisk management by the local community has been provento be an effective way of communicating risk. When a local
community was involved in planning for disaster preparedness, and people took ownership of their own safety
plans, they were better prepared and better able to take thenecessary actions to protect themselves. Successful risk
communication occurs when there is holistic learning,facilitation, and trust. In contrast, risk communication in
the Fukushima nuclear accident was regarded as a case of
failure in terms of the timing of information released, theaccuracy and details of the information provided, and thetrust and credibility of the information sources cited (Shaw2012).
Having only basic or minimum understanding of risk,
how did people respond to the COVID-19 risk in the caseof Japan? Risk perception is different in each country basedon the society’s culture and the government’s actions.
During a state of emergency period, the Japanese peopleobeyed the stay-home request without any law enforcement(Shaw, Kim et al. 2020). Commuting by jam-packed trains
is a notorious daily-life scene in Tokyo, but empty seats
were found in commuter trains after repeated requests fromthe government to reduce the number of people in public
place by 80% compared to before the state of emergency
declaration. People kept social distances, wore masks in

Disaster education is considered one of the components ofsafety education in Japan, which aims to promote a person’s ability to overcome normalization bias that inhibits
realistic disaster threat risk assessment, prediction, andavoidance, and thus makes it possible to take pragmatic,
proactive action against a looming threat (MEXT 2019).
Education for risk communication is scattered among
environmental education, safety education, information
education, and consumer education in the current national
curricular guidelines in Japan. But the topic of natural
hazards and disasters is still dealt with in the confines ofindividual subject areas. That is, the natural environment
and the social environment are covered separately in science education and social studies education, respectively.
Because of the different goals and characteristics of these
two subject areas, natural hazards and disasters have notbeen comprehensively covered despite the need for a crosscurricular approach (Fujioka 2016).
To overcome the division in the curriculum, ESD is oneof the solutions because integrated efforts in numerous
connected fields are required to achieve the construction ofa sustainable society. Experiential learning is also a usefulapproach for children to learn about a concept of risk andrisk management that is difficult even for the adults tounderstand. Since the scale and degree of a disaster could
be different according to the natural and social vulnerabilities of each affected area, a place-based experiential
learning could be an effective approach. Disaster education
is not only limited to formal education. Extracurricular andcontinuous education activities in communities could help

123

UNESCO

Int J Disaster Risk Sci

public spaces, and washed hands and gargled when they
returned home (Tashiro and Shaw 2020). Not only did
individual behavior change to avoid infectious risk, people
also refrained from becoming spreaders of the coronavirus.
In this short period, the Japanese people and society
experienced first-hand the behavioral changes needed to
avoid COVID-19 risk. But discrimination and stigma
against hospital workers and hoarding certain products also
occurred in the society; these behaviors were assumed to becaused by fear of contamination and rumors about potential
shortages potentially caused by the unknown and theinvisible coronavirus.

6 Case of Omuta City
Omuta City in Fukuoka Prefecture has taken deep interestand leadership in promoting ESD through SDG activities.
Working closely with the schools, local communities,
academics, and nongovernment organizations, as well as
business sector, the city has established a collaboration
scheme for DRR, ESD, and SDG.
6.1 Building the Linkage of School and Community
through Education for Sustainable Development
and Sustainable Development Goals
The Omuta City case is analyzed as a good example ofschool and community linkage practiced through ESD.
Omuta City is located in the southeast of Fukuoka Prefecture, adjacent to the Ariake Sea and close to the
Kumamoto Prefecture boundary. Omuta’s economy flourished along with the coal industry as long as coal was
Japan’s primary fuel source. But in 1997, faced withcompetition from alternative fuel sources, the Miike Coal
Mines closed, Omuta’s industry declined, and population
fell by nearly 50% as the city’s work force sought jobs
elsewhere. Today, utilizing the coal mine-related resources,
which are World Heritage sites, Omuta is advancing its
own Omuta-brand SDGs to enhance education that promotes sustainable communities. With the slogan ‘‘Omuta,
an UNESCO Associated School Town,’’ all of the city’s 30
elementary schools, junior high schools, and special needs
schools became UNESCO Associated Schools (ASPnet
School) in 2011 and has been practicing ESD. The Omuta
City Board of Education (BOE) has built an ESD Consortium comprising local companies, nongovernment/nonprofit organizations, the University of Teacher Education
Fukuoka, and others. Through building the ESD Consortium, the linkage of school and community in Omuta City
has been strengthened (Oikawa 2016). In 2018, the city
developed ‘‘Omuta version SDGs’’ by adapting UN SDGs
to align with local issues. The consortium selected several

sustainable development goals and clarified those children’s competencies to be nurtured to achieve the goals
based on former ESD practices (Fig. 3). Schools in the cityalso promote DRR education utilizing their linkage withlocal communities (Omuta BOE 2018).
6.2 Educational Response to COVID-19 in Omuta
City
The Omuta City Board of Education (BOE) has been
conducting responses to COVID-19 infection by collaborating with schools, parents, and local communities since
the COVID-19 pandemic occurred in Japan. Omuta City
has been learning the lessons of the 2011 Great East Japan
Earthquake and Tsunami in Kesennuma City, such as thedisaster management and recovery process (Oikawa 2012).
Omuta BOE made the best use of appropriate ESD experiences and established links with communities and institutions to make response plans to COVID-19 and to
implement them effectively. Under the threat of a spreading COVID-19 infection in Fukuoka Prefecture, Omuta
BOE was required to make quick decisions about principles of and action plans for response, direction to schools,
and information to parents and citizens. Based on accumulated educational and ESD experience, BOE has
implemented continuous responses to prevent COVID-19
from spreading. These plans are adjusted according to thecurrent situation and phase of infection.
6.2.1 Phase 1: Japanese government Request for school
closure (1 March–6 April 2020)
On 28 February 2020, following the spread of COVID-19
in Japan, the Japanese government requested that all
schools in Japan close beginning on 1 March. In a few
days, all schools and boards of education in Japan wererequired to prepare for school closure, to take care of
students, and to respond to COVID-19 infections. The
Omuta BOE also made some response plans to COVID-19
by communicating and collaborating with school principals
and teachers. The BOE held urgent principal meetings
many times to discuss preparedness and responses to thepandemic. It conducted planning and implementing
responses by utilizing the knowledge and experience in
ESD, and it also modified the response of each school
while respecting their initiatives.
In response to specific requests at school, teachers visited students’ homes for health checks while schools wereclosed. The BOE also promoted collaboration with thesocial welfare section of the city office to support students
who needed special assistance, starting a week after school
closure. Concretely, Omuta BOE proposed cooperation
with the Council of Social Welfare to supply food (lunch

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Shaw et al. New Realization of Disaster Risk Reduction Education Japan
Fig. 3 Omuta version
sustainable development goals(SDGs). Source Omuta City
(https://omutacityzoo.org/sdgs)box) for underprivileged children during school closure.
The BOE and teachers of each school delivered these lunchboxes to students of low-income families. Also the BOE
required school principals to invite at-risk students, who
might be exposed to child abuse risks in their families, tocome to their schools to collect their lunch box in order tocheck on their lives at home.
In addition, the BOE negotiated with welfare facilities to
accept handicapped students while special support schools
were closed; the BOE also ordered schools to take care of
students of double-income or single-parent families until
those children could return to after-school day-care centers,
because daytime working parents are unable to provide
supervision while children are home. As a further monitoring action, the Omuta BOE dispatched school social
workers to low-income households and families with achild abuse history. This initiative created an opportunity123

to research children’s meal or health situations, and toprovide lifestyle support during school closure. Throughout
the response, the BOE received advice from specialists,such as a doctor in the public health center, on the bestpractices available to avoid COVID-19 outbreaks at
schools.
6.2.2 Phase 2: Declaration of a state of emergency (7April–14 May 2020)
On 7 April 2020, a state of COVID-19 emergency was
declared in Fukuoka Prefecture. Concern about the
COVID-19 pandemic was increasing among parents andcitizens, because some COVID-19 infected persons werealso found in Omuta City. Schools had to shift the methodof contact with students from in-person home visits toindirect communication, such as letters or emails, toInt J Disaster Risk Sci

prevent the spread of the new coronavirus infection. Omuta
also directed the curriculum coordinators of each school toreorganize a new school curriculum that could make up forlost learning time because of school closure and adjust to
the new school education setting of the post-corona
infection period. All the schools reorganized their curriculum and lesson plans by selecting nonacademic school
events—such as sports day or culture day—to provide
enough lesson hours to learn the reconfigured school curriculum even if the school year was shortened due to school
closure.

Under these conditions, the risk of corona infection
inevitably will increase in evacuation shelters from any
disaster, so evacuees must maintain social distance even in
the shelters. Every municipality, including Omuta City,
must find and reserve other evacuation spaces or shelters to
supplement school space to prepare for a future disaster,which could occur soon and coincide with a corona virus
outbreak. That is a new and common problem for disasterrisk reduction to solve during the period of COVID-19.

6.2.3 Phase 3: Post declaration of a state of emergency(14–31May 2020)

The three key issues of pandemic response in the education
sector can be reflected through: (1) mitigating the disease
impacts on the education sector; (2) preventing increased
disease transmission by the education community; and (3)preventing impacts on the education sector from disrupting
its educational mission. Table 1 shows key lessons from the
Omuta case in these three key pillars of response undertaken by the education sector.
A few general lessons emerged from the Omuta City
case study can be summarized concisely and also applied insimilar conditions when coping with future biological andrelated cascading hazards:

The emergency declaration in Fukuoka Prefecture waslifted on 14 May 2020. Because COVID-14 was calming
down day by day, the BOE could target the day of school
restart and schools had to prepare for reopening school.
Omuta BOE considered the plan of ‘‘distributed schoolday’’3 and implemented on 18 May a two week period as astep to ‘‘simultaneous school attendance.’’ On the other
hand, on 8 May the BOE decided to shorten summer
vacation from 40 to 11 days to recover the delay of learning
due to corona infection. Those are very quick responses
and decisions. Through a clear decision-making process,which involved consultation with not only teachers but also
students and parents, the Omuta BOE was able to build
support for an in-person school restart and alleviate concerns about the restructured school education and schedule.
6.2.4 Phase 4: School reopening (1 June 2020 onward)
On 1 June 2020, all the schools in Omuta City restarted inschool lessons all at once. In reopening school, each school
reconfirmed that ensuring students’ security and safety was
the priority of school education. All schools planned toresume school on the premise that corona infection could
be prevented. School teachers did their best to build abetter environment and lifestyle at each school and classroom to prevent corona infection. For example, practicalactions included enforcement of wearing a mask, temperature measurement and gargling, hand washing, disinfection, keeping social distance, improved ventilation, and soon.
Since reopening, new issues have emerged regarding
disaster risk reduction at school. In almost all the schools,
gymnasiums are designated as evacuation shelters, but they
get crowded with evacuees whenever a disaster occurs.
3This means that students are grouped in different sections, and wereasked to come to school alternate days to avoid the concentration ofpeople in one place.

6.3 Key Learning from Omuta City

(1)

(2)

(3)
(4)
(5)

(6)

Share information about the COVID-19 pandemic
exactly and quickly with the mayor, board members,
city council, schools, teachers, students, and parents;
Promote principles and policies of the educational
response to the prevention of corona virus infection assoon as possible;
Clarify the division of roles of BOE, principals,
teachers, and parents;
Visualize the decision-making process to field based
responses;
Introduce the knowledge and advice of epidemiology
specialists into decision-making and establish rigorous response processes to maximize prevention ofcorona infection; andCreate a proactive planning and response process thatis mutually supportive of and compatible withdisaster risk reduction management

7 Discussion
The new realization of DRR education lies in the responseto new types of hazard such as biological hazards.
Although the Sendai Framework has expanded the scope of
hazards to biological hazards, NaTech (natural hazard
induced technological disaster), and so on, this is the firsttime in recent history that we have faced such a prolonged
biological hazard in terms of pandemic, which has affected123

Shaw et al. New Realization of Disaster Risk Reduction Education Japan
Table 1 Key lessons from COVID-19 responses in the education sector of Omuta City
Mitigating the Impact

Preventing Exacerbation of Transmission

Maintaining Mission Despite
Impacts

Phase 1 (Early
stage)

Educational governance with schoolleadership and Board of Education is
criticalSpecialist advice and science-based decision
making is important

Collaboration with other sectors
such as social welfare isimportant

Phase 2(Emergency
stage)

Reorganization of syllabus/curriculum to Shifting to online communication instead ofcover any delay in education delivery
direct home visits is found effective
is effective

Phase 3 (Postemergency
stage)

Target the day of school restart, and build
support of and confidence in Parent
and Teacher Association with online
discussion

Undertake precaution measures using
innovative technologies, like facial
temperature check, health check, physicaldistancing, and so on

Phase 4
(Recovery
stage)

Ensure students security and safety is apriority of school education, including
reduced impacts of cascading hazard

Build better environment and lifestyle ofschool to prevent corona infection

different parts of global society. Cascading disasters liketyphoons, floods, and heat waves also have been prominent
during the global pandemic in Japan as well as elsewhere.
In a recent report, Das et al. (2020) discussed evacuationand shelter management challenges during floods in west
Japan amidst the pandemic. Usually the schools become
evacuation shelters during disasters in Japan, which createdcritical challenges of shelter management during the
COVID-19 outbreak. In 2020, people did not evacuate toschools in many cases, mainly due to fear of infection and adesire not to affect the education continuity (because mostof school classes are already affected due to pandemic).
Where people have evacuated into the schools—mostly
abandoned school buildings in rural and semirural areas in
Kumamoto Prefecture—shelter management was a key
challenge due to the new government guideline of 60%
occupancy of the shelter to maintain safe physical distancing. Also, a strict health monitoring mechanism was
imposed, and the entry of volunteers was restricted. The
lessons from cascading disasters, as compiled by Das et al.
(2020), will be useful for future school operation during
time of emergency. New learning of DRR education can besummarized below in terms of (1) governance and decision
making; (2) school-community-family linkages; (3) risk
communication and citizen behavior; and (4) use oftechnology.
Educational governance becomes very critical during aswell as after pandemic decision making, where crucial
decisions on the opening of schools and maintenance ofappropriate social behavior inside and outside school(during commuting) become important. All three aspects ofeducational governance (structural, nonstructural, andfunctional) issues become crucial. In many countries
COVID-19 related education is primarily categorized

123

Cancel school events to increase
lesson hours enough to enhancelearning even in a shortenedschool year
Shorten summer vacation torecover lost in-class learning
options due to COVID-19
induced school closures
Reserve alternate spaces andshelters to keep social distancefor evacuation

under health and sanitation education for washing hands
taking proper care of health issues, and so on. But a proper
integration into DRR education is desirable. Also, linkageof the Board of Education with the Social Welfare
department helped in addressing the issues of the vulnerable children.
The connection between school and community,
including families, is very critical for promoting DRR
education. As a lesson of the 2011 Great East Japan
Earthquake and Tsunami, it was reported that disastermanagement, including evacuation and management ofshelter, was remarkably successful in those schools thathave good linkages and collaborations with their communities and outside institutions through high quality DRR
education within the community (Oikawa 2013). From thecase of Omuta City, significant commonalities with school
responses and education to prevent disease spread during
the COVID-19 pandemic can be observed. The school is
not able to prevent the spread of corona infection without
cooperation with community and family, because theschool had to close for a while and to entrust students totheir families and communities as the COVID-19 virus
rapidly diffused globally and locally. In Japan, the linkage
of school and community must be built through collaborative school activities or joint projects with community.
The Parent and Teacher Association (PTA), working in acollaborative system with the local community, was able toachieve broad support for a Community School. Education
for sustainable development embraces all of these initiatives and it also contributes to create a sustainable society
and community; this is the best approach and method tobuild linkages and community engagement (Oikawa
2014a). Thus, the key essence of ESD and DRR educationas school community linkage is reestablished through theInt J Disaster Risk Sci

lessons from pandemic responses, and this leads toachievement of sustainable development goals and emergence of a more resilient society and community.
Risk communication becomes an important factor, andschools can play a vital role by enhancing risk communication (Shaw et al. 2014). For DRR education, providing
appropriate information through schools to community andfamily is effective. In case of pandemic response also, it
was found an effective mechanism to provide the right andtrusted information. A pandemic is an invisible disaster,correct information from a trusted source is crucial, andschools have played important roles in information dissemination. Behavioral changes and being responsible
citizens are of utmost importance, which is linked to school
and community collective education (Shaw, Kim, et al.
2020).
Finally, COVID-19 has seen the use of different types ofinnovative technologies in all sectors, including education.
Several innovative ways to provide online classes andonline classrooms were used to deliver lectures andmaintain teacher and student contact. Health surveillanceusing a thermal camera was common in most of theschools. Different apps were used extensively for contact
tracing in many schools and education sectors. All thesetechnologies have implications for DRR education as well,which can also be used for education continuity throughonline classes (when schools are used as evacuation shelter
after a disaster) or safety notification after a disasterthrough health related apps, as well as regular healthchecks, and so on.
What could be the implication of the COVID-19 experience to disaster education? There is an urgent need for aconversion about disaster prevention education that promotes a true disaster risk reduction and resilience educationin the new risk landscape. Focusing on the Sendai
Framework priority, understanding that risk includes all its
dimensions of vulnerability, capacity, exposure of persons
and assets, hazard characteristics, and the environment.
This holistic approach needs to be included in risk reduction and resilience education (UNDRR 2017a). The current
concept of single hazard DRR education also needs to bechanged. We are increasingly facing cascading hazards andcomplex emergencies with different levels of uncertainties.
Thus, traditional DRR education is significantly challenged
and we need new cycles of learning for holistic DRR andresilience education. Risk communication for complex
emergencies, capacity enhancement, and resilience building are some important key issues.

8 Conclusion
The Sendai Framework has expanded the scope of hazards,
and thus DRR education needs to incorporate new learningfrom COVID-19 responses in the education sector. Cascading risks also become a crucial factor in the prolonged
timeframe of a global pandemic. COVID-19 has seriously
affected the education sector, and its responses are also
varied based on each country’s governance structure. The
case of Japan presented here has drawn the lessons fromthe evolution of DRR education, previous learning from the2011 East Japan Earthquake and Tsunami, and the current
pandemic. The experience of Omuta City, which is achampion city of ESD, shows that SDGs are attainable as apart of a holistic strategy and that governance plays acritical role in education in emergencies. Informed andscience-based decision making by the Board of Educationand schools are critical both in the pandemic as well as in
DRR education. School-community-family linkages, risk
communication, and responsible citizen behavior are key
variables to reduce the impacts of the pandemic disasterand can be adapted to other disaster risk management
needs. Technology has played a critical role in the COVID19 pandemic, which can also be used in future DRR education. New realization of DRR education lies in the factthat it offers an essential lens through which to understanda complex emergency with cascading risks and differential
levels of uncertainties. Also, health education and DRR
education have complementarities, but still need to promote more synergies. Decision making and risk communication for complex emergencies needs to be incorporated
in DRR education, so that it becomes a comprehensive risk
reduction and resilience education, leading to a safer andsustainable society and community.
Acknowledgements The first author acknowledges funding from
Keio University, and the first and second authors acknowledge
funding from Japan Society for Promotion of Science grant.
Open Access This article is licensed under a Creative Commons
Attribution 4.0 International License, which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, aslong as you give appropriate credit to the original author(s) and thesource, provide a link to the Creative Commons licence, and indicate
if changes were made. The images or other third party material in thisarticle are included in the article’s Creative Commons licence, unlessindicated otherwise in a credit line to the material. If material is notincluded in the article’s Creative Commons licence and your intended
use is not permitted by statutory regulation or exceeds the permitteduse, you will need to obtain permission directly from the copyrightholder. To view a copy of this licence, visit http://creativecommons.
org/licenses/by/4.0/.

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Shaw et al. New Realization of Disaster Risk Reduction Education Japan

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123Article

Digital Citizen Science for Responding to COVID-19 Crisis:
Experiences from Iran
Hossein Vahidi 1,2,*, Mohammad Taleai 2, Wanglin Yan 1 and Rajib Shaw 3
EcoGIS Lab, Graduate School of Media and Governance, Keio University, Fujisawa,
Kanagawa 252-0882, Japan; yan@sfc.keio.ac.jp
2 Spatial Decision Making & Smart Cities Lab, Faculty of Geodesy and Geomatics Engineering, K. N. Toosi
University of Technology, Tehran 15433-19967, Iran; taleai@kntu.ac.ir
3 Global Resilience Innovation Laboratory, Graduate School of Media and Governance, Keio University,
Fujisawa, Kanagawa 252-0882, Japan; shaw@sfc.keio.ac.jp* Correspondence: vahidi@sfc.keio.ac.jp or vahidi@kntu.ac.ir; Tel.: +81-466-49-345
1

Citation: Vahidi, H.; Taleai, M.; Yan,W.; Shaw, R. Digital Citizen Sciencefor Responding to COVID-19 Crisis:
Experiences from Iran. Int. J.
Environ. Res. Public Health 2021, 18,
9666. https://doi.org/10.3390/
ijerph18189666

Abstract: The Coronavirus Disease 2019 (COVID-19) pandemic has so far been the most severe
global public health emergency in this century. Generally, citizen science can provide a complement
to authoritative scientific practices for responding to this highly complex biological threat and its
adverse consequences. Several citizen science projects have been designed and operationalized for
responding to COVID-19 in Iran since the infection began. However, these projects have mostly
been overlooked in the existing literature on citizen science. This research sheds light on the mostsignificant online citizen science projects to respond to the COVID-19 crisis in Iran. Furthermore, ithighlights some of the opportunities and challenges associated with the strengths and weaknessesof these projects. Moreover, this study captures and discusses some considerable insights and lessons learned from the failures and successes of these projects and provides solutions to overcome
some recognized challenges and weaknesses of these projects. The outcomes of this synthesis provide potentially helpful directions for current and future citizen science projects—particularly thoseaiming to respond to biological disasters such as the COVID-19 pandemic.
Keywords: citizen science; crowdsourcing; coronavirus disease 2019 (COVID-19); user-generated
content (UGC); volunteered geographic information (VGI); public health monitoring; public healthpromotion; emergency management; mobile health (mHealth); digital contact tracing

Academic Editor: George Crooks
Received: 23 July 2021
Accepted: 1 September 2021

1. Introduction

Published: 14 September 2021

Coronavirus Disease 2019 (COVID-19) has become undisputedly the most severe biological hazard that has been seen in the recent past. It is difficult to track the numbers,
with more than 142 million people affected in 192 countries and territories as of mid-April
2021, resulting in more than 3 million deaths and numerous sufferings that have been
impacting all parts of societies [1]. This is possibly the true representation of our globalized and inter-connected world, where risk is shared globally, yet disproportionately, depending on the country and community’s vulnerability, exposures, capacities, governance mechanisms, technology advancement, innovation, and more importantly, citizen
behavior. There is still a massive gap between our current state of knowledge and theknowledge we need as well as between the available resources and the resources we demand to effectively fight against COVID-19. COVID-19 is a novel type of biological hazard whose many aspects, such as biology, transmission mechanisms, spread and infection
trajectory, and treatment, as well as short- and long-term physical, mental, social, andeconomic consequences, are often uncertain or not (fully) known. Hence, COVID-19 hasraised many new questions and presented various challenges for scientists, practitioners,

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Int. J. Environ. Res. Public Health 2021, 18, 9666. https://doi.org/10.3390/ijerph18189666

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and policy-makers since the pandemic began. This pandemic has shown that professionals and governments are not always equipped or capable of responding to a biologicaldisaster [2] alone, since real-time/near real-time geographically distributed data acquisition, data management, data processing and interpretation, data exchange, and information presentation are the core of its response strategy.
Citizen science is a scientific practice performed, in whole or in part, by volunteers
from the general public [3]. The citizen science movement aims to connect people to science and bridge the gap between the public and scientists [4]. It empowers the generalpublic to make a direct contribution to scientific research [5]. Public participation in scientific research often allows scientists to leverage the power of volunteers to accomplish
tasks that would be too expensive or time-consuming to accomplish through other means[6]. Citizen science also offers other potential benefits to professionals and citizens. These
include enabling the democratization of science, allowing the incorporation of local, traditional, or indigenous knowledge of citizens in scientific research, providing learning
opportunities for citizens, raising awareness in citizens, increasing advocacy among citizens, promoting behavior change among citizens, and enhancing citizens’ physical andmental health, personal enjoyment, social interaction, and satisfaction through contributing to scientific evidence [7–9]. The advent of information and communication technology (ICT) and the rise of Web 2.0 [10] over the past two decades have created a wide range
of opportunities for citizen science. The online digital technologies can usually ease theestablishment and management of citizen science projects for professionals, and can usually simplify the processing, dissemination, and presentation of the contents produced incitizen science projects for them [11]. These technologies can also facilitate the interactions
and communications among professionals and people, allow geographically dispersed
people to participate in citizen science projects, ease data gathering and content generation tasks for citizens, and help volunteers to enhance the quality of their contributions[11–14].
Recently, the field of citizen science has aroused increasing interest in various areasof health and biomedical sciences such as epidemiological monitoring, health behavior
surveillance, environmental health study, molecular biology, and genomics (for more information, see [15–21]). However, to date, relatively less contribution has been made tothis area compared to well-established areas of citizen science such as ecology, conservation, earth sciences, and astronomy [22]. The application of citizen science in the different
phases of disaster management has also gradually been growing over the past few years.
Citizen science has been deployed for addressing various types of disasters, such as earthquakes, floods, hurricanes, biological disasters, and nuclear disasters in previous projects[23] (for more information, see [24–28]). The experiences gained from using citizen sciencein past disasters such as the 2010 Haiti earthquake [29], West African Ebola virus epidemic[30,31], and Fukushima Daiichi nuclear disaster [32,33] have shown that generally, citizen
science can provide great opportunities for enhancing disaster management capabilities
and for reinforcing disaster resilience [34].
Given the various benefits, citizen science can generally provide a complement toauthoritative scientific practices for responding to the COVID-19 pandemic and its detrimental consequences. Since the COVID-19 outbreak began, the use of online citizen science [35] for coping with COVID-19 and its adverse effects has been adopted for a rangeof purposes. For instance, online citizen science has been used for identification and mapping of suspected COVID-19 cases [36], tracing close contact with positive cases of
COVID-19 [37], collecting respiratory sounds to aid diagnosis of COVID-19 [38], and studying risk factors for COVID-19 infection in a large, geographically heterogeneous cohort[39]. Furthermore, it has also been deployed in other COVID-19-related areas, such as designing proteins that can be able to bind to and neutralize COVID-19 [40], analyzing theexisting medicines and anti-viral food molecules to identify previously unknown COVID19 anti-viral properties [41], monitoring emotional responses to the COVID-19 pandemic

Int. J. Environ. Res. Public Health 2021, 18, 9666

3 of 35[42], and studying the long-term physical, mental, and socioeconomic impacts of the
COVID-19 pandemic [43].
It is said [44] that ten years of innovation have been done within a year of the pandemic across the globe, and the same is true for Iran. While COVID-19 has brought significant pressure to the whole society, various social and technological innovations haveemerged in Iran. For example, several citizen science projects have been designed andoperationalized for responding to COVID-19 in Iran immediately after the infection hit
the country—something that was not experienced before in the ecosystem of Iranian citizen science projects. Since Iran was one of the first countries affected by the pandemic,
most of the Iranian COVID-19-related citizen science projects are among the first examplesof their kind in the world. However, they have not been (well-)documented in the related
literature so far, similar to the former Iranian citizen science projects. Differences in culture, language, educational system, political system, deployed instruments, adopted protocols and procedures, funding structures, etc., across the world might influence how citizen science is understood, valued, implemented, and grown [45]. Therefore, every single
citizen science project usually has its own characteristics which make it unique. In thissense, the documentation of citizen science projects across the globe is imperative to understand different attitudes towards citizen science, to reflect barriers to implementationand development of projects, to capture different adopted solutions and to record experiences, knowledge, insights, and understanding to be used in future contributions. Detailed capturing and investigation of the cumulated experiences and lessons learned fromfailures and successes of the performed citizen science projects are essential to improve
future stages of current citizen science projects and successful implementation and improvement of future citizen science projects.
The main goals of this research are (1) to highlight the most significant online citizen
science projects that were carried out for responding to the COVID-19 crisis in Iran, (2) tohighlight some of the opportunities and challenges associated with the strengths andweaknesses of these projects, (3) to provide solutions to overcome these weaknesses, (4)to provide lessons learned and insights from Iranian COVID-19-related projects for deploying in the current and future related citizen science projects and directing future researches in this area. This research makes interdisciplinary connections between citizen
science and other domains such as emergency management, public health, GIScience, informatics, and information technology (IT) to achieve the aforementioned goals. The remainder of this paper is organized as follows: Section 2 provides a brief overview of someof the main characteristics and typologies of citizen science projects. Section 3 aims to shedlight on the state of citizen science in Iran that has been overlooked in the related literatureand provides a brief overview of the situation of the Iranian citizen science ecosystem
where COVID-19-related citizen science projects have been grown. Section 4 presents a
brief overview of the timeline and condition of COVID-19 in Iran. Section 5 reviews thestate of volunteering for coping with the COVID-19 crisis in Iran. Section 6 introduces fivesignificant COVID-19-related online citizen science projects launched by 31 December
2020 in Iran in detail. Based on these backgrounds, Section 7 presents some causes of success and failure of COVID-19-related online citizen science projects, discusses some salient
insights obtained from these projects, and offers some directions for improving current
and future citizen science projects—particularly those for coping with COVID-19 or tackling future pandemics. Finally, the last section is reserved for the conclusion and somerecommendations for future work.
2. Characteristics and Typologies of Citizen Science Projects
Citizen science projects can be classified in many ways considering their various
characteristics. For example, they can be categorized into two major classes based on theirmain outcomes: a scientific/research outcome or a science-informed management/policy/response outcome [46,47]. Citizen science projects can also be categorized based on

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their leadership approach. A citizen science project can have top-down or bottom-up leadership. The citizen science projects that are majorly led by scientists/researchers working
in an academic or a research institution (i.e., scientist-/researcher-led citizen science project), managers/practitioners of the public sector (hereinafter referred to as public sectorled citizen science project), and staff at a civil-society organization (i.e., civil-society-led
citizen science project) use a top-down leadership approach. Citizen science projects thatare led by an individual (i.e., individual-led citizen science project) or a community (i.e.,
community-led citizen science project) use bottom-up leadership [46,47]. Categorizationof citizen science activities based on the expected engagement length for the fulfillment of
the task(s) in citizen science projects is also feasible. Depending on the nature of the tasks,
some tasks in some citizen science projects can be fulfilled by the one-time contributionsof citizens. However, to fulfill some other types of citizen science tasks, citizens are expected to engage more than once in the project. For these types of tasks, the expected engagement length can range from a short-term engagement (a few days or weeks) to longterm engagement (every day and/or over a long period of time) [46,48,49]. The stage(s) of
volunteers’ involvement can also be used as a means of classification for citizen science
activities. Volunteers can be involved in a single stage (including problem definition,
study design, research tools/methods design, data gathering and basic processing/interpretation, data analysis and interpretation, or presentation and dissemination of results)
or multiple stages of a scientific practice [46,48]. Shirk, et al. [50] divided citizen science
projects depending on the degree of participation. In Shirk et al.’s developed typology [50]
(hereinafter referred to as Shirk et al. typology), the citizen science projects were classified
into five main categories: (1) “contractual” projects, where communities request professional researchers to perform a specific scientific investigation and report on the results;(2) “contributory” projects, which are generally designed by professionals (e.g., scientists
and researchers) and for which citizens primarily contribute data; (3) “collaborative” projects, which are generally designed by professionals and for which citizens contribute data
but also help to refine project design, analyze data, and/or disseminate findings; (4) “cocreated” projects, which are designed by professionals and citizens working together andfor which at least some of the public participants are actively engaged in most or all aspects of the research process; and (5) “collegial” contributions, where non-credentialed
individuals perform research independently with varying degrees of expected recognition by professionals. Haklay [51] proposed a typology (hereinafter referred to as Haklay
typology) for the classification of the levels of participation in citizen science projects. In
this typology, four levels of participation in citizen science were identified: (1)“crowdsourcing”, where the citizen acts as a sensor or participates in volunteered computing, (2) “distributed intelligence”, where the citizen performs as a basic interpreter, (3)“participatory science”, where the citizen contributes to problem definition and data collection, and (4) “extreme citizen science”, which includes collaboration between the citizen and scientists in problem definition, data collection, and data analysis.
3. Citizen Science in IranThe state of citizen science in Iran has not been investigated to date. In Iran, similar
to many other countries [52,53], citizen science in its modern form has grown in the last
decade but it is still a relatively novel and unknown concept. So far, the “Academy of
Persian Language and Literature”, the official regulatory body of the Persian language in
Iran, has not introduced a Persian equivalent for the term “citizen science”. However,there are several unofficial parallel translations of the term “citizen science” in Persian.
Among these translations, two Persian terms of “Elm Shahrvandi” and “Daneshvari
Shahrvandi” are used more frequently than others. The term “Elm Shahrvandi” literallymeans “the science of citizen” but may also mean “the science of citizenship” in Persian.
This depends on the context in which it occurs (thus, this could sometimes be misleading
if one has no background in this subject). The other more popular proposed translation,“Daneshvari Shahrvandi” literally implies “conducting the scientific action by citizen”.

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Overall, the term of citizen science (i.e., the different proposed translations for citizen science in Persian) is not a familiar and widely-used term in laity and academia in Iran.
Moreover, currently, no organization exists in Iran to serve as a central reference point forvarious stakeholders of citizen science, nor to bring various stakeholders of citizen science
together and create a network, to coordinate and support the citizen science landscape,and to encourage and accelerate the growth of the citizen science movement in the country. Furthermore, it is noteworthy that citizen science is not currently consolidated in national research programs in Iran.
Almost all of the relatively few existing active or completed Iranian citizen science
projects have been introduced with explicitly related terminologies to citizen science (suchas crowdsourcing project, participatory monitoring project, community-based monitoring
project, community-based conservation project, amateur observation project, and self-reporting project) or even without referring to an explicitly related term rather than a citizen
science project. Consequently, many of the participants who are involved in the Iranian
citizen science projects may not even be aware that they are participating in citizen science
projects. Furthermore, while the characteristics of a citizen science activity [8,47,54] can berecognized in all of these projects, the lack of a common understanding about the notionof citizen science (and its various levels and types) among the professionals has led to theunderestimation and neglect of some existing Iranian citizen science projects when it
comes to listing them in Iran. To the best of our knowledge, most Iranian citizen science
projects were founded (or co-founded) by non-governmental organizations (NGOs) andgrassroots groups, mainly unknown among the general public and their potential stakeholder groups at large. As a result, these projects have substantially remained unnoticed
and undocumented in the existing literature on citizen science.
Some of the existing Iranian citizen science projects (active or completed) focus on
biodiversity mapping, monitoring, and conservation (e.g., see “Iran Bird Watching”(http://www.iranbirdwatching.ir (accessed on 31 August 2021)), “IRAN-VultureConservation” (https://www.vultures.ir (accessed on 31 August 2021)), “TehranBirds”(http://tehranbirds.com (accessed on 31 August 2021)), “PersianLeopard” (http://persianleopard.com (accessed on 31 August 2021)), “PLAN4theLAND’s Project on Monitoring ofBreeding Birds in Hara Protected Area” [55], “Qeshm Island’s Community-based Hawksbill Turtle Conservation Project” [56], and “Common Swift Voluntary Conservation Project” (http://www.iranianbirdingclub.com (accessed on 31 August 2021))). Astronomy is abranch of science that has a high potential for attracting the contributions of volunteers inscientific research in Iran as over 10,000 active amateur astronomers (at different skill levels) and a higher number of astronomy and space enthusiasts live in Iran [57,58]. There
are a few good examples of professional-amateur (pro-am) [59] shoulder-to-shoulder collaborations in the country, where teams of skilled amateur astronomers tightly work together with professional astronomers for conducting formal scientific activities and research (e.g., the monthly sighting of the lunar crescent and conducting of the related research for Hijri calendar purposes that has been organized by “Estehlal Headquarters” in
Iran over the past three decades [60,61]). Moreover, there have been some opportunities
for Iranian amateurs and enthusiasts to voluntarily contribute to the astronomy- andspace-themed domestic citizen science projects based upon their level of expertise (e.g.,
see “Search for Impact Craters in Iran” [62], “Meteorite Hunting Project in Lut Desert ofIran”[63], “Dark Sky Map of Iran” (http://www.astromap.ir (accessed on 31 August2021)), “Observation and Recording of Perseids Meteor Shower Project” (http://ramm.ir(accessed on 31 August 2021)), “Transit of Mercury Data Collection Project”[64], and“Crater Timings During Lunar Eclipse Project” [65]). While the aforementioned scientificdomains are the focus of most of the existing Iranian citizen science projects, some examples of domestic citizen science projects can be distinguished in other disciplines, including ecosystem monitoring (“Participatory Project for Monitoring of Nowrozlo Wetland
Ecosystem” [66]), crowdmapping (e.g., “Mashhad Mobile Map” (https://map.mashhad.ir)(accessed on 31 August 2021), “RAYA” (https://map.tehran.ir (accessed on 31 AugustInt. J. Environ. Res. Public Health 2021, 18, 9666

6 of 352021)), and “ZARBIN Tree Mapping Project” [67]) and public health monitoring and promotion (“Blood Pressure Self-reporting Program” [68] of “Iran National Mobilization forControlling of Hypertension”—see the Section 6 for the COVID-19-related instances ofthis category of domestic citizen science projects). It is noteworthy that before the COVID19 outbreak in Iran, with the exception of an Iranian government-run crowdsourcing project of “Blood Pressure Self-reporting Program” (2019) that attracted approx. 500,000 volunteer citizens [69,70], all the searchable Iranian citizen science projects were small-sized
projects (from several to less than 1000 members).
In addition to the domestic citizen science projects, Iranian citizen scientists are also
contributing to global citizen science projects such as “OpenStreetMap (OSM)”, “eBird”,“iNaturalist”, “Galaxy Zoo”, and “International Astronomical Search Collaboration” (e.g.,“All Iran Asteroid Search Campaign”, which has been organized in collaboration with
Iran’s “Nojum Magazine” [71]), and contributing to the projects and campaigns of international organizations such as “International Meteor Organization”. It should be notedthat the OSM community in Iran (https://osmiran.ir (accessed on 31 August 2021)) is very
active and dynamic, and to the best of our knowledge, the OSM is the most popular longrunning citizen science project among Iranian citizen scientists according to the numberof daily active contributors. There are also a relatively large number of studies related to
the OSM project (mostly in the domain of GIScience) from the perspective of volunteered
geographic information (VGI) [72] that were conducted by Iranian universities and research institutes. These studies are very significant among other Iranian research works
related to citizen science according to the volume of contribution.
4. COVID-19 Pandemic in IranThe first human cases of COVID-19 were reported in Wuhan, China in December
2019 [73]. The World Health Organization (WHO) declared the COVID-19 outbreak as a
Public Health Emergency of International Concern (PHEIC) on 30 January 2020 following
the spread of the infection beyond the borders of China [74]. In late January 2020, Iran
adopted its first specific precautionary measures against the spread of the COVID-19.
These measures included checking the body temperature of passengers arriving from
China at the airports [75,76] among others.
On 19 February 2020, the first cases of COVID-19 infection were confirmed and officially announced in Iran [76,77]. On the following day, the Iranian government establishedthe National Task Force for Fighting Coronavirus—a high-level task force with the fullauthority to lead and coordinate the response to COVID-19 in the country [78,79]. By theend of February 2020, the COVID-19 virus spread was reported in over 60 countries andterritories around the world [80]. On 1 March 2020, the total number of confirmed COVID19 cases in Iran reached 978 (including 385 new daily confirmed cases) [81]. On the sameday, following the spike in the number of positive COVID-19 cases in the Republic of Korea, Italy, Iran, and Japan, the WHO highlighted the epidemics in these countries as its
greatest concern [82]. The WHO declared the COVID-19 outbreak as a pandemic on 11
March 2020 due to the rapid spread of the infection across the globe and the substantial
number of cases reported worldwide [74]. Since then, the virus has continued to spread
across the globe, including Iran. By 31 December 2020, a total of 1,225,143 COVID-19 cases
have been confirmed, 55,223 people have died, and 988,838 people have recovered fromthe COVID-19 disease in Iran [83].
5. Civic Participation through Volunteering for Coping with COVID-19 Crisis in Iran
Civic participation [84,85] is a key principle for promoting emergency and crisis management and enhancing resilience [86–88]. Volunteering [86,89] as one of the pillars ofcivic participation can significantly contribute to the spectrum of emergency and crisis
management phases, from mitigation/prevention and preparedness to response and recovery [90–92]. In the ongoing COVID-19 crisis, volunteers around the world have played

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influential roles in responding to the pandemic and mitigating its health, social and economic impacts on citizens and communities, and they have provided invaluable assistance for the formal organizations and governments [93–95].
The role of voluntary and charitable activities in responding to natural disasters andcrises is significant and remarkable in Iran [96]. This is also the case in the current unprecedented state of public health emergency in Iran. Since the beginning of the COVID-19
outbreak, hundreds of thousands of volunteers across the country have stepped up andplayed a role in supporting their communities, the healthcare system, and other related
public sectors. In many cases, the reasons behind volunteering in Iran (such as the participation of volunteers in different phases of emergency and crisis management) are linked
to the moral, ethical, and religious values, beliefs, and motives of altruism, benevolence,compassion, humanitarianism, collectivism, cooperation, and attaining the pleasure of
God (that have been widely instructed, strongly emphasized, and greatly praised in therich Iranian-Islamic culture of the country) [96–99]. In this context, the faithful and devoted contributions of the unaffiliated (spontaneous) [86,100] and affiliated volunteers[86,101] to the health and welfare of the nation (along with the invaluable selfless, tireless,and diligent services of the Iranian healthcare professionals and practitioners from othersectors) have assisted the government in strengthening the battle against COVID-19 at atime when the country’s combat against COVID-19 has been impeded due to tremendous
adverse effects of the tough sanctions against Iran [75,102–104]. Moreover, these dedicatedvoluntary efforts together with invaluable and sympathetic services of the public and private sectors have considerably helped citizens to overcome post-traumatic stresses [105]of COVID-19. They have also raised hope and promoted solidarity in society. Volunteers
have been involved in various activities such as the production of protective equipment(e.g., mask, gown, and coverall); disinfection of public surfaces; providing assistive/professional services at medical centers; providing social work, chaplaincy, and spiritual careservices; meal preparation and distribution; hygiene kits and items distribution; shopping; running other errands and driving for elderly and vulnerable people; serving at
checkpoints; performing burial rituals; creating cultural products and artworks, donationsof blood (and plasma), money, goods, and facilities; and waiving rental fees. Science, technology, and education are other areas where Iranian volunteers have made contributions
since the beginning of the outbreak in the country (e.g., answering online surveys related
to COVID-19 designed by researchers, participating in Iranian COVID-19 vaccines anddrug clinical trials, designing open-source ventilators, disinfection devices, and low-costmask- and glove-making machines, and educating the community on how to prevent
COVID-19). In the following sections, some of the significant examples of online citizen
science activities in Iran in response to COVID-19 as a form of volunteering in science will
be introduced and discussed in detail.
6. Iranian Online Citizen Science Projects for Responding to COVID-19
Since the beginning of the COVID-19 outbreak, Iranians have contributed to various
COVID-19-related domestic and global citizen science projects. By 31 December 2020, fivesignificant domestic online projects with citizen science characteristics [8,47,54], including
the “Ministry of Health and Medical Education” (MOHME) of Iran’s project for COVID19 self-assessment and self-reporting (hereinafter referred to as CSASR project), AC19
project, Mask project, Gharbalgar COVID-19 project, and the project of “China-Iran Cooperation Group against COVID-19 Disease” (hereinafter referred to as CHIACD project)
can be identified. The main thematic areas of these projects can be listed as (1) self-assessment and self-reporting of COVID-19 related symptoms (CSASR and AC19 projects), (2)digital contact tracing (Mask project), (3) COVID-19 cough audio sample collection (Gharbalgar COVID-19 project), and (4) translation of COVID-19 educational, scientific, andtechnical materials for responding to COVID-19 (CHIACD project). Three of these identified projects (CSASR, AC19, Gharbalgar COVID-19) can be categorized as contributory(crowdsourcing) citizen science projects, and the rest (Mask and CHIACD) are collegial

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8 of 35(extreme) citizen science projects (for more information, see Sections 6.1–6.4). As these five
Iranian COVID-19-related online citizen science projects have remained unnoticed andundocumented in the existing literature in this area, their specifications and characteristics
will be presented, classified, and discussed in Sections 6.1–6.4.
6.1. COVID-19 Self-Assessment and Self-Reporting System and Application (App)The CSASR project—an online project for COVID-19 self-assessment and self-reporting—was launched by MOHME of Iran [106] (https://self.salamat.gov.ir) on 4 March 2020
under the schemes of the “Iran National Mobilization Against COVID-19” program [107].
Iranian citizens can participate in this nationwide surveillance project on a voluntary basis. To use this online web tool that is linked to the electronic health records (EHRs) of
Iranians, a volunteer participant is required to provide his/her national identity number,date of birth (for validation of the identity), place of residence (province and county), andmobile phone number. By answering a few questions about the symptoms and risk factors, this tool helps the participant to voluntarily assess and report his/her symptoms. This
tool, then, determines whether the participant should visit a healthcare center for further
assessment and testing. The identified suspected cases of COVID-19 through this web tool
are provided with advice about personal and familial protection and referred to the nearest selected health center. The participants are enabled to update and re-submit theirhealth condition and symptom information anytime in this system. The identified suspected cases of COVID-19 through this system are contacted by healthcare workers so thatfurther investigations can be conducted, and contact tracing can be undertaken [106] under the “Iran National Mobilization Against COVID-19” program [107]. The
crowdsourced data through this symptom tracking [106] system provided the publichealth officials with a clearer picture of the spatio-temporal spread of COVID-19 acrossthe country and allowed them to implement a data-driven response in the early stages ofthe outbreak. This participatory system enables authorities to perform early screening of
citizens and triage suspected cases. Moreover, by reducing unnecessary visits to medical
centers, this web tool has decreased the risk of citizens’ exposure to the disease, prevented
more spread of infection, and reduced the burden on the healthcare system. Based on thelatest publicly available information, by 3 April 2020, over 12 million people self-reported
their symptoms and health condition via this system [108]. The number of participants in
CSASR project is the highest number ever reported (by 31 December 2020) in an Iranian
citizen science project (for more information, see Section 3 and Table 1). The general specifications of the CSASR project (including the project’s scientific area, the number of contributors, the least expected engagement length needed for the fulfillment of the project’stask, the adopted technology for data collection, and the launch date) were summarized
and presented in Table 1.
Table 1. The general specifications of five identified Iranian COVID-19-related online citizen science projects.

Project Name

Scientific Area

CSASR

Epidemiological
Monitoring

AC19

Epidemiological
Monitoring

Number of Contributors/Registered Users

Least Expected Engagement
Length for Task(s) Fulfillment

One-time (if there is no>12 million (by 3change in the contributor’sApril 2020)
health condition after the firstcontribution)
One-time (if there is no≈4 million (by 15change in the contributor’sMarch 2020)
health condition after the firstcontribution)

Technology for
Data Collection/Data Exchange

LaunchDate

Dedicated Web
App

4 March2020

Dedicated Web
App/DedicatedMobile App

3 March2020

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Mask

Epidemiological
Monitoring>1 million (by 21
April 2020)

Long-term

Gharbalgar
COVID-19

Artificial Intelligence≈500 (by 28 April
2020)

One-time

CHIACD

Community Health

One-time/Short-term≈300 (in early May(depending on the type of the
2020)
task)

Dedicated Web
App/DedicatedMobile App
Dedicated Web
App/DedicatedMobile App
Social Media

2 March2020
10 April
2020
24 February 2020

Some of the main characteristics of the CSASR project (including the outcome of the
project, the project’s leadership approach, the stage of volunteers’ involvement in the project, the type of project based on Shirk et al. typology, and the type of project based on
Haklay typology) were categorized based on the presented typologies in Section 2 andwere presented in Table 2.
Table 2. Some of the main characteristics of five identified Iranian COVID-19-related online citizen science projects.

Type of ProType of Project
Outcome of Citizen Leadership Ap- Stage(s) of Volunteers’ Involveject(Haklay TypolScience Project
proachment(Shirk et al.
ogy)
Typology)
Science-informed
Top-down: pub- Single-stage: data gathering and
CSASR
management/polContributory Crowdsourcing
lic sector-led
basic processing/interpretationicy/response
Science-informed
Top-down: pub- Single-stage: data gathering andAC19management/polContributory Crowdsourcing
lic sector-led
basic processing/interpretationicy/response
Multiple stages: problem definition, study design, research
Science-informed
Bottom-up: com- tools/methods design, data gatherMask
management/polCollegial
Extrememunity-led
ing and basic processing/interpreicy/response
tation, data analysis, and interpretation
Top-down: scienGharbalgar
Single-stage: data gathering andScientific/research tist-/researcherContributory Crowdsourcing
COVID-19
basic processing/interpretation
led
Multiple stages: problem definiScience-informed
tion, study design, data gathering
Bottom-up: comCHIACD
management/poland basic processing/interpretaCollegial
Extrememunity-led
icy/response
tion, presentation, and dissemination of results
Project
Name

In addition to the aforementioned main official system designed for self-assessment,
self-reporting, and monitoring of COVID-19 in Iran, the “COVID-19 Disease Operation
Management Headquarters in Tehran Metropolis” in collaboration with the “Ministry ofInformation and Communications Technology (MICT) of Iran” set up another government-led mobile (for Android platforms) and web app named “AC19” (https://ac19.ir) on
3 March 2020 for COVID-19 self-assessment. To register in this app, the volunteers need amobile phone number. The app asks users for their personal and biometric information(name/username, city of residence, gender, age, weight, and height). Next, users answer
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and exposure history to evaluate whether they should visit a healthcare provider or physician for further COVID-19 related assessment. The app also gives some recommendations on what to do next. The users can repeat this online self-assessment test anytime andupdate their information in this app. The app also offers other services for users, such asproviding the latest COVID-19 news, updates and advice from reliable sources, governmental agencies, and medical centers’ information. Contrary to the current version of the
app that only records the user’s city of residence, the app had collected the precise locationof the user via GPS in addition to the information about the user’s city of residence (thatwas directly provided by the user) in the early releases of this app—the functionality that
had enabled the initiative to obtain VGI about the distribution of suspected COVID-19
cases at a fine spatial scale beside the coarse spatial scale. Iran’s minister of MICT revealed
a fine-scale COVID-19 aggregate risk map for the Greater Tehran area [109] and a coarsescale COVID-19 aggregate risk map for Iran [110] to the public using the crowdsourced
information through the AC19 app on 9 March 2020 and 11 March 2020, respectively. The
acquired crowdsourced information from this app was used by the officials, majorly inthe first stages of the pandemic in Iran. In this term, the gathered information by this app
served as a complementary data source for conducting a rough estimate of COVID-19
distribution and size of the outbreak in Tehran and across the country. It also helped raise
the awareness of the public about the spread of the infection, which convinced citizens tostay at home. According to the latest publicly available information, by 15 March 2020,
approx. 4 million volunteers contributed to this system [111]. The general specificationsof the AC19 project (including the project’s scientific area, the number of contributors, theleast expected engagement length needed for the fulfillment of the project’s task, theadopted technology for data collection, and the launch date) were summarized and presented in Table 1. Moreover, some of the main characteristics of the AC19 project (including the outcome of the project, the project’s leadership approach, the stage of volunteers’
involvement in the project, the type of project based on Shirk et al. typology, and the typeof project based on Haklay typology) were categorized based on the presented typologies
in Section 2 and were presented in Table 2.
6.2. COVID-19 Digital Contact Tracing App
The “Mask” app (https://mask.ir (accessed on 31 August 2021)) was initially designed
for digital contact tracing (also known as proximity tracing or app-based contact tracing)[106,112] based on a centralized architecture [113]. This app was voluntarily developedby a group of professors, students, and graduates in the fields of Computer Engineeringand Mathematical Sciences from Iranian universities (including “Sharif University ofTechnology”, “Shahid Beheshti University”, and “Amirkabir University of Technology”)
in collaboration with a group of medical specialists in response to the outbreak of COVID19 in their country. This non-profit project was launched on 2 March 2020 and was later
endorsed and supported by MOHME of Iran [114]. Citizens’ participation in this contact
tracing project was on a voluntary basis through the released mobile (for Android platforms) or web versions of the app. Once the app was downloaded or delivered over theinternet through a browser interface, the users were required to register in the systemusing an Iranian mobile phone number and provide some information on their healthcondition to benefit from all the functionalities of the app. The project could log memoryof all close proximity contacts of the app users using Bluetooth, GPS, manual pinning of
the contact location, or scanning of barcode and QR code. The users could also record theclose physical contact information of their family members using this app. The app allowed users to be informed if in the past 14 days they were closely exposed to any otherapp users who had been definitely diagnosed with COVID-19 by MOHME’s medical centers without revealing the identity of the infected person. Furthermore, a COVID-19
symptom checker tool for self-reporting of the daily health condition of the app users was
integrated in the app. This self-evaluation function told the app users what to do next andif they needed to get medical care by asking a few questions on their health condition andInt. J. Environ. Res. Public Health 2021, 18, 9666

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symptoms and by deploying the records of the users. Besides the aforementioned major
services of this app that were only available for the registered users, the app provided aninteractive grid heat map of the confirmed and suspicious COVID-19 cases across Iran(produced based on the obtained data from Iran’s MOHME) and daily statistics, news,and educational and awareness materials about the COVID-19 disease that were open to
the public [115–117]. Based on the latest publicly available information, on 21 April 2020,
the total number of active installed instances of this contact tracing app (downloaded fromdifferent Android marketplaces or the project’s website) exceeded 1 million installations(for more information, see Section 7.3.1.1) [118]. Due to the relatively low uptake of thisapp (which has also has been a challenging issue for many similar projects worldwide—
for more information, see Section 7.3.1), the Mask project stopped its digital contact tracing service in early November 2020. The general specifications of the Mask project (including the project’s scientific area, the number of registered users, the least expected engagement length needed for the fulfillment of the project’s task, the adopted technology
for data collection, and the launch date) were summarized and presented in Table 1. Furthermore, some of the main characteristics of the Mask project (including the outcome ofthe project, the project’s leadership approach, the stages of volunteers’ involvement in the
project, the type of project based on Shirk et al. typology, and the type of project based on
Haklay typology) were categorized based on the presented typologies in Section 2 andwere presented in Table 2.
6.3. COVID-19 Cough Audio Sample Collection
The “Machine Intelligence and Robotics Department, University of Tehran”, Iranlaunched a crowdsourcing program named “Gharbalgar COVID-19” [119] on 10 April
2020 for collecting cough sounds as well as the basic demographics and medical historyof the participants. The crowdsourced data through this app is used by the researchers of
this department for the training of machine learning-based predictive models that are developed for the early screening and diagnosis of suspicious and positive COVID-19 cases.
Both healthy and unhealthy participants were welcomed in this project. To collect the datafrom the volunteers in this program, a mobile app was released for Android devices(available in Persian and Arabic languages) and a web app was developed (available in
the Persian language) for the devices using other operating systems. The data was gathered from app users by utilizing a basic questionnaire and recording a few seconds ofcoughing through the microphone of the device [119,120]. By 28 April 2020, almost 500
volunteers contributed to the Gharbalgar COVID-19 project. The general specifications of
the Gharbalgar COVID-19 project (including the project’s scientific area, the number ofcontributors, the least expected engagement length needed for the fulfillment of the project’s task, the adopted technology for data collection, and the launch date) were summarized and presented in Table 1. Moreover, some of the main characteristics of the Gharbalgar COVID-19 project (including the outcome of the project, the project’s leadershipapproach, the stage of volunteers’ involvement in the project, the type of project based on
Shirk et al. typology, and the type of project based on Haklay typology) were categorizedbased on the presented typologies in Section 2 and were presented in Table 2.
6.4. Translation of COVID-19 Educational, Scientific, and Technical Materials
Initiated by a Chinese language instructor, the CHIACD project [121] was establishedon 24 February 2020. The project was established at the early stages of the pandemic when
the appropriate and reliable resources about prevention and protection methods against
COVID-19 in languages other than Chinese were limited. Thus, this project aims to raiseawareness and educate the Iranians about the COVID-19 disease by voluntary gathering,
synthesizing, and translating the Chinese educational and scientific materials about
COVID-19, presenting the produced outputs in appropriate formats, and disseminatingthem in society. Moreover, it aims to transfer China’s experiences in fighting COVID-19

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to the Iranian health workers through voluntary translation and dissemination of the Chinese educational, scientific, and technical materials about COVID-19 [122]. The first core
members of this voluntary group were the Chinese and Persian language students andscholars from Iran and China. Later, new volunteers with different backgrounds (e.g.,
medical sciences and engineering), nationalities (Afghan volunteers), and Chinese andPersian language familiarity levels have joined this team over time. To put various capabilities and the expertise of the volunteers to better use, and to facilitate the collaborationand drive the group’s objectives, the volunteers’ activities have been structured under thefollowing working groups: (1) information collection, (2) general translation, (3) medicaltranslation, (4) external relations with the health workers and centers, (5) graphic design,(6) video production, (7) proofreading and quality assurance, and (8) digital products dissemination. The group mainly uses WeChat, a messaging and social media app to organize the group’s activities, hold meetings, facilitate the communication between members
and working groups, assign tasks, and exchange raw and produced digital materials. The
group is obtaining COVID-19 related information only from authoritative and reliable
Chinese sources. Public translation services that can be performed by a translator’s general knowledge are mostly conducted by volunteer translators from fields other than medical sciences in this project. To enhance the quality of the medical specialized translation
tasks, these translations are only performed by or under the direct supervision of the volunteer translators with a medical science background. Furthermore, before the dissemination of the group’s translated products to the audience of the project, all the products
are reviewed carefully by a team volunteers to ensure the appropriate quality of the final
products. The generated contents of the group are shared on official pages and groups ofthe project on social media and messaging platforms (Instagram, Aparat, Telegram, andTwitter) for the general public audience of the group. In addition to the group’s commitment to raising the awareness of the citizens about the COVID-19 disease, the group has
been able to play a role in creating a direct bridge between Iranian and Chinese healthworkers and medical centers for exchanging their latest scientific information and experiences alongside the existing formal intergovernmental collaborations. In this term, thegroup is voluntarily collaborating with an Iranian social network for medical science professionals named “TritApp” (https://tritapp.net (accessed on 31 August 2021)) for establishing the communications and translation of the exchanged Persian and Chinese questions and answers between Iranian and Chinese health workers and medical centers in
the two countries [123]. In early May 2020, the total number of volunteer members in the
CHIACD project was around 300. The general specifications of the CHIACD project (including the project’s scientific area, the number of contributors, the least expected engagement length needed for the fulfillment of the project’s tasks, the adopted technology fordata collection/data exchange, and the launch date) were summarized and presented inTable 1. Furthermore, some of the main characteristics of the CHIACD project (including
the outcome of the project, the project’s leadership approach, the stages of volunteers’
involvement in the project, the type of project based on Shirk et al. typology, and the typeof project based on Haklay typology) were categorized based on the presented typologies
in Section 2 and were presented in Table 2.
7. Insights from the Past for the Current and Future COVID-19-Related Citizen Science Projects
In the following sections, some insights from five selected Iranian COVID-19-related
citizen science projects as well as other related studies in this area will be presented anddiscussed to be used in citizen science projects in the future, particularly those in the domain of biological disasters such as COVID-19.

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7.1. Initial Steps Needed for Capacity Building for Citizen Science in Public Sector and Academic
and Research Institutions of IranTo build the capacity for citizen science projects, five critical steps can be recognized:(1) identifying and engaging all actors in the citizen science projects, and enhancing thevisibility of citizen science activities, (2) assessing the capabilities and needs of stakeholders, (3) developing citizen science projects’ visions, missions, and action framework, (4)developing resources (e.g., developing technical infrastructure, guidelines, and educational material and provision of financial and human resources), and (5) evaluating theimplementation to foster further development [124]. Citizen science capacity building is
an iterative and adaptive mechanism that requires the active engagement of all stakeholders from society, science, and policy [124].
In Iran, the government has a significant influence on social, economic, and technological changes. As discussed earlier, citizen science is a relatively new concept in Iran.
Currently, citizen science is not integrated into the organizational culture of governmentalorganizations in Iran. Thus, most of the influential people in governmental organizations
who can benefit from citizen science might be unfamiliar and lack the necessary
knowledge regarding how this approach can be leveraged to address various challenges
encountered by their organization. Furthermore, similar to many other countries, there is
still considerable skepticism among the Iranian policy-makers, decision-makers, and practitioners on the quality and trustworthiness [125] of the user-generated content (UGC)[126] produced in the citizen science projects; consequently, even many of those who arefamiliar with the concept usually have hesitations using such data in formal applications.
Raising the profile of citizen science within an organization usually rests on the leadershipof senior staff. Hence, before citizens are expected to embrace the citizen science projects,
one of the vital tasks for building the capacity for government-driven citizen science projects in Iran is to raise the knowledge and come to a common understanding among the
key personnel in the governmental organizations (particularly those whose involvement
in and support from the ecosystem of citizen science projects is essential) about this concept, its pros and cons, and its potential applications for attaining the missions of theirorganizations and distributed problem-solving. Furthermore, it is necessary to change theconventional mindset of the official stakeholders of citizen science about the quality of
citizen scientists’ generated content—an attitude that always underestimates the citizen
science data quality. The previous studies showed that the quality of generated data incitizen science projects can approach and even may exceed that of authoritative sources[127,128]. Therefore, to deal with the existing concerns among officials, it is crucial to highlight some successful examples of citizen science projects across the globe whose outputs
have been employed for solving real-world problems, and it is necessary to raise theirknowledge about the existing adopted approaches for assuring and enhancing the qualityof the contributions in citizen science programs. As it was mentioned before, there is currently no governmental or non-governmental organization in charge of supporting, developing, and coordinating citizen science activities in Iran. As one of the first steps, it istherefore crucial to establish a governmental entity for promoting and coordinating theutilization of citizen science across the Iranian government and society. This entity has totrain human resources, provide consultation services, finance citizen science activities,
provide technical and legal support, regulate and standardize citizen science activities,
connect various stakeholders, and develop best practices for designing, implementing,and assessing citizen science programs in order to surmount the existing obstacles, limitations, and delays and to build the capacity for citizen science.
Citizen science can permit academic and research institutions to access to previously
inaccessible areas by enriching and enlarging their research scope, can consolidate theposition and recognition of academic and research institutions in society, can provide new
resources and opportunities to them, and can enhance public trust in them [129]. Academic and research institutions can contribute to citizen science by providing their professional infrastructure and facilities, educational and research capabilities, ethical andInt. J. Environ. Res. Public Health 2021, 18, 9666

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legal background, and funding [129]. While in many countries, citizen science was established and mainly has been developed by academic and research bodies [130], the role of
Iranian academic and research institutions in running citizen science projects has not beenprominent yet. To the best of our knowledge, the most notable Iranian citizen science projects were initiated from outside of academia and research bodies. The main outcomes ofnotable Iranian citizen science projects (for more information, see Section 3) are mostly
science-informed management, policy, or response. Citizen science projects with scientific/research outcomes in the list of notable Iranian citizen science projects are in the minority. The concept of citizen science is less well-known in most Iranian academic andresearch institutions. Furthermore, citizen science has not been included in the academic
and research culture of Iranian academic and research institutions yet. Currently, there isno institutional structure or venue dedicated to leading, coordinating, promoting, supporting, and funding citizen science (or Open Science [131] as a related concept) withinthe “Ministry of Science Research and Technology” (MSRT) of Iran, MOHME of Iran, or
Iranian academic and research institutions. Nowadays, many scientists and researchers
across the world have been approached to design more inclusive citizen science practices
to involve diverse groups of citizens in various aspects of the scientific and research process. However, in the landscape of Iranian scientist-/researcher-led citizen science projects, to date, the designed participation level for the involvement of citizens in the implemented citizen science projects has not gone beyond the crowdsourcing level, mostly due
to a lack of knowledge and understanding about the concept and various aspects of citizen
science. These are also the case in the context of Iranian COVID-19-related citizen science
projects. Among the five identified Iranian COVID-19-related online citizen science projects, only one project (Gharbalgar COVID-19) was initiated by scientists/researchers. Similar to other Iranian scientist-/researcher-led citizen science projects, the level of citizens’
participation in this project was limited to the crowdsourcing level (Table 2).
The aforementioned recommendations for building the capacity for citizen science
within the Iranian government are also generally valid for citizen science capacity building in Iranian academic and research institutions. Establishment of the institutional structures and entities in charge of leading, developing strategies and operating framework,
coordinating, promoting, providing technical and legal supports, and funding citizen science within Iran’s academic and research system at different levels should be considered
as a high priority task. Organizing scientific training programs and events for raisingawareness, reaching a common understanding, and fostering knowledge and skills of Iranian scientists and researchers about various theoretical and practical aspects of citizen
science is pivotal in shaping the citizen science movement in academic and research institutions. Consequently, it should also be given higher priority. Furthermore, as anotherinitial step for building the capacity for citizen science and accelerating citizen science
movement within Iranian academic and research institutions, it is crucial to develop freecustomizable platforms by (for) Iranian academic and research bodies. This will ease conducting a variety of citizen science projects by scientists and researchers.
7.2. Enhancing the Effectiveness of Citizen Science Projects for Emergency Response through
Early Preparedness and Coordination
Contrary to many other thematic categories of citizen science, citizen science projects
relevant to emergency response must become operational in a short time since deferring
the issue can cause loss of life and other costs to societies and nations. Hence, to foster theeffectiveness of citizen science projects for emergency response, it is crucial to build thecapacity for these projects, mainly during the disaster preparedness phase. Although, in
general, citizen science-based solutions have still not been embedded in the normal working routines of Iranian organizations (including the MOHME of Iran) and the organizations do not have clear and long-term visions and comprehensive plans and strategies inthis area, the MOHME of Iran unveiled its COVID-19 self-assessment and self-reportingInt. J. Environ. Res. Public Health 2021, 18, 9666

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system and integrated it into its official screening and follow-up system and EHR database within a relatively short time after confirming the first cases of COVID-19 in the
country. This unprecedented rapid digital response was mainly powered by the accumulated data, knowledge, and skills, and created an organizational structure and established
IT infrastructure in MOHME of Iran during its prior crowdsourcing project, the Blood
Pressure Self-reporting Program in 2019, which was Iran’s first large-scale experience in
employing citizen science in healthcare. The previous studies [106,132,133] also showedthat the pre-established organizational structures, organizational memory, pre-defined
objectives, protocols, procedures and strategies, and pre-existing generic and scalable citizen science infrastructures can significantly reduce the time and cost of implementationand can enhance the organizational adaptability and applicability of citizen science programs for responding to disasters and emergencies.
The COVID-19 pandemic is the first biological disaster experience at this scale in Iran.
Therefore, similar to many other countries, many loopholes and shortcomings (e.g., see[134]) emerged in the activities of the public health emergency response system in theinitial phase of the epidemic in the country. In the early days of the COVID-19 outbreakin Iran, there have been simultaneous efforts (the public sector-led projects of CSASR andAC19 and the community-led project of Mask) for crowdsourcing various health information for means of epidemiological monitoring (Tables 1 and 2). There is considerable
overlap between the goals and missions of two government-led projects (CSASR andAC19)—therefore, the contents of the gathered data in these two projects were almost thesame. Furthermore, there are some areas that both Mask project and the two aforementioned government-led projects are commonly collecting data about (for more information, see Sections 6.1 and 6.2). While each of these three citizen science projects may
perform well within its own functional areas, the overlaps or some similarities among thegoals and missions of these projects have at best caused the fragmentation of
crowdsourced health information and have at worst also caused the occurrence of duplications or redundancies in the gathered information, which is a waste of time, energy, andresources for the stakeholders and the volunteers. To reduce/eliminate the redundant data
production efforts in the government-led citizen science programs, governments have todefine/revise their data gathering policies, strategies, and procedures, as well as their collaboration plans in such a way to clarify and assign the roles and responsibilities of eachstakeholder of citizen science projects for responding to the public health crisis in advance.
Moreover, to reduce/eliminate the duplication and fragmentation of the multi-sector
health information (including crowdsourced and authoritative health information) generated in the different phases of the public health crisis and to share the generated contents
between the authorized stakeholders, it is necessary to aggregate and exchange the sparse
datasets in compliance with the data privacy laws, protection standards, and protocols[18,135,136] in a real-time (or near real-time) manner through an integrated information
system [137], data clearinghouse [138], or geoportal [139]. In this context, adopting the
pre-approved protocols and standards [140] provides an effective solution for data interoperability [141] and facilitates the seamless integration of the generated crowdsourced
datasets. It is noteworthy that the provision of these arrangements (which facilitates multisector citizen science data exchanging and data integration) may also increase the role ofaccredited non-government-led citizen science projects (i.e., the projects led by private
research bodies and private academic institutions, civil societies, and communities) ingathering data (such as public health- and emergency-related data), which have beenmostly crowdsourced so far by the governments. The inclusion of accredited non-governmental citizen science initiatives in the focused domain may trigger more social and technological innovations in data crowdsourcing that lead to providing more diversified options for the citizens (to opt into the project that best fits their requirements and preferences). Furthermore, this inclusion may facilitate the connection with people and communities and may foster the sense of trust among citizens as data contributors (by involving

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the non-governmental bodies in the administrative process of data gathering). Consequently, these may increase the number of data contributors in the focused domain.
7.3. Organizational Measures for Enhancing the Recruitment and Retention of Volunteers
Volunteers are one of the main pillars in all citizen science projects. In this sense,
generally, recruiting and retaining a higher numbers of volunteer participants can accelerate the achievements of most citizen science projects and is integral to the success ofmany of them [142]. The recruitment and retention of citizen scientists in citizen science
projects needs some organizational structures and measures. However, in Iran, which hasless history in the modern form of citizen science, most citizen science project organizers
generally have not had any prior training and experience in setting up and managing
these projects. Moreover, as mentioned earlier, there are no scientific or professional institutions for guiding and training Iranian citizen science project organizers and transferring good practices to them. Therefore, even many of conventional organizational
measures that have been widely practiced in modern citizen science projects for improving the initial participation and long-term engagement of citizen scientists have not been(fully-) implemented in most Iranian citizen projects.
The figures on the number of contributors/registered users in the identified Iranian
COVID-19-related citizen science projects (Table 1) indicate that the three identified projects in the area of epidemiological monitoring (CSASR, AC19, and Mask) could attract
vast populations of people to themselves. This level of public attention (in terms of thenumber of contributors/registered users) to Iranian citizen science projects was not experienced before in the ecosystem of Iranian citizen science projects. Engagement in CSASR
and AC19 projects have a mostly one-time nature. However, for the proper fulfillment of
the contact tracing task in the Mask project, a long-term engagement of the participants isnecessary (Table 2). Compared with many other citizen science projects, the issues of recruitment and retaining of volunteers play a more critical and decisive role in the degreeof failure and success of the digital contact tracing projects (for more information, see Section 7.3.1). This feature makes contact tracing projects good choices for studying the impact of various influencing factors on the initial participation and sustained participationof the people in the citizen science projects and creates a common ground for discussing
and synthesizing the insights that can be obtained from previous related researches andpractical experiences inside and outside the field of citizen science.
In this sense, in the following sections, some lessons learned from the Iranian contact
tracing project about recruitment as well as some generic directions obtained from otherrelated citizen science projects will be presented and discussed. These highlighted issues
and directions might be deployed in the future not only for enhancing the recruitment
and retention of volunteers in the citizen science projects for tracing infectious diseases
such as COVID-19 but also in other categories of citizen science projects.
7.3.1. Volunteer Recruitment and Retention in Contact Tracing Projects
Previous studies showed that voluntary digital contact tracing could reduce thespread of the COVID-19 epidemic [143,144]. However, a digital contact tracing project canbe a game-changer only if it can attract and sustain the citizens’ mass engagement[143,145,146]. A study [147] in the UK estimated that the COVID-19 epidemic could becompletely suppressed if at least 80% of all smartphone users (56% of the total population)
adopt the digital contact tracing app. Hence, while there were early hopes that the digitalcontact tracing projects could play a key role in controlling COVID-19 infection in theaffected countries, due to the unfulfillment of the required mass public engagement inthese projects, there is no single country to date that can claim that its digital contact tracing project has significantly contributed to the reduction of COVID-19 transmission [148].
For instance, a report [149] from Iceland, a country that has had the largest uptake of adigital contact tracing app in the world (38% of the country’s population as of May 2020),
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been significant yet. Another example is France’s digital contact tracing app that was initially downloaded by about 1.9 million people (approx. 2.8% of the country’s total population) as of June 2020; however, shortly after, around 0.5 million of those 1.9 million people uninstalled or deactivated the app. Until late June 2020, only 68 users of this app reported that they had been diagnosed with COVID-19; these reports resulted in notifications for only 14 other app users who had contacted these people [150]. The situation in
Iran is also more or less the same. Iran was one of the pioneers in the launching of thedigital contact tracing app (Mask app). The country has a young population—out of theapprox. 83 million people living in Iran in 2019, 24.6% of the country’s population wasunder the age of 15, 22% of the population was 15–29 years old, and only 6.4% of Iran’s
population was 64 years old and above [151]. Furthermore, according to a conservative
estimate [152] in 2019, Iran had a considerable smartphone penetration rate of approx.
55% (for other estimates, see [153,154]). Moreover, the internet penetration rate in Iranstood at 70% by the end of 2018 [155]. However, according to available statistics, as ofearly June 2020 (more than 3 months after the start of the Mask project), the app had only
about 1 million users (≈approx. 1.2 % of the country’s population) in Iran [156]. Even if it
is ideally assumed that all the people who activated the Mask app on their smartphones
actively used the main functionality of the app—contact tracing (which is a very unrealistic assumption), similar to most other existing COVID-19 contact tracing apps, the uptake rate of this app was well below the estimated threshold needed for a digital contact
tracing app to be significantly effective.
Prior to the onset of the pandemic, various studies had been conducted to identify
the antecedent factors for uptake and engagement with apps such as participatory mobile
health (mHealth) apps (for more details, see [157–159]). Within the growing field of citizen
science, some studies also have been conducted to determine what factors influence people’s participation in citizen science projects and why volunteers continue their participation in these projects. These studies intended to shed light on the various dimensions suchas social, behavioral, cognitive, motivational, legal, managerial, technical, and technological dimensions affecting the participation and engagement of people in citizen science
projects. The various influencing factors on the initial participation and sustained participation of people in the citizen science projects generally can be categorized into two broad
categories of dispositional factors (i.e., attributes of individuals) and organizational factors (i.e., attributes of the project and its organizers) [142,160,161].
Most of the recent studies that have raised the problem of COVID-19 contact tracing
apps’ low adoption from the organizational perspective have placed great emphasis on
studying the impact of various technical factors and technology-related legal and ethicalfactors such as users’ privacy, data protection, transparency, service quality, instrument
and interface design on the participation and long-term engagement of people in contact
tracing projects. Generally, the successful addressing of technical issues and technologyrelated legal and ethical issues that were extensively studied and discussed in these studies (which were mostly conducted in western societies and have backgrounds other thancitizen science) may lead to an increase in the adoption and user retention in the COVID19 contact tracing apps. However, there are also some other less-discussed organizational
factors beyond these factors that significantly impact the uptake and long-term deployment of contact tracing apps. To this end, in the following sections, the role of promotion,
advertising, and marketing, as well as recognition, communication, and feedback on the
recruitment and retention of volunteers in the contact tracing project will be discussed in
more detail through forging interdisciplinary connections among citizen science, psychology, sociology, emergency management, and public health.
7.3.1.1. Promotion, Advertising, and Marketing
Despite their considerable benefits, contact tracing apps are characterized by various
technical shortcomings and inconveniences as well as legal and ethical concerns. Thus, if

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one became aware of the existence of a contact tracing project, he/she would usually estimate the perceived costs (including the various shortcomings, inconveniences, and concerns) and benefits (including personal and public benefits) of deploying a contact tracing
app to decide whether to install (or continue to deploy) a contact tracing app. If the benefits of the decision outweigh its costs, the person adopts the app (or maintains its use)
[162–164]. To ensure mass adoption and continued use of a contact tracing app, in addition to the necessity for minimizing the costs of participation in a contact tracing project(through addressing the existing shortcomings, inconveniences, and concerns) and theneed for informing people about the launch of the contact tracing program, citizens must
be made aware of the various benefits of attending a digital contact tracing project[163,165,166], the contents of the tasks and the updates from the project. It was argued
that the lack of awareness of an existing citizen science project (i.e., volunteering opportunity) and lack of information and understanding of volunteering task(s), volunteering
responsibilities, participation requirements, and personal and public benefits of the project are key barriers to recruiting people with diverse backgrounds in a citizen science
project [142,167]. This implies that the promotion, advertising, and marketing for citizen
science projects are effective ways for recruiting volunteers in citizen science projects andstimulating the uptake of citizen science project apps by informing people and raisingpublic awareness and understanding [142,168]. The insufficient promotion and advertising or use of inefficient marketing strategies are among the most significant reasons forthe failure of many Iranian citizen science projects in attracting citizens, and the Mask
project is not an exception to this.
Contrary to most of the existing COVID-19 contact tracing apps in the world thatwere implemented or funded by governments, the well-developed Mask app was produced on a non-governmental, non-profit, and voluntary basis by a group of computerscience and engineering scholars and experts. Consequently, the project organizers had
intrinsically limited resources and authority for mounting mass nationwide advertising
campaigns compared with many other similar projects around the world. The project was
initially introduced by the advertisement contents (e.g., text, image, and video advertisements) shared through the project’s website, official channels on social media and messaging platforms (Telegram Messenger, Instagram, Twitter, Soroush Messenger, and Bale
Messenger), and an online video-sharing platform (Aparat), that in total, these channels
have been able to attract approx. 25,000 members and followers so far. The project also
used celebrity and elite endorsement on social media in the early weeks of its launch.
Furthermore, the project has received media coverage by various online Iranian news
agencies as well as online and print newspapers since its appearance. Following the scientific and ethical approval of the project by MOHME, the MOHME and several highranking state officials have also formally recommended installing the Mask app or havetalked about it. Moreover, the Islamic Republic of Iran Broadcasting (IRIB)—Iran’s stateowned media corporation (which owns over 70 television channels and 80 radio stations)—has covered and introduced the Mask project in several television programs.
The list of television programs related to the Mask project that were broadcasted by
IRIB, as well as the formal endorsement, recommendation, and promotion of the Mask
project by the MOHME and several high-ranking Iranian state officials from 2 March to
30 June 2020, were extracted from the accessible online sources. It should be noted that
this list may miss a few other incidents (e.g., the Mask project’s few broadcasted shortvideo advertisements on the IRIB television service) whose details (i.e., the incident or theoccurrence date of it) could not be retrieved from available online sources. A total of 13
different incidents were identified on 9 different days in the abovementioned period, thedetails of which are demonstrated in Table 3.

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Table 3. The list of identified television programs broadcasted by IRIB related to the Mask project and the endorsement,
recommendation, or promotion of the Mask project by the government from 2 March to 30 June 2020.

Event Day No.

Date

1

21 March 2020

2

5 April 2020

3

17 April 2020

4

19 April 2020

520 April 2020

628 April 2020

7

9 May 2020

829 May 2020

Details
Content: news report on Mask project [169]
Host program (IRIB TV channel): a news program (IRIB TV1)
Duration: 3:00 min
Viewership level of host program: highContent: the minister of MOHME of Iran sent an official letter to the director-general of IRIB to introduce the Mask project and request for the showing of the animated advertisement videos of the project and the coverage of
it in the IRIB’s programs [170]Content: news report on Mask project [171]
Host program (IRIB TV channel): a news program (IRIB TV1)
Duration: 2:16 min
Viewership level of host program: low
Content: news report on Mask project [171]
Host program (IRIB TV channel): a news program (IRINN)
Duration: 2:16 min
Viewership level of host program: low
Content: mass SMS message of MOHME of Iran to all cell phones nationwide with recommendation to install Mask app [172]Content: the president of Iran introduced the Mask app and its applications
in monitoring and tracking the disease [173]
Venue: in the briefing of National Task Force for Combating Coronavirus
Disease weekly meeting (live broadcasted by IRINN)
Content: news report on Mask project [174]
Host program (IRIB TV channel): a news program (IRIB TV1)
Duration: 2:54 min
Viewership level of host program: highContent: talk show on Mask project [175]
Host program (IRIB TV channel): an entrepreneurship and business program (IRIB TV1)
Duration: 23:15 min
Viewership level of host program: low
Content: in-studio interview on Mask project [176]
Host program (IRIB TV channel): a news program (IRIB TV1)
Duration: 6:25 min
Viewership level of host program: highContent: the spokesperson of the government of Iran announced the government’s (and the MOHME of Iran’s) support of the Mask app and recommended Iranians to use it [177]
Venue: in the weekly press conference of the spokesperson of the government of Iran (live broadcasted by IRINN)
Content: the spokesperson of MOHME of Iran announced that the Mask app
is the only approved app by MOHME [178]
Venue: in MOHME press conferenceContent: the deputy minister of MOHME of Iran recommended Iranians to
install the Mask app [179]
Venue: in MOHME press conference (live broadcasted by IRINN)
Content: COVID-19 daily status report by the spokesperson of MOHME of
Iran (including the recommendation to Iranians to use Mask app) [180]Int. J. Environ. Res. Public Health 2021, 18, 9666

9

17 June 2020

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Host program (IRIB TV channel): a news program (IRINN)
Duration: 00:36 min
Viewership level of host program: low
Content: news report on Mask project [181]Host program (IRIB TV channel): a news program (IRIB TV1)
Duration: 3:17 min
Viewership level of host program: high

The Android version of Mask app (that is the most popular version of the app) canbe downloaded either from Iranian Android marketplaces (Cafe Bazaar, Myket, Charkhoneh) or from the project’s website. Among these, Cafe Bazaar is by far the most popular platform for downloading this app. Figure 1 shows the “total number of active installed instances of the Mask app (downloaded from Cafe Bazaar Android marketplace)”(TNAIIMA) per day from 2 March to 30 June 2020. The TNAIIMA ranged from 0 (on 2
March 2020) to 1,037,129 (on 12 May 2020) and reached 851,602 on 30 June 2020.

Figure 1. (1) Total number of active installed Mask apps per day (raw data courtesy of Mask project); (2) timeline of theidentified television programs broadcasted by IRIB related to the Mask project and the endorsement, recommendation, or
promotion of the Mask project by the government (from 2 March to 30 June 2020). Notes: the figures for the total numberof active installed Mask apps per day are limited to the installed instances of the Mask app downloaded from Cafe Bazaar
Android marketplace; the numbering of the events is the same as that in Table 3.

Furthermore, the amount of change in the TNAIIMA (compared to the previous day)per day (i.e., the total number of new installations of the app on each day minus the total
number of new uninstallations of the app on each day) was computed and illustrated in
Figure 2. The amounts of change in the TNAIIMA in the study period ranged from −5755(i.e., at least 5755 new uninstallations of the app compared to the previous day) on 24 June
2020 to +209,478 (i.e., at least 209,478 new installations of the app compared to the previousday) on 18 April 2020. The timeline of the identified events (see Table 3) was also depicted
in Figures 1 and 2.

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Figure 2. (1) Amount of change in the total number of active installed Mask apps (compared with the previous day) perday; (2) timeline of the identified television programs broadcasted by IRIB related to the Mask project and the endorsement, recommendation, or promotion of Mask project by the government (from 2 March to 30 June 2020). Notes: thefigures for the amount of change in the total number of active installed Mask apps per day are limited to the installed
instances of the Mask app downloaded from Cafe Bazaar Android marketplace; the numbering of the events is the sameas that in Table 3.

Figure 2 shows that in most cases, a significant rise in the increment rate of TNAIIMA
on the event day and its consecutive day (event day no. 1, 2, 3, 7 in Table 3) occurred afteran event, or a significant drop in the reduction rate of TNAIIMA on the event day and/or
its following day (event day no. 6, 8, 9 in Table 3) occurred compared to the previous dayof the event. However, the magnitudes of these significant growths in increment rate or
declines in the reduction rate of TNAIIMA are not the same. The significant escalation in
the increment rate or the significant drop in the reduction rate of the TNAIIMA declines
over the following few days of the event. Figure 2 also illustrates that the project experienced the sharpest rise in the increment rate of the TNAIIMA following event day no. 3(sending the mass short message service (SMS) text messages by MOHME to all Iraniancell phones on 17 April 2020)—with at least 312,557 new installations on the event day
and its consecutive day. Immediately after this intense wave of app installations, there
were a series of television programs related to the Mask project and the endorsement andrecommendation of the Mask project by the government on 19 and 20 April 2020 (event
day no. 4 and 5). However, although there were considerable numbers of new installationsof the app on and right after the days of event day no. 4 and 5 (at least 122,876, 84,615, and41,088 new installations of the app on 19, 20, and 21 April 2020, respectively), they wereless than the massive wave of new installations occurring after event day no. 3. It is expected that promotion, advertising, and marketing can potentially increase the total number of new installations and decrease the total of new uninstallations of the app each day.
While more comprehensive research is still needed in this area, it seems that the cumulative effects of event day no. 3, 4, and 5 were (among) the main driving force(s) for theobserved massive increase in the total number of new installations of the app between 17
and 21 April 2020 (at least 561,136 new installations during this period).
Some previous studies highlighted the positive impact of SMS text messaging on improving the uptake of public health interventions [182,183]. The SMS is also integral toemergency communications [184] for timely and fast dissemination of notifications for
mitigating damage and reducing life loss. A previous study [185] showed that SMS, followed by television, have more comprehensive information dissemination capabilities
than other information mediums, including microblogs and news portals in disaster pre-Int. J. Environ. Res. Public Health 2021, 18, 9666

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warning and recommendation. This study found that the SMS has a shorter delay time,higher coverage ratio, and speed of information dissemination among the other media
mentioned above. A survey [186] in early April 2020 indicated that among the different
organizations involved in COVID-19 crisis management in Iran, Iranians trust thehealthcare system and MOHME of Iran the most, followed by the media (IRIB television
service was identified as the most trusted and used media among the others in this study).
The quantitative analysis is out of the scope of this study. While more data is required(that was not available for this research) and more comprehensive research is needed, it
seems that these could (at least partially) explain the reason for attracting enormous numbers of people to the project in a short time after event day no. 3. According to anothersurvey [187] in early April 2020 in Iran, 65.7% of survey participants identified the IRIB as
their primary source of news about COVID-19, followed by other mediums including Telegram Messenger (8.3%), Instagram (7.2%), satellite television channels (6.3%), news websites (6.1%), friends and acquaintances (1.9%), and WhatsApp (1.4%). Moreover, 63.4%
said they received their primary education about COVID-19 mainly from the IRIB. The
equivalent figures for Telegram Messenger (7.2%), Instagram (7.2%), satellite television
channels (3.9%), news websites (7.8%), friends and acquaintances (4.2%), and WhatsApp(2.8%) are significantly lower. These findings reveal the vast influence of the nation-wide
media—IRIB (particularly the IRIB television service as the most popular service ofIRIB)—in shaping public opinion about COVID-19-related issues and may explain thesubstantial impact of the television programs on attracting people to the project. Previous
studies highlighted the importance of adequate and effective advertising and communication frequency in strengthening the previous information and reinforcing the audiences’impression [188]. Therefore, while in general, it seems that the identified nine events
served as the main driving forces behind the significant rise in the app’s uptake, it can be
hypothesized that the app could achieve higher uptake levels if the frequency of theevents (media coverages, endorsements, etc., by the government) in the aforementioned
period was appropriately increased.
Overall, it can be stated that in Iran, the government’s role in raising public awareness about the COVID-related citizen science projects (such as the digital contact tracing
project) was essential and irreplaceable. Additionally, the government plays a crucial rolein informing people about the functionalities and requirements of these projects and theirbenefits for personal and public health and in encouraging citizens to adopt them due toits extensive and influential media power (mainly through the television service) and social capital [189] emerging from the health system (derived from the public trust in it).
Therefore, the government should strengthen and expand its support for these projects,
particularly for a participation-dependent voluntary project such as digital contact tracing, whose effectiveness and success is highly dependent on the broad participation ofpeople in the project. Moreover, it should be noted that, similar to many other Iranian
projects with citizen science characteristics, most of the participants who are involved in
the Iranian COVID-19-related citizen science projects are not aware that they are participating in citizen science projects. Hence, raising the knowledge and understanding of the
projects’ audience and participants about the concept of citizen science and its various
benefits, alongside introducing these projects under the term of citizen science, may help
to enhance the recruitment and retention of volunteers in these projects. Therefore, involving these considerations during the promotion, advertisement, and marketing forthese projects is necessary. Furthermore, as mentioned earlier in Section 4, the previous
studies revealed that moral, ethical, and religious values, beliefs, and motives are the main
drivers of voluntary activities for emergency and crisis response in Iran. Traditionally,
most of these activities have been carried out in the offline context. Consequently, thesphere of prosocial behavior in response to emergency and crisis circumstances has notbeen well expanded into cyberspace in public opinion, and the culture of online volunteering in this context has not been adequately formed in Iranian society. To this end, it is
crucial to tightly connect the value and necessity of the contribution of citizens in online

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COVID-19-related citizen science projects (such as contact tracing programs) into theaforementioned moral, ethical, and religious values, beliefs, and motives. Therefore, since
the media has a vast potential for promoting prosocial behavior and its drivers [190,191],
the power of media should be exploited for promoting and recognizing moral, ethical,
and religious merits of participating in COVID-19-related citizen science projects (including the contact tracing projects) in Iran that leads to fostering participation and long-term
engagement of people in these projects. It is noteworthy that while generally, some mediums are more influential than others, the previous studies recommend the employmentof a combination of different mediums (e.g., SMS, television, social media, news websites,
print newspapers) for conveying the message and advertising, as this enhances the efficiency of information dissemination and marketing among various groups of audiences[185,192]. Thus, to raise public awareness and understanding about participation-dependent citizen science projects, it is crucial to take the distinct advantages of different mediums by exploiting combinations of communication channels.
7.3.1.2. Recognition, Communication, and Feedback
Various intrinsic and extrinsic motives [193,194] could drive the engagement of people in citizen science projects [195,196]. Intrinsic motivation refers to engagement in an
activity due to the achievement of internal rewards such as a sense of enjoyment, satisfaction, or pride. Extrinsic motivation refers to participation in an activity because of obtaining a separable outcome (i.e., attaining a specific external reward or avoiding a negative
consequence) such as a score, money, or fame [193,194]. Since the creation of the mechanisms for fostering the intrinsic motivations of people for engagement in citizen science
projects is difficult and not always possible, many project organizers prefer to rely on using extrinsic motives. In citizen science, people generously contribute their valuable timeand effort for free; therefore, it is essential that all contributions of volunteers be recognized appropriately by the organizers of citizen science projects regardless of the level of
their contributions [142,195]. The recognition of volunteers’ efforts in a meaningful andcredible manner can also positively influence the long-term engagement of volunteers by
extrinsically motivating them to continue their involvement in the project [168,197,198].
The form and amount of recognition should be appropriate to the nature of the project
and tasks and consistent with the characteristics of volunteers such as their values, norms,
and culture. Furthermore, the extrinsic incentives should be designed in a way that is not
perceived as controlling an individual’s behavior and reducing their autonomy [199]. Otherwise, it may undermine the intrinsic motivation of participants, change how tasks areperceived by volunteers, reduce the self-image and social approval benefits, and tempt
participants to play the system or cheat, resulting in drop-out and/or inaccurate outputs[200–205]. Recognition can happen in various ways in citizen science projects, such as
writing a thank you message for all contributors, offering a certificate, promoting volunteers’ roles, or giving a gift, voucher, and monetary reward for high achievers [142,206].
The Iranian contact tracing app did not implement a concrete recognition system to copewith the drop-out problem. However, it seems that using the proper recognition and rewarding strategies in contact tracing projects such as the Mask app (and other similar
citizen science projects in other areas) could assist in stimulating the app users’ motivations and overcome the problem of declining volunteer participation and retention overtime. In this sense, different rewarding mechanisms (e.g., providing verbal appreciation,
adding a badge to the volunteer’s online profile, offering a bonus or discount card, giving
hygiene kits, and granting priority in receiving some services) should be carefully investigated to find the best solutions for providing incentives for long-term engagement of
citizens in contact tracing projects and to ensure the trustworthiness of the data. It is noteworthy that the incentives for the contact tracing app users should be chosen in a way that
does not cause injustice and consequently digital divide in the society (e.g., if the free hygiene kit is used as an external motive, it is required that the kits be also provided for the
lower-income citizens besides the citizens who use a contact tracing app).

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Citizen science projects require long-term outreach strategies and constant communication with the audiences via appropriate channels (e.g., email, SMS, blogs, discussion
forums, and social networks) to sustain project engagement [132,168]. To this end, it is
crucial to establish personalized communication with non-active members of the project,alongside frequent communication with the entire community [207]. As the level of involvement increases in a citizen science project from crowdsourcing to extreme citizen
science (for more details, see: [208]), it is desirable to move from simple one-way communication to two-way communication (and more advanced levels of dialogic communication) in the project [132]. Like many other contact tracing projects, the Mask project suffered from the lack of a concrete communication plan for the retention of its users. However, it seems that defining and implementing a set of effective communication tactics isnecessary for contact tracing projects such as Mask to cope with declining volunteer retention and drop-out over time.
The participants in the voluntary projects need to feel that what they are doing isuseful and being appropriately used [160,209]. In this sense, providing continuous feedback on how a volunteer’s overall contribution or the entire outcome of a citizen science
project helps citizen scientists understand how their contributions were used and how
they impacted science, society, and the environment [132,210]. Prior experiments demonstrated that positive feedback could enhance the intrinsic motivation of participants compared to neutral or no feedback. [211]. Therefore, providing feedback plays a vital role involunteer retention in citizen science projects [168]. No feedback was given to the Mask
project participants. However, it is expected that giving feedback to participants of a contact tracing app about the number of traced infected and suspected cases of COVID-19
through the app could encourage them to continue their contribution to the project. The
Mask project did not provide the general outcome of the project (e.g., the number of detected cases and true notifications) to the public. Nevertheless, it is believed that announcing the general outcome of a contact tracing project to the general public and reflecting
the positive contribution of the project to the epidemiological investigation, epidemic control, and consequently the public health to the society accordingly may motivate morecitizens to install and use the app.
7.4. Social Media as a Platform for Citizen Science Emergency Response Projects
The platform of an online citizen science project [212] may offer one or several services on the internet such as the gathering, processing, searching, discovery, and sharingof UGC, presenting UGC and other related data, describing tasks and guidelines, providing educational and technical materials and tools, making the potential target audiences
aware of the volunteering opportunity in the project, registering the volunteers, andproviding social networking, communication, and discussion features for the stakeholders of the project.
Social media is an integral part of daily life in many societies, with over 3.6 billion
active users worldwide in 2020 [213]. Social media platforms provide an online interactive
environment built on the foundation of the Web 2.0 paradigm through which individuals,
communities, and organizations can connect and communicate together, can generate,share, present, and search content, can discuss their issues and opinions, and can learn
about, explore, advertise, and promote things [214,215]. Designing and implementing aplatform for a citizen science project from scratch enables the project’s organizers to personalize every aspect of the platform and the services it provides; however, this could be
difficult, expensive, and time-consuming and might limit its visibility and adaptability. If
developing a new platform for a citizen science project is not a feasible or optimal solution,an alternative option might be to use the customizable commercial/free citizen science
platforms or deploy the existing non-specialized platforms such as social media platforms.
Previous studies have showed that social media can play an influential role in facilitating and shaping civic participation [216]. Social media allows for immediate interaction
and communication with a large, diverse, and geographically dispersed audience. Most

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25 of 35social media platforms are free to use and easy to start using. Moreover, many people arefamiliar with their features and functionalities. These platforms are usually built on robust, modern, scalable, fast, secure, and reliable infrastructures. Social media platforms
can often effectively improve the awareness about and visibility of the activities. Consequently, the various features and functionalities of social media platforms can create manypotential opportunities for providing the different services needed in citizen science projects.
Social media platforms have been mostly used as an advertising and promotion medium to recruit and retain volunteers in citizen science projects [217–219]. These platforms
have also been deployed to facilitate interactive and real-time communication and discussion between citizens and other stakeholders of the citizen science projects, to provide
feedback to volunteers, to post announcements and updates, to instruct volunteers, andto disseminate the projects’ results [219–221]. Relatively few citizen science programs havegone one step further and leveraged the capabilities of social media platforms for collecting the contributions of citizen scientists. For example, Soysal, et al. [222] used social media for crowdmapping of the urban red fox population. To this end, volunteers were asked
to send sighting reports and/or photographs of the urban red foxes they observed withthe observation location (either by sending a GPS coordinate or nearest cross streets) andtime (as well as other optional information) to the organizers of this project via Facebook,
Twitter, or Instagram. As another example, to record Italian dialects and document their
linguistic variation, a citizen science project [223] developed a Telegram Bot (an automated software that runs inside the Telegram Messenger environment). This app, whichruns inside Telegram Messenger, enables a volunteer to submit his/her voice recording
and to enrich it with the associated location to his/her dialect (either by sending a GPS
location or inputting the name of the place) into the project.
Both top-down citizen science projects (citizen science projects with top-down leadership) and bottom-up citizen science projects (citizen science projects with bottom-up
leadership; i.e., collegial citizen science projects) can benefit from the various services thatcan be offered by social media platforms. Notably, the bottom-up citizen science projects
with limited resources and budgets and the (top-down or bottom-up) citizen science projects that need to be launched urgently may take advantage of social media’s existing infrastructure to connect with the large numbers of potential audience and provide theirservices (e.g., collecting data, displaying or playing obtained data, discussing, advertising,and promoting) immediately and for free or at low cost. Two of the Iranian citizen science
projects that were launched during the pandemic also took advantage of social media
platforms for offering their services. Mask and CHIACD citizen science projects were bothdeveloped through a bottom-up approach by a group of volunteer citizens (without a topdown design and management of health and medical science professionals) in response
to a biological crisis that impacted their society. The Mask project developed and launched
its own platform for contact tracing in a short time after conceptualizing the project, relying on the profound expertise of its founders and its volunteer technical team in IT. Nevertheless, the Mask project employed a mixture of different social media platforms (Telegram Messenger, Instagram, Twitter, Soroush Messenger, Bale Messenger, and Aparat)
for advertising and promoting itself in public and posting related news. Compared to the
Mask project, the CHIACD project used social media’s capabilities more extensively—thestrategy that allowed the organizers to eliminate additional workload or costs for developing the project’s platform. To this end, the CHIACD project leveraged the capacity of a
combination of social media platforms (consisting of WeChat, Instagram, Aparat, Telegram, Twitter, and TritApp) to provide its various essential services such as UGC collection and raw data exchange, providing two-way communication, discussion, feedback,and output dissemination and presentation services. It is noteworthy that each social media platform has its own strengths and weaknesses; therefore, choosing the right social
media platform or combination of social media platforms to provide the required services
and functionalities for citizen science projects is pivotal to success.

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8. Conclusions and Recommendation
This research shed light on the most significant online citizen science projects carriedout to respond to the COVID-19 crisis in Iran. Moreover, this study attained and discussed
some considerable insights and lessons learned from the failures and successes of theseprojects, enriching them by incorporating knowledge gained from other citizen science
projects over the past years. Findings from this synthesis offer potentially valuable directions for the current and future citizen science projects that aim to respond to biologicalhazards such as the COVID-19 pandemic. This study highlighted some initial steps thatneed to be taken for capacity building for citizen science in Iran’s public sector and academic and research institutions. This research also argued that the provision of an effective response to an outbreak such as the COVID-19 crisis through citizen science requires
building capacity and needs preparation for conducting citizen science projects in advance. Furthermore, this study discussed the influence of various organizational factors
on the recruitment and retention of volunteers in COVID-19-related citizen science projects and mainly digital contact tracing programs. Remarkably, we highlighted the prominent role of project promotion, advertising, and marketing as well as recognition, communication, and feedback provision for the volunteers’ contributions on the participationand long-term engagement of participants of these projects that have been less focused onin the previous studies. This article also called attention to the high capacity of social media for providing a wide range of services (e.g., data acquisition, data presentation, discussion, advertisement, and promotion) for citizen science projects with limited resources
and budgets or those required to be launched urgently. Limited/lack of access to up-todate information about citizen science projects in Iran—particularly COVID-19-related citizen science projects—were two of the obstacles to doing this research. Moreover, thedearth of previous research on the various dimensions of Iranian COVID-19-related citizen science projects was among the main barriers to this research. However, we hope that
this research can pave the way for future research in this direction.
COVID-19 has caused mental health problems among people worldwide, including
people in Iran. Furthermore, schools and universities have been closed in Iran, and instruction has been switched to online as a part of measures to reduce the spread of
COVID-19 in the country since late February 2020. This long-term disruption of in-classeducation has resulted in an education crisis in Iran, similar to many other countries. Engagement in citizen science projects could potentially improve the mental health and wellbeing of volunteers, and citizen science can serve as a beneficial educational tool for citizen
scientists. Therefore, utilizing the potential capacity of relevant existing active Iranian citizen science projects such as those in the field of biodiversity monitoring, astronomy, andgeographical mapping (while practicing social distancing) is recommended to reduce theaforementioned adverse consequences of COVID-19 in the country.
Citizen science has a broader implication in emergency response, one beyond thisglobal pandemic. While citizen science has been studied extensively and practiced widelyin some fields, relatively less contribution has been carried out on citizen science for disaster management. Currently, more than 4.6 billion people around the world actively use
the internet. Moreover, the number of smartphone users worldwide today surpasses 3.5billion and is to rise rapidly in the next few years. With the current penetration of theinternet and smartphones, it is becoming much easier to engage people and communities
in the disaster management process through citizen science. Higher engagement in theseprojects offers a vast range of opportunities, particularly for developing countries, whereobtaining accurate and updated data and plans are always a significant challenge. The
insights from this study can be used to overcome some existing barriers to operationalizing citizen science projects for disaster management and can be deployed to enhance theperformance of these projects, particularly in developing countries.

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Author Contributions: Conceptualization, H.V. and R.S.; Methodology, H.V.; Data curation, H.V.;
Formal analysis, H.V.; Investigation, H.V.; Resources, H.V.; Software, H.V.; Visualization, H.V.; Project administration, H.V.; Writing—original draft, H.V.; Writing—review & editing, H.V., M.T.,
W.Y. and R.S. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Acknowledgments: The authors would like to thank the following persons, who graciously contributed their valuable time, knowledge, and input over the course of this research: A. Bonn, A.
Sharifi-Zarchi, H. Moradi, M. Tabatabaeian, V. Ahmadi, H. Pourkhorsandi, J. Hua, O. Solaymani
Fard, K. Kookaram, H. Nikaein, A. Delkhasteh, A. Hashemi, H. Mirzakhalil, M. Talezadeh, A. Nikkhah, J. Parastegari, S. Ghaziasgar, B. Nezhadbahman, M. Rezaie-Atagholipour, V. Javadi, and A.
Shokouhi.
Conflicts of Interest: The authors declare no conflict of interest.

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International Journal ofEnvironmental Researchand Public Health

Review

Urban–Rural Partnership Framework to EnhanceFood–Energy–Water Security in the Post-COVID-19 Era
Priyanka Mitra 1 , Rajib Shaw 1, * , Vibhas Sukhwani 1 , Bijon Kumer Mitra 2 , Md Abiar Rahman 3 ,Sameer Deshkar 4 and Devesh Sharma 5
1

2

3

4

5

*



Citation: Mitra, P.; Shaw, R.;
Sukhwani, V.; Mitra, B.K.; Rahman,
M.A.; Deshkar, S.; Sharma, D.
Urban–Rural Partnership Framework
to Enhance Food–Energy–Water
Security in the Post-COVID-19 Era.
Int. J. Environ. Res. Public Health 2021,
18, 12493. https://doi.org/10.3390/
ijerph182312493
Academic Editors: Rodney P. Jonesand Paul B. Tchounwou
Received: 8 October 2021
Accepted: 24 November 2021
Published: 27 November 2021

Graduate School of Media and Governance, Keio University, Endo 5322,
Fujisawa Shi 252-0882, Kanagawa, Japan; priyankamitra87@gmail.com (P.M.); vibhas@sfc.keio.ac.jp (V.S.)
Institute for Global Environmental Strategies (IGES), 2108-11 Kamiyamaguchi,
Hayama 240-0115, Kanagawa, Japan; b-mitra@iges.or.jp
Department of Agroforestry and Environment, Bangabandhu Sheikh Mujibur Rahman Agricultural
University, Salna, Gazipur 1706, Bangladesh; abiar@bsmrau.edu.bd
Department of Architecture and Planning, Visvesvaraya National Institute of Technology, South AmbazariRoad, Nagpur 440010, Maharashtra, India; smdeshkar@arc.vnit.ac.in
Department of Atmospheric Science, School of Earth Sciences, Central University of Rajasthan, NH-8, Bandar
Sindri, Ajmer 305817, Rajasthan, India; deveshsharma@curaj.ac.in
Correspondence: shaw@sfc.keio.ac.jp; Tel.: +81-466-49-3641

Abstract: Food, energy, and water (collectively referred to as ‘FEW’) security forms the key to humansurvival as well as socioeconomic development. However, the security of these basic resources isincreasingly threatened due to growing demand. Beyond the widespread implications on publichealth, Coronavirus disease (COVID-19) has further raised additional challenges for FEW security,
particularly for urban populations, as they mainly outsource their FEW demands from rural areas
outside their physical boundaries. In light of that, this study reviews existing literature on FEW
security to highlight the growing relevance of urban–rural linkages for realizing FEW security, especially against the backdrop of the COVID-19 pandemic. To achieve this, relevant research documents
have been identified through Elsevier’s Scopus database and other sources (by applying searchequations). The authors have accordingly underlined the necessity of shifting the conventional urbancentric approach to city region-centric development planning for the post-COVID-19 era. To thisend, a framework has been suggested for translating physical urban–rural linkages to a partnershipenhancing a collective response. The major elements of this framework are the conceptualizationof national-level policies to support urban–rural linkages. The framework can play the role of ascience–policy–action interface to redesign the FEW system in city regions.
Keywords: urban–rural partnership; food–energy–water security; global goals; sustainable development
goals; COVID-19

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distributed under the terms andconditions of the Creative Commons
Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).

1. Introduction
Rapid urbanization has today become one of the major sustainability challenges
worldwide, particularly in developing countries [1]. By 2018, urban areas were already the
habitat of around 55% of the world’s total population, a proportion due to reach 68% by
2050 [2]. Correspondingly, urban areas have emerged as the demand centers of natural
resources such as food, energy, and water [3,4]. At the same time, this trend in rapid urbanization is resulting in inequality, unsustainability, polarization, and divergence in terms ofdevelopment and social inclusion between urban and rural areas [5]. Due to the growing
concentration of economic activities and services, cities are becoming the preferred destinations for rural migrants, wishing to pursue employment opportunities and improved
quality of life [6]. Unplanned urbanization and rural-to-urban migration create various
social, environmental, and sustainability challenges. A business-as-usual development
approach prioritizes mainly economic and social dimensions, with environmental impacts

Int. J. Environ. Res. Public Health 2021, 18, 12493. https://doi.org/10.3390/ijerph182312493

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often sidelined [7]. However, to realize sustainable development, development planningneeds to be conducted through an integrated lens of economic growth, social development,
and environmental conservation [8]. In the context of sustainable urbanization, managing
economic prosperity and protecting the natural resources in rural regions can ensure food,energy, and water (collective referred to as ‘FEW’) security for urban areas [9]. Hence, theinterlinkage of urban and rural has come into focus for sustainable and resilient development. A sustainable development approach, in the context of developing countries, needs
to be viewed as a means of optimizing interactions between various underlying factors
including poverty, climate change, rapid urbanization, and food insecurity that can makeor mar socioeconomic development and environmental conservation, rather than being
regarded as an ideal development pathway.
Typically, urban–rural linkages are referred to as the spatial flows of people, capital,
goods, services, sectorial and financial flows, and information between rural and urban
areas [10,11]. Thus, the umbrella of urban–rural linkages covers a broad variety of themes
within the domain of urban and territorial planning, such as strengthening small andintermediate towns. The associated functions of social links, economic dynamics, andenvironmental synergies maintain the interdependencies between urban and rural areas.
Encouraging an urban and rural partnership in a local context is important for realizing
a transformation towards sustainable development. The importance of urban–rural partnership is, accordingly, being acknowledged in global and regional development agendas
in European countries, and in development policies worldwide. For instance, Japan’s
5th Basic Environment Plan recognized the necessity of urban–rural linkage for economic
revitalization, and for a low carbon, and resilient society, introducing the Circulating andEcological Sphere (CES) concept [12].
As urban populations heavily rely on rural areas for their FEW needs [13,14], theimportance of urban–rural partnership has been highlighted by several studies [15–17].
Since population growth increases food demand in urban areas, the strengthening ofurban–rural connections has become a determinant for food security and nutrition [18]. In
parallel, the urban–rural partnership is also gaining attention, with cities declaring theircommitment to the race for a net-zero emission society and capturing the potential of solar
energy resources that are available in rural areas. Several cities in Europe, Japan, andother regions are now establishing a collaboration to achieve 100% renewable targets by
2050 [19,20].
Coronavirus disease 2019 (COVID-19), caused by the novel coronavirus, was firstdetected in December 2019, and the World Health Organization (WHO) declared thecoronavirus outbreak a pandemic on 11 March 2020. In response to the pandemic, various
responses have been imposed by the national and local governments that brought changes
in urban–rural flows, including people’s movement, food supply chain, services, etc. The
widespread implications of the pandemic on human societies, beyond the implications
on public health, have raised additional questions about the conventional concepts ofurban development and resilience, particularly in developing countries. Taking due
account of supply chain disruptions, it has been realized that urban–rural interlinkages
must be carefully considered in the responses to COVID-19, and recovery strategies andactions, as well as the localization of the FEW security, should be emphasized to reboot the
global economy.
A great deal of existing literature focuses on FEW sectors independently [21–23],
however few studies have discussed the relationship between urban–rural partnershipand the FEW nexus [24,25]. Some studies related to the FEW nexus and COVID-19 havealso been published [26–28]. However, the importance of urban–rural partnerships tostrengthen the FEW nexus for the post COVID-19 era has not yet been discussed. In lightof that, this paper advances the current understanding of urban–rural linkages, framing
them within the integrated management of FEW for the post COVID-19 era.
Mainly based on a literature review, the three key objectives of this study are: (1) To
review existing literature on urban–rural linkages and their relevance for FEW security;

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based on a literature review, the three key objectives of this study are: (1)3To
Int. J. Environ. Res. Public Health 2021, 18,Mainly
12493
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review existing literature on urban–rural linkages and their relevance for FEW security;(2) To understand the effects of the COVID-19 pandemic on FEW security; (3) To suggest
a feasible policy level framework to translate urban–rural linkages to partnership.
(2) Overall,To understandthe effectsof thepandemicon FEW security;(3) To foundasuggest athis paper
comprises
sixCOVID-19
sections. Section
2 establishes
a theoreticalfeasiblepolicylevel
frameworktotranslateurban–rural
linkagestopartnership.
tion (on urban–rural linkages and FEW nexus) for the readers to better comprehend thisOverall,thispaper comprises
six sections.
2 establishes
a theoreticalfoundaresearch.
Section3 describes
the adopted
researchSection
methods,
while Section
4 provides
antion (on urban–rural linkages and FEW nexus) for the readers to better comprehend thisoverview of the research findings. Within the broader discussion of study findings, Secresearch. Section 3 describes the adopted research methods, while Section 4 provides antion 5 discusses the suggested urban–rural partnership framework, and some key concluoverview of the research findings. Within the broader discussion of study findings, Section 5
sions and research limitations are summarized in Section 6.
discusses the suggested urban–rural partnership framework, and some key conclusions
and research limitations are summarized in Section 6.
2. Literature Review
2.1.
of Urban–Rural Linkages
2. Significance
Literature Review
2.1.Urban
Significanceof Urban–Rural
Linkagesand rural
regions exist
as interdependent entities connected through various
spatialUrban
and sectoral
flows(referto1). Rural regions
serve
as centersfor key
reand rural regions existFigure
as interdependent
entities
connected
throughvarioussources
such
as
food,
water,
energy,andlabor,
whicharecrucialfor
urban
regions.
Simispatial and sectoral flows (refer to Figure 1). Rural regions serve as centers for key resources
larly,
regions
opportunities
forareruraldwellers,
creating
markets
for agrisuchurban
as food,
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crucialfor urban
regions.
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urban
culturaland becomingof temporary
employment
shelter. Urban–
regionsproducts,
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forsources
rural dwellers,creating
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products,
rural
canbe definedas the direct(and two-way)flow Urban–ruralof resources between
geo-beandlinkages
becoming
sourcesof temporary
employment
and shelter.
linkages cangraphicallyand rural flow
areasof[10,29,30].
the continuity andcondefined asdispersed
the directurban(and two-way)resourcesEnhancing
between geographicallydispersed
nectionbetween
urban
and
rural
regionsis
crucialfor
reducing
poverty,achievingasaturban and rural areas [10,29,30]. Enhancing the continuity and connection between urban
and rural
regions
is crucial
formanagement
reducing poverty,
achievingsatisfactory
level maintainof access to
isfactory
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anda atthe same timeandof resources,
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essential
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On the otherhand,
unplanned
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rapid
other
hand,that
unplanned
and for
rapid
urbanization
is attributed
to theloss ofagriculturalurbanization
is attributed
wetlands,
and forest[25,31].to the loss of agricultural land, wetlands, and forest [25,31].

Figure1. 1.
Conceptual
diagramof ofurban–rural
linkagewithsustainable
development
goals(SDGs).
FigureConceptual
diagramurban–rural
linkagewithsustainable
development
goals(SDGs).

2.2.
Urban–Rural
Linkage
AchievingGlobalAgenda2.2.
Urban–Rural
Linkage
forforAchievingGlobalAgendaThe
importancelinkages
betweenurban
andruralareas
areasis isrecognizedrecognizedininglobal
globalThe
importanceofoflinkages
between
urban
and
rural
frameworks
such
as
the
2030
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development
goals(SDGs,
frameworks such as the 2030 Agenda, with its sustainable development goals (SDGs, refer
to Figure
andSendai
the Sendai
Frameworkfor Disaster
Reduction,andwasfirst
first
torefer
Figure1) and1)theFrameworkfor Disaster
RiskRisk
Reduction,andwasacknowledged
theVancouverAction
ActionPlan
Plan(Habitat(HabitatI) I)[32].
[32].The
The
commission
Humanacknowledgedinin
the
Vancouvercommission
onon
Human
Settlements in 1999 also appealed to consider the urban–rural interdependence in theimplementation of the UN-Habitat program [33]. In 2003, the UN-Habitat emphasized
urban–rural linkages in the publication “Urban-Rural Linkages Approach to Sustainable
Development”. At the United Nations conference in 2012, member states also committed

Int. J. Environ. Res. Public Health 2021, 18, 12493

4 of 16“to work towards improving the quality of human settlements, including the living andworking conditions of both urban and rural dwellers in the context of poverty eradication
so that all people have access to basic services, housing, and mobility” [34]. The significanceof urban–rural linkages has also been described further in the New Urban Agenda in 2016,
where member states committed to supporting “the role of small and intermediate cities andtowns in enhancing food security and nutrition systems, providing access to sustainable,
affordable, adequate, resilient and safe housing, infrastructure and services, and facilitate
effective trade links across the urban-rural continuum” [35]. This agenda has encouraged
the implementation of sustainable urban and territorial planning to promote interactions
among urban, peri-urban, and rural areas, in both developing and developed countries.
SDG 11—“Sustainable cities and communities” emphasizes the importance of national urban policies and regional development plans for positive economic, social, andenvironmental links between urban and rural areas. It calls for sustainable urbanization
incorporating participatory approaches and the integration of climate change and disaster
resilience into development policies and plans at all levels of settlement planning. Urban–
rural interlinkages are also critical for achieving other SDGs, including SDG 2 (food), SDG 6(water and sanitation), SDG 7 (energy), and SDG 15 (land) (as highlighted in Figure 1 earlier).
Urban–rural linkages can play an important role in mitigating the risks of both naturaland man-made disasters. The Sendai Framework for Disaster Risk Reduction 2015–2030
also encourages an upgrade of knowledge on disaster risk for all possible aspects of exposure, properties of vulnerability and hazard, strengthening of disaster risk governance,
and accountability for disaster risk management [36]. Urban–rural linkages can support
modifying the situation of disasters in rural areas and can help minimize the vulnerabilityof rural residents [37]. Moreover, many development agencies, such as the Organization for
Economic Cooperation and Development [38], the Department for International Development [39], and the World Bank [40] are now placing urban–rural linkage in their investment
projects, thereby recognizing poverty mitigation and achieving broader equality.
2.2.1. Urban–Rural Partnership to Implement Regional Development Plan
(EU Rurban Program)
Agreed by the European Parliament in 2010, RURBAN refers to the actions for sustainable urban–rural development and partnerships, managed by the European Commission.
The European Union (EU) has given due importance to urban–rural linkages while working
together with other countries and regions on the understanding that stronger urban–rural
linkage is more beneficial in terms of more efficient land use and planning, efficient services,and sustainable natural resource management. Herein, the urban–rural partnership is increasingly being considered as a tool for regional development to replace the conventional
policies of discrete urban and rural development. Starting from the second half of the 1990s,
the EU has also raised awareness on urban–rural partnership through specific research
programs such as Study Programme on European Spatial Planning (SPESP), European Spatial Planning Observation Network (ESPON), and the 6th Research Framework Program.
Consequently, several national level initiatives have emerged to promote urban–ruralpartnerships in European countries such as Germany, the UK, France, and Spain.
It has been realized that urban–rural partnerships cannot be established without
engaging local actors. This is because the process and outcomes are influenced by local
and regional conditions. The EU has highlighted the urban–rural partnership as a specificform of governance for integrated territorial development. Primarily, such partnerships
are set on a sub-regional level that is supported by a regional and national–legal andfinancial framework. Nevertheless, the EU provided major value to promote urban–ruralpartnerships depending on the community objective of economic, social, and territorial
cohesion. Urban–rural partnerships were put forward in a rather new and challenging dimension, distributing the policy and funding of European cohesion and rural development
to member states and regions. The EU framework requires specific methods to incorporate
urban–rural issues into future programs. However, the EU administrative bodies werereluctant to include new strategic issues or governance approaches to complement urban–

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rural partnerships using a certain tool for experimentation, innovation, capitalization, anddeveloping policy.
2.2.2. Urban–Rural Linkage in the Basic Environment Plan of Japan
Against the backdrop of recent global policy agreements such as the 2030 Agenda for
Sustainable Development, the 5th Basic Environment Plan was approved by the Ministryof Environment of Japan (MOEJ) in 2018. The two main ideas outlined in this plan arerespect for planetary boundaries and urgent achievement of the SDGs [41]. Therefore,
MOEJ introduced the CES concept in its plan for a sustainable transition. This concept
is an integrated policy approach that includes three principal elements: (1) a low-carbon
society, (2) resource circulation, and (3) living in harmony with nature. These elements
were proposed in Becoming a Leading Environmental Nation in the 21st Century—Japan’s
Strategy for a Sustainable Society in 2007. For this, a framework was established within the
CES to promote the interaction and cooperation of the three elements. The concept of acircular economy and low-carbon society is built on the ideas of reducing waste, producing
renewable sources of energy, and employing ecosystem services without any damage
which ultimately optimizes human activities and minimizes their impact on nature [42].
The CES encourages spatial linkages to establish advanced methods for sustainability andintegrated responses at a local scale, which are in contrast to existing approaches. There
are four approaches to execute the CES: (1) urban–rural linkages, (2) ecosystem-based
solutions, (3) decarbonization, and (4) resource circulation.
The CES concept motivates the formation of intricate and more sustainable urban–
rural linkages based on the current flows of food, goods, people, capital, waste, natural
resources, and renewable energy. These strengthened linkages are intended to carrypotential revised chains of ecological production and consumption in such a way thatcities and towns can meet their primary resource demands within regional boundaries andbecome self-sufficient for energy and food while reducing waste [43].
2.3. Urban–Rural Linkage for Optimization of FEW Nexus
The FEW nexus refers to the tight interconnection between food, energy, and water
systems. Furthermore, the security of each of the independent resources is reliant upon
the realization of the overall FEW security. Nevertheless, demand for FEW in urban areas
is met through both local in-boundary and, to a larger extent, transboundary production [44], and this rising urban demand has far-reaching environmental impacts, fromin-boundary to outside of urban area boundaries. Accordingly, there is a need to optimize
the production and supply of FEW resources to urban areas, at both city in-boundary
and transboundary scales. A potential approach to realize this could be the evaluation of
trade-offs and co-benefits among environmental effect categories, which can be inferredthrough water and energy footprints [44]. Water footprints inform on water removal fromwatersheds, risk of water scarcity in the operation of industries or power plants, and risks
to crop production. This type of evaluation of trade-offs enables sufficient measures to betaken at a suitable level in four key categories to gain water security: (1) changes in FEW
demand, (2) in-boundary versus transboundary FEW supply relocation, (3) interventionof in-boundary production system, and (4) intervention in trans-boundary production
along with cross-sectoral food, energy, and water interactions. Execution of these measures requires interventions in supply–demand governance, integrated energy planning,
integrated use planning, technological interventions, lifestyle change, and ways to engage
citizens in the decision-making process at the urban–rural functional region level.
3. Research Methods
For reviewing the state-of-the-art scientific literature related to urban–rural partnershipand FEW security, two major sources are considered. The first is peer-reviewed literature
identified through the Elsevier’s Scopus data: The search was performed with keywords’Food, Energy, Water, Security, Urban, Rural’ in the ‘ALL’ category, and a total of 39 literature

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were retrieved initially (on 22 March 2021). Another search was performed on the samedate with the keywords ‘Food, Energy, Water, Security, COVID-190 in the ‘ALL’ category,
and a total of 38 documents were found. After a manual screening of literature titles,
abstracts, and sometimes full papers, the relevant documents were extracted for review.
The second source is grey literature identified through other sources: Beyond the Scopus
search for peer-reviewed literature, other online and offline sources were also considered
to identify relevant (and up-to-date) research documents, such as government documents
and reports, international organization documents and reports, conference proceedings,
and newspapers. Similar keywords to those used for Scopus were also applied to othersearch engines (including Google Scholar), thereby identifying relevant documents to gaina better understanding of the subject and on the impacts of the COVD-19 pandemic.
4. Growing Relevance of Urban–Rural Linkage for FEW Security
4.1. Urban–Rural Linkage for Food Security
Rapid urbanization is reshaping the land-use pattern in functional urban–rural regions,which increases the challenges of achieving the global goal for zero hunger (SDG-2).
Urbanization plays a significant role in increasing the demand for agricultural products
in terms of both the growing population and dietary changes, which may increase risks
to food security both for urban and rural populations [45]. Rural agricultural productionis the major source of food for people living in contiguous urban–rural areas [46]. Looseinterconnections between urban and rural areas have a negative effect on food security andnutrition for vulnerable people in cities and rural communities [47,48]. Strengthening theurban–rural linkage is one of the keys to mitigating the risk of food insecurity. Furthermore,strengthened urban–rural linkages can support inclusive economic growth by connecting
rural agricultural production with urban markets, creating food supply chain-related, nonfarm business and job opportunities in rural, peri-urban, and urban areas, and promoting
urban technical support and investments in farms located in rural areas. Changes inthe dietary choices of the urban population also influence crop cultivation. To mitigate
these concerns and to strengthen urban–rural linkages, especially against the backdrop of
pandemic emergencies, there is a need for city–region level responses, several examples ofwhich are highlighted in Table 1.
Table 1. Examples of city–region food system approaches in response to pandemics.
City

City Region Food System Approach

SourceAntananarivo, Madagascar

Mapping of food flow, regulating productquantities along with discovering theimportance of each actor in the food chain.

[49]

Medellín, Colombia

In response to the COVID-19 crisis, theterritorial position and the city region foodsystems notion have been incorporated in thecity’s food and nutrition security programs.

[50]

Colombo, Sri Lanka

CRFS has been introduced to ensurecommunities can easily access food by any
alternative supply chain linkages bysynchronizing with multi-stakeholders
across administrative boundaries.

[51]

The impact on food systems due to the COVID-19 pandemic calls attention to theopportunities that can be captured by connecting local production and consumption. Cities
and wider regions need to have an action plan for helping resilient food systems, ensuring
that: (1) the food supply chain is diversified and resilient to future shocks, (2) food access ismaintained, and (3) mitigation is in place for vulnerable food system actors, which include
small-scale producers, migrant labors, low-income, and neglected groups.

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7 of 164.2. Urban–Rural Linkage and Energy Security
Huge investment is required for electricity production, and these are highlighted whenmoving towards decarbonized cities and industrial activity and managing investment for
renewable options. Renewable technologies provide an edge over fossil fuel options as
they produce little or no air pollution and can be utilized instantly. Renewable technologies
are also economically helpful. The cost of electricity that solar photovoltaics and offshore
wind generate is competitive with fossil power, resulting in costs being cut by 25–40%
between 2018 and 2023 [52]. Renewable energy has become an essential part of the solution
towards a net-zero emission world. Today, there are more than 100 cities globally thatare mainly powered by renewable energy, most of which are in Africa, Europe, North
America, and South America. Among these 100 renewable cities, only Inje in the Republicof Korea is located in Asia. Many other cities across the world have set a target to achievea 100% renewable energy supply by 2050. Achieving 100% renewable energy within city
territory is challenging considering the limited available space and lack of natural resources.
Therefore, many cities (several examples shown in Table 2) are now building partnerships
with neighboring or far distant rural areas for achieving a 100% renewable supply [53].
Table 2. Urban–rural partnership for achieving renewable energy target of selected cities.
City

BarcelonaFrankfurt

Frederikshavn

GenevaYokohama

Country

VisionUrban–Rural Partnership

Spain

An energy-independent city
through achieving 100%
renewable energy (RE) by 2050

In light of the limited resources and opportunities at thecity level, the municipality coordinateswith the wider metropolitan area to achieve the 100% RE
vision by 2050.

Germany

100% RE by 2050
50% energy savings
25% RE generation within thecity territory
25% RE produced in the region(metropolitan area)

It is difficult for the city of Frankfurt to achieve its “100%renewable” target on its own. It needs resources from themetropolitan area and even regional level for wind powerand biomass.

100% RE by 2030

The objective of 100% RE cannot be achieved withouttransforming the resources to the energy available in thesurrounding area of Frederikshavn. Biomass is considered
as an opportunity to boost agriculture while it develops as
an energy supplier. Off-shore wind power is also tackled
through DONG Energy.

Switzerland

100% RE by 2050

To explore the locally available wood biomass, themunicipality contributed to establishing a local industry,where benefits come through municipal forestry and froma partnership with the Geneva Association of private
forest owners to ensure that the selling price of woodbiomass is fair. This partnership ensures private owners’
sustainable and free-of-charge management of forests. It
promotes job opportunities in the local area.

Japan

Achieve carbon neutral by 2050
8% RE produce within city
92% RE supplied from outsideof the city

Yokohama has concluded agreements on RE with
12 municipalities including Kuji City, Ninohe City,
Kuzumaki Town, Fudai Village, Karumai Town, Noda
Village, Kunohe Village, Hirono Town and Ichinohe Town,
Aizuwakamatsu City, and Koriyama City, which haveabundant renewable resources based on CES concept.

Denmark

Among the listed cities in Table 2, Yokohama City in Japan and Frankfurt City inGermany have set targets to achieve 100% RE by 2050 through a combination of energy use
efficiency improvement and increased energy supply from renewable sources. However,both these cities have limited resources within the city boundaries to ensure 100% RE
generation in the city region. For example, it is estimated that Yokohama needs to receiveInt. J. Environ. Res. Public Health 2021, 18, 12493

8 of 1619.1 billion KWh in energy supply from renewable sources to achieve the ambitious carbon
neutral target by 2050. However, estimates have revealed that only 8% of the total energy
demand can be produced within the city boundary. Therefore, Yokohama needs to secure
the remaining 92% from outside of the city area through collaboration with other cities,
towns, and villages, which have abundant RE resources. Yokohama has accordingly signed
agreements with 12 local governments in the Tohoku region with abundant RE sources.
Under these agreements, the partner cities, towns, and villages supply RE to Yokohama
City. This collaboration has helped create a circulating and ecological sphere to generate
a positive economic cycle, including RE and environmental value. Similarly, the city ofFrankfort has established collaboration with stakeholders in the city area, harnessing RE
potential beyond the city boundary that can cover 184% of its power needs by 2050 [54].
This cooperation opens up new opportunities to convert cities and regions from energy
consumers to RE prosumers, thereby creating value.
4.3. Urban–Rural Linkage and Water Security
Due to rapid urbanization, the demand for water for urban populations is projected
to increase by 50–80% by 2050 [55]. To meet the growing urban water demand in the faceof declining freshwater availability, the most common response is water reallocation fromrural to urban regions. The increase in such trends implies that there are growing conflicts
between cities and their surrounding rural areas, particularly in the global south [56,57].
A survey identified at least eight important issues that need urban–rural cooperation,
including water allocation, water quality, flood control, water allocation, wastewater
treatment, physical accessibility to a water source, water storage, provision of water
services, and ownership of water [58]. In light of that, urban–rural collaborations canoffer a win-win solution for water security at the regional level. Several good examplesof urban–rural partnerships for water management and security have been identified indifferent places (Table 3). These include water use efficiency improvement in agriculture(e.g., Southern California in the US, Reus in Spain), improving groundwater recharge (e.g.,
Kumamoto in Japan), managing water source forest (Kanagawa in Japan), and promoting
environment-friendly organic agricultural practices (Munich in Germany). Introducing
incentive mechanisms can enhance urban–rural cooperation on water management andwater security. Urban–rural cooperation can also generate multiple benefits for both sides,
including water security for urban populations and increased incomes for rural people, as
well as creating new job and business opportunities.
4.4. Impact of COVID-19 on FEW Nexus
Since 2020, the world has been facing the devastating effects of the COVID-19 pandemic, which has had a direct impact on FEW security [26–28] in terms of both demandside and supply-side disruptions (overview presented in Figure 2). For instance, nearly
2.1 billion people worldwide already lacked access to safely managed drinking water [59],and so frequent handwashing has emerged as a constrained resource when trying to follow the World Health Organization’s advisory on hygiene. In the case of demand-side
disruptions, increased hygiene habits and medicalization has led to increased medical
waste generation, which may have significant impacts on soil or water pollution if notproperly treated. The treatment of additional medical waste or wastewater also requires
more energy supply [60–63]. Water is further considered as the key component to fightagainst COVID-19 globally, as countries that lack chemical-based disinfectant depend more
on a water source [64,65]. The water ecosystem is also greatly affected by biomedical waste,
and this is hampering water supply sources and ultimately harming the environment [66].
In Bangladesh, at least 14,500 tons of waste from healthcare was generated across thecountry due to COVID-19 in April 2020 [67]. India also experienced a 46% increase in
COVID-19-related biomedical waste generation in between April and May 2021, withmany municipalities of India recording a sharp increase (up to 25%) in domestic water
consumption (e.g., Kozhikode in Kerala and Ahmedabad in Gujarat) [68].

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Table 3. Urban–rural cooperation for water management and water security.
LocationIssuesMechanism of Collaboration

Benefits

Southern California,
US

Water stress andvulnerability to drought

San Diego city-initiatedagreement to givecompensation to the farmers
for water conservation

Nearly 100 million cubic meters(MCM) were saved by farmers andsent to the city. It is target is 237
MCM by 2021

Reus, Spain

Water allocation problem between
cities and agriculture

A water market mechanism
was introduced by theirrigation subscriber
association that includes theReus city, other municipalities,
and small rural landowners.
The water right is distributed
based on fixed price

Kumamoto, Japan

Kumamoto City, which
completely relies on groundwater
resources faced groundwaterlevel depletion

Incentivizing paddy fieldowners for groundwater
recharge

Kanagawa, Japan

Water quality of majorwater source rivers ofprefectural water is being affected
due to poor management of water
source forest

Introduced conservation andrestoration of water source
environment through taxationand this revenue is used forsupporting management
water catchment areas in the
upstream

The city water supply source, theMangfall valley, experienced
nitrate and pesticide pollution
due to intensive agricultural
practices

The municipal water utility
introduced a voluntary
payment scheme to promoteorganic farming

Munich, Germany

-

-

-

-

-

-

Reduced urban water demand
Increased water use efficiency
in agriculture
Revenues are used to financedams and otherinfrastructures

Increased groundwater
recharge that improved water
security for the city
Improved income of paddy
field owners

Improved quality of riverwater quality
Support for local forest
businesses
Creates jobs in forest
management sector

Improved water quality(nitrate concentration reduced
to 7 mg/L)
Reduced water treatment cost
Large market for organic
farming in Germany

Food security is also under stress due to widespread disruptions along the supply
chain, as well as impacts on agricultural production due to mobility restrictions [69,70].
Demand-side disruptions include reduced mobility, dietary changes, reduction in industrial
operations, and quarantine regulations, and these force people to take a local production
approach. This implies that the FEW nexus at the local level should be assessed andoptimized to avoid tradeoffs. If local production is to increase, then more water and energy
will be required from local sources.
Demand-side disruptions such as a reduction in everyday mobility for work or social
events results in low energy demand. Decreased leisure activities are also responsible forlowering energy demands. Lockdowns are expected to further disrupt energy demands
significantly as primary energy consumption decreased [71]. It has been reported in some
European countries that energy demand fell during the first wave of COVID-19 [72]. The
pandemic also affected tourism, also resulting in lower demands for energy along withfood and water. On the other hand, quarantine regulations may result in higher electricity
and water requirements. These kinds of measures influence the overall FEW resource
consumption profile.

more on a water source [64,65]. The water ecosystem is also greatly affected by biomedical
waste, and this is hampering water supply sources and ultimately harming the environment [66]. In Bangladesh, at least 14,500 tons of waste from healthcare was generated
across the country due to COVID-19 in April 2020 [67]. India also experienced a 46% inin COVID-19-related biomedical waste generation in between April and May102021,
Int. J. Environ. Res. Public Health 2021,crease
18, 12493
of 16with many municipalities of India recording a sharp increase (up to 25%) in domestic water consumption (e.g., Kozhikode in Kerala and Ahmedabad in Gujarat) [68].

Figure 2.
2. Implications
Implicationsof
ofCOVID-19
COVID-19on
on thethe FEW
FEW nexus
nexus (image(image source:
source: modified
modified fromfrom [26]).
[26]).
Figure

The cross-linking perspective of COVID-19 and FEW nexus is also considered toFood security is also under stress due to widespread disruptions along the supply
prioritize links to reduce the complexity of disruptions. Increased hygiene activities andchain, as well as impacts on agricultural production due to mobility restrictions [69,70].
biomedical waste has an effect on the two sub-nexuses: the food–water sub-nexus due to
Demand-side disruptions include reduced mobility, dietary changes, reduction in induspollution of the land and, consequently, the water sources, and the energy-water nexus
trial operations, and quarantine regulations, and these force people to take a local producdue to increasing demand for water and energy for wastewater treatment. On the othertion approach. This implies that the FEW nexus at the local level should be assessed andhand, disruptions due to decreased mobility and dietary changes during quarantine are
optimized to avoid tradeoffs. If local production is to increase, then more water and enforcing basic supplies to be produced locally [73–75]. This impact points to crosslinks
ergy will be required from local sources.
between COVID-19 and both the food–water sub-nexus and the energy–food sub-nexus, as
Demand-side disruptions such as a reduction in everyday mobility for work or social
enhanced local food policies require water and energy. There are also other disruptions
events results in low energy demand. Decreased leisure activities are also responsible forthat will result in changes in the demand for water or energy resources. For example,
lowering energy demands. Lockdowns are expected to further disrupt energy demands
staying at home increases electricity and water demand [76]. With the increased energy
significantly
as primaryenergy systems
consumption
decreasedDue[71].toItthis
has kindbeen ofreportedin somedemand, energy
management
are increased.
instability,
it isEuropeancountries
that
energydemandfell
during
the
first
wave
of
COVID-19[72].
difficult to assume what the exact COVID-19-related changes are in terms of water useTheforpandemicalso
affected
tourism,
also
resultinginlower
demands
forenergyalong
withelectricity supply.
food and water. On the other hand, quarantine regulations may result in higher electricity
andwater requirements. These kinds of measures influence the overall FEW resource con5. Discussion
sumption
profile. Urban–Rural Linkages for FEW Security in Post-COVID-19 Era
5.1. StrengtheningThe
cross-linking
of COVID-19
andconclude
FEW nexus
alsoimportanceconsideredoftoFEW
priFrom this review perspectiveof existing literature,
we canthatistheoritizelinks
toreducethecomplexityofdisruptions.
Increased
hygieneactivities
andsecurity is increasingly being recognized at policy and governance levels, althoughbiat
omedical
waste
has
an
effectonthetwosub-nexuses:thefood–water
sub-nexus
due
tovarying levels and sectoral considerations. It is also being recognized that cities arepollutionof thelandonand,consequently,
watersources,andthe energy-water
nexus
increasingly
reliant
theirsurroundingthe
rural
areas
for FEW
supplies[77]. For instance,due
toincreasing
demand
for
water
and
energyforwastewater
treatment.
On
the
other
in terms of energy security, it is underlined in Section 4.2. that most cities cannot achieve
hand,
disruptions
due
todecreased
mobility
anddietarychangesduringquarantineare
net-zero emission within their city boundary. While nearly 60% of the world’s population
lives in cities (that occupy only 2% of land area) [35], in-boundary FEW production isconstrained due to high density and limited space. On the other hand, peri-urban and rural
areas often lack the infrastructure they require, including human, financial, and technicalresources to ensure an optimal use of regional natural resources.
As highlighted in Section 2, the importance of urban–rural linkages and FEW resource
security (such as water for all, clean energy, and food security) has, accordingly, been
acknowledged on global agendas, in regional programs, and for national development
strategies. As discussed in Section 4.1, urban–rural linkage plays a very important role forInt. J. Environ. Res. Public Health 2021, 18, 12493

11 of 16

food security, particularly in times of emergency. Enhancing local production and local
consumption can thus improve resilience for food supply systems against the various
externalities such as disruptions during pandemics. In response to the food supply risk
due to the COVID-19 pandemic, a city–region food system approach has been promoted
in different parts of the world (see Section 4.1). This approach clearly acknowledged thecritical role of urban–rural linkages in mitigating food insecurity during emergencies.
Global leaders are working together, aiming for a net-zero emission world by midcentury, and, as such, a huge expansion of renewable energy (RE) would play a vital role inachieving this goal. As cities account for 70% of the world’s energy consumption, actionsin and by cities have received special attention for achieving important global goals andnational development targets. In fact, more than 700 cities have made a wide range of commitments for achieving carbon neutral or net-zero emission targets by 2050 [78]. Achieving
these commitments requires radical decarbonization measures such as achieving 100% RE,
which, in many cases, go beyond city boundaries. Cities need to explore collaboration withsurrounding rural areas to utilize the maximum potential of available decarbonization
options that can be the engine to achieve net-zero emission. As discussed in Section 4.2,
several cities in developed countries have realized that they must collaborate with rural
areas if they want to achieve their 100% RE energy targets. This can generate a positive
economic cycle, linking RE and environmental values. Urban–rural partnerships for the
expansion of RE can also bring new job opportunities. Grid-connected renewables aremainly located outside of cities, which can create new job opportunities in rural areas. It isestimated that the RE sector will create nearly 300,000 new job opportunities in India by
2022 [79]. In particular, RE power plants can create permanent job opportunities for thosepeople who migrated to rural are due to the pandemic [80].
While poor water management in terms of both water use efficiency and water environment conservation are some causes of increased water insecurity worldwide, Section 4.3
shows how collective urban–rural actions can help to improve water management in different regions. Cities need to secure reliable and quality water supply for their growing
populations, as well as for fueling economic activities. Offering economic incentives canenhance improvements in water use efficiency and water environment conservations inrural communities, as observed in the cities of San Diego in US, Kumamoto in Japan, Reus
in Spain, and Munich in Germany (refer to Table 3).
Broadly, FEW security is inherently inter-linked and inter-dependent. Overlooking
the nexus that exists for FEW resources management in rural areas not only aggravates
the risk to FEW sectors in those areas, but it also creates threats to FEW security for urban
populations. Furthermore, the COVID-19 pandemic also places additional concerns on the
FEW nexus, as responses to the pandemic have direct impacts on FEW due to disruption
on both supply and demand side, as discussed in Section 4.4. In the post-COVID-19-era,
more emphasis should be put on the localization of FEW security and resilience to mitigate
such risks in the future. There is also likely to be an increased demand for local ecosystemservices related to FEW due to intensive economic activities and demography changes.
This implies that the dynamics of the FEW nexus will also change along with promotionof localization. Therefore, the local-level FEW nexus, particularly in the urban–ruralcontinuum, is likely to also gain more attention in the post-COVID-19 era.
Here lies an opportunity to create a win–win relationship between urban and rural
areas toward a self-reliant and resilient region. Cities can take advantage of the abandoned
natural resources available in rural areas to meet the growing demand for FEW for their
population. On the other hand, a city can offer necessary support for better management of
the FEW nexus in rural areas in order to ensure an efficient and optimum use of resources
for higher productivity. This can also generate multiple benefits for rural populations,
including inclusive economic growth and new job opportunities.

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12 of 16

5.2. Framework for Translating Urban–Rural Linkage to Partnership
In the post-COVID-19 era, building urban–rural partnership is essential to formulatea sustainable recovery plan for FEW systems and to redesign these systems. This canbe achieved by acknowledging the interdependence of urban and rural areas, thereby
optimizing the FEW nexus.
Conventional urban and rural governance is designed for the management of issues
and challenges within a specific area’s own spatial boundaries only, and underestimates
the value of surrounding landscapes for their resilience and sustainable development.
Ignorance of urban–rural linkages in the national legislation and policies is also one of
the main reasons for the disconnected management of FEW resources. In recent years,
urban–rural linkages have been strengthened in some developed countries or regions, withnational governments and regional authorities formulating strong supporting policies. For
example, urban–rural linkages have been promoted in some of Japan’s major government
policy documents such as its Basic Environmental Plan. Furthermore, several supporting
schemes have been launched to promote urban–rural linkages. As discussed in Section 2,
urban–rural partnerships have also been promoted by the European Union with various
supporting schemes, and many European countries have established good practices inurban–rural linkages that can serve as guidance for developing countries. This implies thatnational governments should take proactive steps to promote urban–rural partnership byformulating appropriate legislation, strategic guidelines, and relevant policies, as well as
by offering technical and financial assistance.
These national-level interventions are expected to trigger cooperation initiatives between urban and rural governments. Upscaling the sustainability of urban–rural cooperation requires a platform that brings together all key stakeholders from urban–rural regions
to ensure horizontal coordination and to formulate a common vision and integrated actions
for a sustainable FEW system. This platform can play the role of a science–policy–action
Int. J. Environ. Res. Public Health 2021,interface
18, x
13 of 17by connecting people, skills, and money from the city region. Strengthened urban–
rural partnerships will lead to a collective response to address disruptions in the system,
formulation of integrated recovery policies, and a redesign of FEW systems through the
optimum
useoptimumof local resources,
skills,and finance.
A strong
urban–ruralpartnership partwill
through theuse of local
resources,
skills, andfinance.
A strong urban–rural
notonly will
enhancethe resiliencethecity region,
butcitywillregion,
also contribute
thecontributelocalizationnership
not onlyenhance of
theresilienceof thebut will to
also
to
of
national
andglobalgoals.
Figure3
illustratesasuggestedframeworkforenhancing
the localization of national and global goals. Figure 3 illustrates a suggested framework
urban–ruralpartnerships.
for enhancing
urban–rural partnerships.

Figure3.3.Framework
Frameworkofofurban–ruralurban–ruralpartnership
capturing
multiplebenefits(imagesource:auFigure
partnershipfor forcapturing
multiplebenefits(imagesource:authors).
thors).

6. Conclusions
This study highlights the importance of strengthening urban–rural linkage for thecollective security of FEW in the post-COVID-19 era. Based mainly on a review of theexisting literature, this study develops a precise understanding of the importance of ur-

Int. J. Environ. Res. Public Health 2021, 18, 12493

13 of 16

6. Conclusions
This study highlights the importance of strengthening urban–rural linkage for thecollective security of FEW in the post-COVID-19 era. Based mainly on a review of theexisting literature, this study develops a precise understanding of the importance of urban–
rural linkages and sets out a city-region perspective for FEW security. It also synthesizes
the impact of COVID-19 measures on the FEW nexus, for disruption to both demandand supply, discussing how the pandemic and various countermeasures have altered therelationship across the FEW nexus. A framework on how to translate urban–rural linkages
into partnerships has also been suggested to manage FEW systems in a collective manner.
The important elements of the proposed framework are the formulation of national-level
policies to support urban–rural linkages, the provision of guidance and technical andfinancial assistance through national schemes, and the engagement of multistakeholder
platforms at a city-region level. Multistakeholder platforms can play a role as science–
policy–action interfaces that enhance the collective response, sustainable recovery plans,
and the redesign of the food, energy, and water nexus in an urban region.
To meet the increasing demand for FEW by rapidly growing populations is challenging, particularly for urban areas that mostly rely on supply from outside of city boundaries.
Hence, urban–rural linkages should be properly acknowledged for enhancing the securityof FEW resources. This study found that existing literature highlights the application ofurban–rural linkage for FEW security, however focuses on a single or dual resource security
issue. While FEW security is interlinked, this study argues for collectively managing the
FEW nexus both on the supply side (rural areas) and demand side (urban areas) throughstrengthening urban–rural linkages.
The authors acknowledge that this research is subject to certain limitations, as it ismainly based on a review of existing literature. Although the study findings are expected
to remain relevant for the long term, the situation surrounding the COVID-19 pandemic
is changing constantly, and a growing number of studies are further highlighting good
examples of FEW security from around the world. The future scope of this researchaccordingly entails case-specific studies at a local level, wherein the applicability of the
proposed framework for translating urban–rural linkages into partnerships can be tested.
Author Contributions: Conceptualizing, investigating, review, and editing was done by all authors.
The original draft was prepared by P.M., R.S., B.K.M., S.D., M.A.R., D.S. and V.S. have provided
overall guidance, supervision, project administration, and funding resource. All authors havecontributed significantly to developing this paper and agree to the published manuscript. All authors
have read and agreed to the published version of the manuscript.
Funding: This research was funded by the Asia-Pacific Network for Global Change Research (APN)with reference number CRRP2020-05MY-Shaw.
Acknowledgments: This study has been conducted under the project ‘Developing Urban-Rural
partnerships framework to mitigate climate-induced water availability impacts on Food, Energy, andWater (FEW) security at regional level’ funded by the Asia-Pacific Network for Global Change Research (APN) with the project reference number CRRP2020-05MY-Shaw. This study is also supportedby the Japan Science and Technology (JST) under the Belmont Forum Sustainable Urbanization
Global Initiative (SUGI) on Food-Water-Energy Nexus with the project reference M-NEX. Authors are
grateful to three anonymous reviewers who have immensely helped in improving the manuscript
and Emma Fushimi, IGES Japan for her kind support in proof reading and edits. The third author(V.S.) also extends thanks to the Ministry of Education, Culture, Sports, Science and Technology(MEXT), Japan for providing scholarship.
Conflicts of Interest: The authors declare no conflict of interest.

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The current issue and full text archive of this journal is available on Emerald Insight at:https://www.emerald.com/insight/1759-5908.htm

Shelter management during
pandemics: lessons fromcascading risks ofcyclones and COVID-19
Sujit Mohanty
Keio University, Fujisawa, Japan

Ambika Dabral and Ranit Chatterjee

Sheltermanagement
duringpandemics

Received 22 September 2020
Revised 27 December 2020
3 February 2021
Accepted 5 February 2021

Rika India, Delhi, India, andRajib Shaw
Keio Universiy, Fujisawa, Japan

Abstract
Purpose – The concept of multi-purpose cyclone shelters has been found effective in saving various lives
during past cyclones. The recent cyclone Amphan, which hit the Indian states of Odisha and West Bengal in
the middle of pandemic COVID-19 has posed severe issues related to cyclone shelter management in the rural
areas. The purpose of this paper is to investigate the case of Odisha in a pandemic and draw some key lessonsof cyclone shelter management, which can be useful for future cascading risks in other parts of the country
and the region.
Design/methodology/approach – Cyclone shelters are critical infrastructures in the management of
cyclones, associated hazards and saving crucial lives. The effective management of shelters during
emergencies is dependent on the existing institutional mechanism, local stakeholders and their understandingof the key functions of the emergency shelters. This paper reviews the key challenges through literature,reports and direct interviews of ﬁeld professionals and practitioners.
Findings – In normal times, cyclone shelters are used as schools and their management lies with the local
communities and/or elected bodies. Some of the key emerging issues include: the convincing population atrisk for evacuation with proper care, existing emergency shelters being repurposed as COVID-19 facilities,
need for hygiene and safety material, special arrangement and segregation of population at higher risk of
COVID-19 and large destruction of social infrastructures.
Originality/value – During cascading disasters, adaptive governance becomes important. With the studyof cyclones during the pandemic period, the paper draws key decision-making and governance points ofcyclone shelter management. This case analysis can be useful to other similar situations during the prolonged
pandemic time.

Keywords Early warning system, COVID-19, Cascading risk, Critical infrastructures,
Cyclone amphan, Cyclone shelter management, Shelter management
Paper type Case study

1. Introduction
Critical infrastructures (CI) are physical structures, facilities, networks and other assets thatprovide services that are essential to the social and economic functioning of a community or

The authors acknowledge support from India Japan Laboratory of Keio University.

International Journal of Disaster
Resilience in the Built
Environment© Emerald Publishing Limited
1759-5908
DOI 10.1108/IJDRBE-09-2020-0103

IJDRBEsociety (United Nations Ofﬁce for Disaster Risk Reduction, 2017). Further, the CI ensures thesafety and well-being of the population (OECD, 2019). From the perspective of disaster risk
management, CI are basic lifeline infrastructures that aid in saving lives, connecting toaffected communities, supporting response and relief operations and ensuring continuity ofnormal functioning of life. These include hospitals and health care centers, water supply,
power grids, telecommunication, transmission lines, transportation network, control rooms,
emergency shelters, etc. These CI functions as an interrelated system of systems andinteract with each other for supporting the normal functioning of key services. Due to this,the impact on one often triggers a cascading effect on others during disasters (Private Sector
Alliance for Disaster Resilient Societies [ARISE], UNDRR, 2017).
Thus, the resilience of CI is a deﬁning factor for a hazard to become a disaster. The
Sendai Framework for Disaster Risk Reduction (2015–2030) lays down seven global targets.
Target D calls for substantial reduction of disaster damage to CI and disruption of basic
services through, amidst others, developing their resilience by 2030 (United Nations Ofﬁce
for Disaster Risk Reduction, 2015). Besides, the resilience of CI is crucial toward achieving
other global targets of the Sendai Framework including a substantial reduction in disastermortality, number of disasters affected people and direct disaster economic losses. Mohanty
et al. (2020) did an extensive review on CI and its role in disaster risk reduction. OECD (2019)deﬁned CI as systems, assets, facilities and networks that provide essential services for thefunctioning of the economy and the safety and well-being of the population.
Hazards such as cyclones and ﬂoods often trigger large-scale evacuations in the
coastal and at-risk communities. During such times, the emergency shelters offer safe
spaces to the evacuated population till it is safe for them to return to their dwellings.
Thus, particularly for coastal communities, emergency shelters are considered as CI as
they help in reducing potential life loss and injuries. The management of emergency
shelters during normalcy and disasters is full of diverse challenges and requires
institutional and community level preparedness and awareness for their effective use.
Some of these challenges include space management, management of basic services at the
shelter, management of relief aids, etc.
Along with a huge life loss, the current pandemic of COVID-19 has caused large-scaledisruption in the socio-economic functioning of the global society. Different parts of
the world such as the Philippines (Typhoon Vongfong); India and Bangladesh (Super
cyclone Amphan); the Solomon Islands, Vanuatu, Fiji and Tonga (Cyclone Harold) havebraved cyclones or typhoons or hurricanes during the current pandemic (UNOCHA,
2020). This has aggravated the challenges for the respective authorities and stakeholders
in the management and functioning of the emergency shelters. These include, among
others, increased fear among the evacuated population of contracting the COVID-19
infection, ensuring physical restrictions measures during evacuations and at shelters,
exposure to crowded conditions movement restrictions of external aid-workers,
deployment of teams for needs assessment (UNOCHA, 2020), increased use of personal
protection equipment (PPE) and hygiene supplies and practices and the involved
additional cost (CDC, 2020a, 2020b).
This paper explores various such challenges faced in the functioning and management ofshelters during complex risks of cyclones and the pandemic. A case of the Indian coastal
state of Odisha is studied for understanding the management of emergency shelters with a
special focus on their management during the complex risks of super cyclone Amphan and
the COVID-19. Further, the paper seeks to draw key lessons and good practices undertaken
by local authorities and local communities for the same.

2. Methods
The paper uses the case study approach to study shelter management during cyclones andﬂoods in general and pandemics in particular. This has been done by studying the Indiancoastal state of Odisha, which is frequented by cyclones and ﬂoods each year and has also
recently braved the super cyclone Amphan during the current pandemics. This provides agood case for exploring the challenges in the management of shelters from the perspective ofcascading and complex risks. The paper makes use of both primary and secondary data forundertaking the study. The secondary data is collected through the desk-based review of
relevant resources. The secondary data such as government reports, studies, guidelines,
memorandum have been collected through consultation with the relevant ofﬁcers of the
Odisha State Disaster Management Authorities. The primary data is collected throughinterviews of key personnel at the state level and the ﬁeld level. The interviews were guided
by a detailed open-ended qualitative questionnaire that covered various aspects of shelter
management during normalcy, cyclones/ﬂoods and complex risk of cyclones and COVID-19.
Some of the key issues targeted through the questionnaire include accessibility andsuitability of location, capacity and space management particularly during COVID-19, key
facilities available in the shelter and impact of COVID-19 on them, the functioning ofshelters during normalcy and disasters, the mechanism for operation and maintenance ofshelters, social acceptance of shelters during cyclones/ﬂoods and COVID-19, etc.
The key limitation of the study is that at the time of writing this paper, the state of
Odisha was braving the ﬂoods due to which the interviews of all the key ofﬁcials andstakeholders could not be scheduled. However, the study includes the interview of one
community mobilizer from one of the Cyclone Amphan affected districts and one State
personnel who looks after the management of shelters at the state level.
3. Literature review
Resilience is deﬁned as “the ability of a system, community or society exposed to hazards toresist, absorb, accommodate, adapt to, transform and recover from the effects of a hazard ina timely and efﬁcient manner, including through the preservation and restoration of its
essential basic structures and functions through risk management” (United Nations Ofﬁce
for Disaster Risk Reduction, 2017). The resilience of CI is a deﬁning factor in mitigating theadverse impacts of a potential hazard. Resilience, in the context of CI, is deﬁned as the abilityof a facility or asset to anticipate, resist, absorb, respond to, adapt to and recover from a
disturbance. Out of the various approaches of vulnerability reduction, the engineeringschool of thought emphasizes the presence of safe structures and built environments inhazard-prone areas along with appropriate construction practices and materials to increase
their resistance (McEntire et al., 2010).
Findings based on a study in South-Western Bangladesh highlight that the
infrastructure and structural protection requirements include multi-purpose cyclone shelters(MPCS) along with permanent embankments and suggested dependence of local
communities on them because of their critical importance in reducing disaster risk andsaving lives (Wedawatta et al., 2016). The concept of having in place structurally engineered
infrastructures as cyclone shelters was undertaken in Bangladesh during the 1960s and in
India post a devastating cyclone in Andhra Pradesh in 1977 (Dash and Walia, 2020).
Afterward, the concept of establishing MPCS was introduced to ensure that regular
maintenance of the structures even during non-disaster times. This also helps in ensuring
efﬁcient utilization of the MPCS by local authorities and local communities.

Sheltermanagement
duringpandemics

IJDRBE3.1 Key challenges faced in shelter management during COVID-19
One of the key guiding principles for emergency shelters includes their being disasterresilient so that the evacuated population is not further inﬂicted with any life loss or injuries
due to other potential risks in the shelters (NDMA, 2019). This principle is signiﬁcantly
relevant in the context of cascading and complex risks. The recent occurrences of various
cyclones amid the pandemic of COVID-19 are among such complex risks that haveaggravated the challenges for the affected population, local authorities, response agencies
and other key stakeholders. While the emergency shelters do provide a haven to theevacuated populations, their potential crowded settings provide a high-risk ground fortransmission of COVID-19. This has posed new challenges in managing and ensuring
effective management and functioning of emergency shelters in various aspects. Some ofthese challenges include convincing the population-at-risk to evacuate to shelters amid fearof COVID-19 infection; physical distancing, respiratory etiquettes and hygiene practices atthe emergency shelters (CDC, 2020a); efﬁcient management of available physical andﬁnancial resources; reduced availability and access to external aid due to COVID
restrictions.
Fear and uncertainty about the COVID-19 in the local population made it challenging forthe local authorities, community mobilizers, response agencies and volunteers to convince
the population-at-risk for evacuation. There have been cases of some families ﬂeeing the
emergency shelters in West Bengal during cyclone Amphan amidst fear of getting COVID19 infected (Ober, 2020). There are also recorded incidents of some of the affected areas
refusing relief aid due to fear of contracting infections (Ober, 2020).
The COVID-19 and its essential requirement of physical distancing reduced the effective
capacity of the existing emergency shelters and fewer evacuated persons could beaccommodated in a given shelter. The Centers for Disease Control and Prevention (CDC)
prescribed the evacuated population to maintain a six feet distance from other evacuees
outside one’s household (CDC, 2020b). To ensure that the used emergency shelters are
COVID-proofed and duly comply with required norms of physical distancing, during thecyclone Amphan, the emergency shelters could accommodate only 0.2 million persons
instead of their usual capacity of 0.5 million persons (Ober, 2020). Similarly, in Bangladesh,around three times the usual numbers of emergency shelters and other infrastructures wereused during cyclone Amphan (Ober, 2020).
The cases of Indian coastal states of West Bengal and Odisha illustrate another kind ofchallenge for the local authorities during the management of dual risks of COVID-19 andcyclone Amphan. Much before the states were struck by the cyclone, various existing
emergency shelters were repurposed into different facilities for the management of COVID19 (Dasgupta, 2020). These include quarantine centers, temporary medical centers (TMC),
centers for the migrant workers returning from other states. Due to this, on the receipt of thewarning for the cyclone, the local authorities and stakeholders had to promptly identify new
and safe structures such as schools, colleges, community halls and government buildings,
which can be repurposed as emergency shelters. While some of these buildings were alreadyvacant due to COVID-19 imposed lockdown.
The COVID-19 has necessitated the local authorities to ensure the provision of additional
supplies and services such as clean water for regular handwashing, soaps, disinfection gels,sanitizers, masks and PPE for ﬁrst-line responders. Not only is this an additional pressure
on the budget of local authorities but also this can be challenging at times considering that
often the natural hazards such as cyclones and ﬂoods disrupt the water supplies, drainage
and sanitation and power infrastructures; thus, indirectly impacting the COVID-19 control
measures (T.V.Pandya, 2020).

The prompt response and relief actions by non-governmental agencies, for the
management of cyclones amid the restrictions of COVID-19, are also dependent on
the timely ease of restrictions by the local authorities. The cases of cyclone Harold, cyclone
Amphan and typhoon Ambo illustrate how the high-risk perceptions and awareness of local
authorities on cyclones, ﬂoods and the high risk they pose to life and health of the
population can trigger the local authorities to appropriately relax the COVID-19 restrictions
for facilitating early actions by external stakeholders (Lux, 2020). Besides, in some cases,
various COVID-19 restrictions on travel and movement limited the assistance, theheadquarters of non government organizations (NGOs) and other external stakeholders canprovide to their local partners in the affected areas (Lux, 2020). This highlights a crucial
aspect of the local actors being adequately trained and equipped to perform the required
roles even with limited support from outside.
In a recent report from Japan, Das et al. (2020) explored the key challenges in evacuation
centers in post-ﬂood situation during COVID-19. The report focused on evacuation behavior,
the community’s reluctance to go to evacuation centers for the fear of contamination, spaceissues in evacuation centers (due to 40% occupancy guideline from the government), speciﬁc
care in the centers to avoid contamination and volunteer management. The reportemphasized on adaptive governance approach and urged for a strong link of local
governments, civil societies and communities.
4. Management of shelters during complex risks of COVID-19 and cyclone
Amphan: a case study of Odisha
The state of Odisha is located on the eastern coast of India and among other hazards, it isfrequented by tropical cyclones and ﬂoods almost every year. It has a vast coastline of
480 km, which makes it highly vulnerable to tropical cyclones and tidal surges (Figure 1).
The state has 11 major rivers; the largest river system of Mahanadi along with its tributaries
and distributaries poses a severe threat of ﬂoods in the state. The increased frequency andseverity of these hazards are attributed to climate change. Over the past two decades,
tremendous efforts have been made by the Government of Odisha in institutionalizing
disaster risk management. The concerted efforts by various stakeholders have led to a
substantial reduction in life loss during recurring cyclones, ﬂoods and other hazards. One of
the steps in this direction is having in place safe multi-purpose cyclone and ﬂood shelters
supported by a robust mechanism of their management. Because of its hazard-prone proﬁleand an effective shelter management system in place, the current study selected the State of
Odisha as a case study to better under the management of shelter, especially during thecurrent times when the risk of cascading or complex emergencies are on the rise.
4.1 COVID-19 situation in Odisha
The ﬁrst case of COVID-19 was reported in the State on March 16, 2020. The State wasamong the ﬁrst ones to announce the lockdown. It was the ﬁrst Indian State to set up a
dedicated hospital for COVID-19 patients (NDMA and CDRI, 2020). As per the Press Release,
Government of Odisha, up to midnight of August 19 2020, the number of positive cases is70,020 with 380 deaths. So far, 48,576 persons have already recovered/discharged. Besides,
Odisha is one of the major sources of migrants who travel to other states for work. Due tothe current pandemic and resultant national lockdown, the return of a large number of
migrant workers posed additional challenges for the management of the COVID-19 situationin the state.

Sheltermanagement
duringpandemics

IJDRBE

Figure 1.
Wind and cycloneprone zones of Odisha

4.2 Impact of cyclone Amphan in Odisha
The Super Cyclonic Storm Amphan crossed West Bengal as a Very Severe Cyclonic
Storm with a speed of 155 kilometers per hour (kmph)–165 kmph gusting to 185 kmph
across Sundarbans. The damages in the State of Odisha were mainly caused by gusting
wind and heavy rainfall. It affected around 4.53 million people from 9,838 villages of 97
blocks and 272 wards of 22 Urban Local Bodies in 10 districts of the State. A total of200,346 people were evacuated from vulnerable areas of Odisha to 4,314 shelters(Government of Odisha, 2020).
Besides causing varying levels of damage to kutcha houses, pucca houses, huts andcowsheds, Amphan and associated heavy rainfall have led to the death of 17 large milch
animals, 7 small milch animals, 14 draught animals and 4,685 poultry birds. Further, it has
affected 1,903 livestock and 18,875 poultry birds. Over 3,000 hectares of agriculture,horticulture and perennial crops have sustained a crop loss to the extent of 33% and above(Das et al., 2020). In addition to these, Amphan has caused damage to around 151 kilometers(kms) of rural roads, over 200 kms of public works department (PWD) roads, 17 kms ofurban roads, 3 kms of drainage, 73 kms of embankments, 71 PWD buildings, 646
Anganwadi Centers, 1,552 primary school buildings, 298 Gram Panchayat Buildings/
Community Centers. Due to damage to their equipment and raw materials, 5,400 traditional
craftsmen and artisans have lost their livelihood (Das et al., 2020). In the Final Memorandumof Super Cyclonic Storm Amphan, the Government of Odisha notes that Amphan has led todamage and loss of public properties amounting to INR 2,209.61m and an amount of
152.72m was spent on immediate relief needs.

4.3 Cyclone shelters in coastal India
In India, various lessons are learned from the Odisha Super Cyclone of 1999, which struck
the state with over 300 kmph of wind speed. It was recognized that precious lives were lost
due to the lack of safe emergency shelters. Further, the importance of cyclone shelters ascritical life-saving infrastructure was exempliﬁed by 23 cyclone shelters in some of thecoastal districts of the State, which reportedly provided refuge to and saved 42,000 lives
during the Super Cyclone of 1999. These were constructed by the Indian Red Cross Society(Odisha State Branch). This was an eye-opener for the government and has thereafter
positioned cyclone shelters as CI for safeguarding lives (Odisha State Disaster Management
Authority). The critical role emergency shelters (cyclone and ﬂood) have played during
disasters in Odisha is further underscored by studying the cases of various disasters thestate braved post-Super Cyclone 1999 too. Table 1 shows a comparative data set of life loss
and the number of persons evacuated along with the number of shelters used during major
cyclones faced by the state.
In the aftermath of the Super Cyclone of 1999, the Indian coastal state of Odisha hasrecognized the need for disaster resilient shelter buildings as part of its long-term disasterrisk reduction initiatives. This led to the construction of around 135 MPCS by theGovernment of Odisha using Chief Minister’s Relief Fund, Prime Minister’s Relief Fund andsupport from World Bank. Subsequently, the National Cyclone Risk Mitigation Project(NCRMP) was initiated in 13 prone states and union territories (UT) of India in a phase-wisemanner. NCRMP was envisaged to undertake suitable structural and non-structural
measures to mitigate the effects of cyclones in the coastal states and UTs of India. The key
components of NCRMP included construction and sustainable maintenance of MPCSs,
improved access and evacuation to shelters, construction of coastal embankments;
strengthening of early warning and communication systems and enhancing capacity andcapability of local communities.
Another project having the component of the construction of MPCS is the integrated
coastal zone management project (ICZMP). The key objective of ICZM is building national
capacity for the implementation of a comprehensive coastal management approach in the
country. It is being piloted in the states of Gujarat, Odisha and West Bengal.

Sheltermanagement
duringpandemics

4.4 Cyclone shelter management system in Odisha
In Odisha, there a total of 879 multi-purpose cyclone and ﬂood shelters. Out of these, 65 havebeen constructed by the Indian Red Cross Society and the remaining by the Government of
Odisha under various schemes and programs including NCRMP, NCRMP (Additional
Financing), ICZMP, through funding from Prime Minister and Chief Minister’s Relief Fund,World Bank, Container Corporation of India, etc. (OSDMA, 2014a, 2014b). Most of these

CycloneDeaths

Persons evacuatedShelters used

Super cyclone, 1999
Very severe cyclonic storm, Phailin, 2013
Very severe cyclonic storm, Hudhud, 2014
Very severe cyclonic storm, Titli, 2018
Very severe cyclonic storm, Bulbul, 2019
Extremely severe cyclonic storm, Fani, 2019
Super cyclonic storm, Amphan, 2020

10,000
27
3
71
0
64
0

42,0009,83,642 (cyclones), 1,71,083 (ﬂoods)
2,55,043
3,60,132
11,458Around 15,500,00
2,00,346

23
4,197
2,143
1,612
100
9,177
4,314

Source: Memorandum, Government of Odisha

Table 1.
Number of deaths
and persons
evacuated during
major cyclones in
OdishaIJDRBEshelters are situated inside existing school premises or adjacent to schools. Five of the MPCS
constructed under NCRMP are shelters-cum-storage. The capacity of these shelters varies
from 1,000–2,000 persons. Shelters have provision for separate hall and toilets for men andwomen along with one extra room for sick/labor room and one store-room. The shelters areprovided with basic amenities such as water, light and sanitation. Drinking water isprovided through a submersible pump. Each shelter has a power backup through a 5 KVA
generator set.
A community-based management and maintenance system is in place for the shelters inthe state whereby Cyclone/Flood Shelter Management and Maintenance Committees(CSMMC/FSMMC) have been formulated and imparted managerial training. CSMMCs and
FSMMCs are registered as a society under the Societies Registration Act, 1860, and aregoverned by by-laws of the respective societies. The committees are constituted through a
Pali Sabha (special community meeting) convened by the local Block Development Ofﬁcer/
Sarpanch (village head) of the concerned block/Gram Panchayat (village council). Eachcommittee comprises around 21–25 members. Sarpanchs of concerned Gram Panchayat andExecutive Ofﬁcers in the urban local body are ex-ofﬁcio Presidents of the committees. The
composition of committees reﬂects a mix of local government ofﬁcials, political members
from concerned ward and hamlets and representatives from different sections of thecommunity including representatives of women, persons with disabilities, scheduled caste/
tribe, self-help group, local NGO/village club, etc. Such a composition is effective for
nurturing the culture of community ownership in the usage and management of the shelters.
The local community is responsible for the day-to-day maintenance of the shelter and is
supported and cooperated by the committee.
Another special feature of cyclone shelter management in Odisha is that the shelters arebeing used as multi-purpose shelters. During normal times, these are used as schools andthis is supported by the provision of an inbuilt backboard in the hall and the respective
Headmaster is responsible for cleaning and maintaining the shelter. Besides when not in use,shelters could be used for government programs, social, cultural and economic purposes on
payment of user fees. A joint account is used for keeping the collected fees and the same
could be spent for repair, maintenance and disaster preparedness activities. However, no
one is allowed to use the shelter or its campus permanently. As the primary purpose of theseinfrastructures is that of cyclone and ﬂood shelter, so when used for other purposes, the laid
down norm is to vacate the building and keep it ready for use as shelter on receipt of early
warning. In addition, the shelter management system has a laid down mechanism for
dispute resolution whereby any dispute regarding management or use of shelters is brought
to the notice of the local Block Development Ofﬁcer, respective District Collector and
OSDMA.
5. Shelter management during cyclone Amphan and COVID-19: key emerging
issues
The state of Odisha has faced cascading or complex risks in the past when in 1999 it has
experienced 2 cyclones within 11 days. In 2014, the state braved back-to-back cyclone
Phailin and two rounds of ﬂoods, which has increased the duration of the disaster phase.
This also necessitated an evacuation of around 0.98 million persons from 14 districts due tocyclones and a subsequent evacuation of around 0.17 million persons from 3 districts thatwere severely affected by ﬂoods. During Phailin, the most common problems reported by
evacuees to shelters include concerns of insufﬁcient space, shortage of food and water andthe absence of toilet facilities (OSDMA, 2014a, 2014b).

The challenges posed by the current pandemic of COVID-19 in Odisha were aggravatedfor the government machinery and other stakeholders when the warning for Super Cyclonic
Storm Amphan was received. On receipt of warning for Amphan, the key stakeholders wereasked to ensure preparedness measures for prompt response and relief and to immediately
check and keep all multi-purpose cyclone and ﬂood shelters ready for use. At the shelter
level, meetings of respective CSMMC/FSMMC were organized to ensure all measures aretimely taken and required facilities are in place in the shelter. The actions included
undertaking prompt repair work if needed; testing the water supply system, generators,
inﬂatable tower lights, mechanical cutters and other equipment available in the shelter. Fuelarrangements were also made for generators and other equipment (SRC, 2020). Twoteachers were identiﬁed as in-charge of each of multi-purpose cyclone and ﬂood shelters andother alternate shelters and they were to coordinate and report on the management ofshelters. Cooked food through free kitchens was provided to the evacuees.
5.1 Convincing population-at-risk for evacuation amidst fears of transmission of COVID-19
infection
To begin with, one of the key challenges posed by COVID-19 was that in some cases people
were hesitant in leaving houses and taking refuge in shelters. Before the receipt of thewarning for cyclone Amphan, the communities were being made aware of the impacts of
COVID-19 and were advised by the local authorities to stay inside and venture out only fornecessary work. However, immediately after the cyclone warning, the population-at-risk
were asked to prepare for evacuation and leave for safe shelters. This drastic shift inadvisories by the local authorities from stay-in orders to evacuation orders made itchallenging for the local population to perceive the complex risk. This required sensitizationof the people on the necessity of evacuation from vulnerable locations and how the cyclone
could be more be life-threatening than the COVID-19 infection. The challenge wasparticularly higher for evacuation in COVID-19 red zones. During the dissemination of early
warning and evacuation operations, efforts were made by community mobilizers and othervolunteers to sensitize the affected population on aspects of physical distancing, and wereasked to use masks/clean cloth to cover their mouth and noses during evacuation and theirstay at the shelter.
5.2 Existing emergency shelters being repurposed as COVID-19 facilities
The ﬁrst COVID-19 case was reported in Odisha on March 16, 2020. When the warning forAmphan was received on May 15 2020, the number of positive cases of COVID-19 in theState was 672 with 3 deaths (IPR, 2020). By this time, some shelters were already being used
as COVID-19 TMC in the state to quarantine people coming from different states/countries.
This along with the need for following physical distancing protocols required identifying
additional structurally safe infrastructure that could be used as emergency shelters forevacuees (SRC, 2020). The vacated shelters, which were earlier used as TMCs were
thoroughly sanitized to prevent the spread of infection and also to gain the conﬁdence ofincoming evacuees.
5.3 Need for hygiene and safety material
It was found that the pandemic-induced requirement of physical distancing was notpractical to be followed by the response and relief forces who were undertaking evacuationand search and rescue operations, clearance of emergency routes, etc. Besides, it waschallenging for the response forces to undertake these operations while wearing the full PPE
suits as it was impacting the efﬁciency and speed of the operations to be undertaken. The

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IJDRBEhigh prevailing temperature made it further difﬁcult. Thus, the response forceswere advised to wear masks and follow adequate COVID-19 protocols withoutcompromising the efﬁcacy of response and relief operations.
At the shelter level, the pandemic mandated additional provision of PPE and extra
supplies such as masks, soap and an adequate supply of water. However, at the local level, it
was not possible to promptly arrange and distribute individual PPE kits/masks/face shields
to all the evacuees. Thus, the community mobilizers ensure that evacuees are duly sensitizedfor carrying their masks, cloth pieces and practice personal hygiene and physical distancing
to the best extent possible during their stay at the shelters. The respective shelter
committees and in-charges ensure an adequate supply of clean water for handwashing andmaintaining personal hygiene through the provision of water tankers, wherever required.
The shelter committees and in-charges were also advised to make use of liquid soaps insteadof traditional soap bars in the shelters to mitigate the spread of any infection among theevacuees in the shelters.
5.4 Special arrangement and segregation of population at higher risk of COVID-19
Various special arrangements were undertaken at the shelter level to mitigate the potential
spread of COVID-19 infections among the evacuees, shelter managers and volunteers.
Provision of cooked meals with the help of local self-help groups was undertaken. Aspects ofphysical distancing were practiced for the dining arrangements of the evacuees. Considering
the higher vulnerability of elderly persons and pregnant women to COVID-19, theauthorities recommended the shelter managers and in-charges to separate them from otherevacuees and refrain them from mingling with younger people as far as possible. Moreover,pregnant women with deliveries due in the next 15 days were directly taken to hospitals.
5.5 Large destruction of social infrastructure
As per the Memorandum, no human life loss has been reported during cyclone Amphan(Special Relief Commissioner, Government of Odisha, 2020). However, large destruction anddamage to public properties have been experienced due to cyclonic winds and heavy
rainfall. In terms of ﬁnances, maximum losses have been incurred by Panchayati Raj andDrinking Water Department due to damage to Anganwadi Centers, primary schoolbuildings, buildings and community centers, roads and drinking water supply systems(Special Relief Commissioner, Government of Odisha, 2020).
Large damage to social infrastructure such as schools and community centers in rural
areas is a point of concern as often these structures are used by local communities for taking
refuge during disasters. Besides, the current COVID pandemic has limited the capacity ofexisting shelters due to various physical distancing norms. This has increased the need ofidentifying alternate safe shelters and social infrastructure such as schools, colleges andcommunity centers are expected to play this critical role. Thus, the physical and structuralresilience of the existing and identiﬁed emergency shelters is of paramount importance
while assessing and building the capacity of any community.
6. Discussions
Key learning for shelter management during cascading risk can be summarized as follows:
6.1 Understanding multiple and cascading risks for building disaster-resilient shelters
The Target D of Sendai Framework for Disaster Risk Reduction (2015–2030) calls for a
substantial reduction of disaster damage to CI and disruption of basic services through,among others, developing their resilience by 2030 (United Nations Ofﬁce for Disaster Risk
Reduction, 2015). Besides, the resilience of CI is crucial toward achieving other global targetsof the Sendai Framework including a substantial reduction in disaster mortality, the numberof disaster-affected people and direct disaster economic losses. Complete assessment of CI
systems/assets covering all aspects from threat to outcome in a disaster is crucial formeasuring the resilience of CI (Petit et al., 2011). Thus, the construction and management ofshelters should be duly based on an informed understanding of disaster and climate risks.
Cyclones are associated with events such as heavy rainfall, strong winds and tidal surge.
The identiﬁcation of the shelter location, design, construction material and practices should
be cognizant of all the potential risks. Besides the associated hazards, the risk assessment
should be inclusive of all potential hazards including the local ones.
Such a practice was followed by Odisha in the aftermath of Super Cyclone of 1999
whereby a technical need-assessment study was conducted by IIT (Indian Institute ofTechnology) Kharagpur for identiﬁcation of 512 locations vulnerable to cyclone andstorm surge within 10 km zone of coastline in 6 coastal districts of the state. Accordingly,
designs and sites of the shelters were ﬁnalized along with the provision of an approachroad to each of them. Cyclone shelters in Odisha have been constructed to structurally
withstand high wind speed and moderate earthquakes. Constructed above high ﬂood
levels with raised platforms and stilted ﬂoors, the shelters on the ﬁrst ﬂoor do not getaffected by very heavy ﬂoods (OSDMA, 2014a, 2014b). There is also a provision of thelightning arrestor system in some shelters. Due consideration of multi-hazard risks forthe construction of safe shelters can go a long way in mitigating impacts and damages
possible due to cascading and complex risks. However, considering the new andemerging risks such as that of COVID-19, which have compounded the challenges for
shelter management, the disaster-resilient features of emergency shelters should consider
critical aspects of natural ventilation. Natural ventilation of closed and crowded settings
is considered to be very effective in ensuring fresh air circulation and potentially
eradicating the COVID-19 virus (PAHO, 2020).
6.2 Undertaking assessment of resources for the management of cascading risks
For the management of future complex risks, it will be very useful to re-assess the effective
capacities of existing resources available in the shelter. These include calculating
the effective space/area available in the shelter for sleeping and dining purposes withdue considerations for aspects of physical distancing. For example, to re-assess the effective
sleeping area in a shelter, the suggested standards can be laid down for adequate distance
between two beddings along with mechanisms such as ensuring alternate head-totoe arrangements for persons belonging to different families (PAHO, 2020). Similarly, thecalculation of effective space should also consider the space requirement of wheelchairbound persons. Other key points of considerations include estimating an adequate amountof safe and clean water, necessary hygiene material, dustbins, etc. that should be madeavailable so that all persons in the shelter can practice the recommended norms of handwashing, sanitizing, safe disposal of wastes, etc. It includes re-assing the required quantityof soaps, disinfectants and human resources to ensure safe management of the shelters. To
undertake such re-assessment, minimum standards for different resources/practices can belaid down with the help of health and subject-experts. This can aid in undertaking strategic
decisions for using a particular shelter by having a better understanding of its maximum
and effective capacities to cater to different risks.

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IJDRBE6.3 Modifying the existing layouts and practices in the emergency shelters
Dedicated areas in the shelter for speciﬁc purposes such as sleeping, dining and queues
should be modiﬁed in due consideration of norms of physical distancing. These can bemarked in chalk or tapes (CDC, 2020a, 2020b) or paint along with appropriate signages duly
displayed in local languages. At shelters with fewer capacities, safe makeshift arrangements
can also be undertaken in the adjacent space for sanitizing the evacuees, disinfecting theirbelongings, area for handwash, dining area, area for segregating/isolating evacuees athigher risk of infection.
Members belonging to the same family can be grouped and made to stay together withlimited or no physical interaction with others in the shelter. To avoid transmission of
infection in closed spaces, practices of cooking in shelters can also be replaced by either
distribution of pre-packaged meals or pre-cooked meals for the evacuees. Foods andbeverages can be served in disposable dishwares to avoid sharing of common surfaces
and things (CDC, 2020a, 2020b). Besides these, pathways/entries to the shelter can be
restricted to limit crowding or allowing restricted entry. Other means to limit crowding andensuring physical distancing in shelters in establishing separate entry-exit points or oneway movement or putting footprints at a suitable distance on the ﬂoor. Staggered timing/schedule for dining, drinking water, bathing, washing or availing of other services at the
shelter can also be used to restrict the interactions and mingling of persons in the shelter.
6.4 Repurposing existing resources and spaces as shelters
The need for identiﬁcation of alternate buildings as shelters can be met by repurposing
vacant, underused or private buildings such as schools, colleges, hotels and community
centers (AON, 2020). Temporary building features such as partitions can be used to makerespective facilities serve the required purpose. However, these alternate buildings should be
duly identiﬁed after undertaking assessment measures such as rapid visual screening to
examine the probable hazards and risks in the buildings. As these assessments are to betaken by trained and skilled personnel, it is recommended that these buildings are preidentiﬁed during times of normalcy as preparedness and capacity-building measures by the
local authorities.
6.5 Enhancing the accessibility of shelters
Accessibility of the shelters is of paramount importance in assessing their effectivenessduring disasters. Cyclones and associated hazards often disrupt, ﬂood, obstruct the accessroads to shelters. Thus, the aspect of safe and easy access to the shelter by the at-risk
community is pertinent. The case of Odisha shows both the ease and safe access to shelters
have been duly considered during the assessment study by IIT Kharagpur. The basic
principle followed by the study was to ensure that each individual can access the safe shelter
without having to run for more than 2.25 km and without crossing any natural barrier
during any disaster. A grid analysis of 10 square km (3.15 km X 3.15 km) for identiﬁcation of
the location of shelters (OSDMA, 2012). The sites chosen are wide enough so that accessroad could be developed.
Another aspect of accessibility is that the built environment has traditionally been
designed with healthy people in mind. Emergency shelters as a part of the built environment
should be speciﬁcally designed to ensure easy access and usage by all with a special focus
on the needs of persons with disabilities, old age, etc. Faruk et al. (2018). The shelters in
Odisha have varied features of universal design to make them accessible and friendly in use
by persons with disabilities. These include a unisex multiuse accessible toilet, contrast color

band steps and path to make them visible during dimmed light, handrails, ramps, tactile
tiles on the pathway from the entrance gate and in corridors.
6.6 Understanding local community and context
Often it is experienced that the community at-risk is a bit reluctant in leaving theirbelonging and going to safe shelter. Though the interaction with one of the community
organizers of Odisha suggests that because of extensive awareness programs and therecurring nature of ﬂoods and cyclones, the community now readily takes refuge in safe
shelters during disasters. Still, a few cases are experienced where they tend to delay leaving
the dwelling till the very last moment or till enforced with help of the Police Department. In
the backdrop of this, it is valuable to understand the local needs and issues to make theshelter more and readily accepted by the community at-risk. The case of the multi-purpose
cyclone and ﬂood shelters of Odisha provides a useful insight in this regard. The ground
ﬂoor of the shelters can be used for sheltering livestock during disasters. Thus, it tends toaddress the concerns of those households whose livelihood are dependent on their livestock
and are concerned about leaving them alone during disasters.
It has been experienced that the management and maintenance of safe shelters are best
done at the lowest level by the local community and authority. Such a principle ofdecentralization is crucial from multiple perspectives. First, it brings a sense of ownership in
the local community, which enhances the usage and acceptance of these shelters to thefullest. Second, the local community and authorities are better placed for the close and dayto-day supervision and maintenance of the shelters. Third, during disasters, it is not
humanly and administratively possible and efﬁcient for a centralized authority to manage
the local needs and requirements of a particular shelter.
6.7 Local interventions
The review of cyclone shelters of Bangladesh highlights that in the absence of a bottom-up
approach, which includes key local stakeholders for establishment and management of cyclone
shelters, various crucial issues such as those concerning special needs of gender, disabled
population, children, signages, storage facilities, space management to suit local contexts areoften left out (Faruk et al., 2018). Thus, participative identiﬁcation of potential risks including
health risks in and around the shelter by the local community and stakeholders should bepromoted. These may include non-structural hazards, issue of snake bites, reptiles, water
stagnation, vector borne-diseases, improper disposal of waste, etc. Participative mechanism ofidentifying local issues can bring forth a collective and more acceptable solution to the problem
identiﬁed. The capacity building of the local communities, community-based organizations,
volunteers, etc. is very crucial so that they can sustain their efforts toward the management ofshelters at the local level even with limited external assistance, which becomes challenging intimes such as pandemics and resulting restrictions in travel and mobility.
Considering the cascading risks posed by COVID-19, during the warning period of
cyclone Amphan, the local government in Odisha with the help of Block Development
Ofﬁcers and other ﬁeld ofﬁcials pre-identiﬁed, inspected, veriﬁed alternate buildings anddeclared them as safe shelters for cyclone Amphan. These included schools, colleges andsome private buildings. However, such prompt action by local authorities during the
response phase can be undertaken when during the pre-disaster phase, the local
stakeholders have been made aware of potential local risks and are duly trained to performtheir respective roles, which in this case includes rapid survey/assessment of alternate
structures to declare them safe for use during disasters. Thus, this underscores a criticalneed for building the capacity of the key local stakeholders at regular intervals. Apart from

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IJDRBEits safe location, all-weather access and connectivity to safe shelters is one of the deﬁning
factors in making the shelters effective during disasters. Lack of such a resilient road
network and transport infrastructure has been found as a major impediment for mostvulnerable and remote coastal and riverine communities to reach safe shelters in
Bangladesh (Alam and Collins, 2010). This can also cause potential delays in thedissemination of early warning to these communities by local authorities. Thus, a crucialrole of local government lies in effective monitoring and regular maintenance of CI
connecting the shelters with the communities.
There are provisions for solar energy, rainwater harvesting, etc. in some of the cyclone
shelters in Bangladesh (Faruk et al., 2018). These provisions can be useful in overcoming theissues faced in some of the shelters concerning the shortage of water especially during
COVID-19, which has necessitated frequent hand washing and sanitizing to curb the spreadof the infection. Joint efforts by the local community and authority in this direction can go along way in overcoming some of the potential issues faced in the shelters during disasters.
6.8 Technological interventions
The case of Odisha brings forth the use of digital platforms for the registration of migrants
for TMC. Similar database management systems could also be explored for registering theevacuees at shelters. Considering the challenges posed by the current pandemic, such asystem can also be integrated with COVID-19 risk assessment and risk communication
applications such as Aarogya Setu, the COVID-19 risk assessment tool and others. These
tools could be used during the early warning dissemination phase along with ﬁeld surveys
by community mobilizers (in areas with limited digital literacy or resources). This could be
useful in segregating persons at high-risk and special measures could be then undertaken
for them. This may seem a challenging task considering the lakhs of evacuees but possibly
by building the capacity of local community and disaster management teams of each shelter,such efforts could be undertaken at the shelter level. Besides, map-based tools could be used
for pre-identifying and mapping the locations and capacities of alternate safe infrastructurethat could be used as shelters during complex emergencies.
However, it must be acknowledged that cyclones and ﬂoods often lead to power outages,
so dependency on any technological intervention should be mindful of these limitations.
This requires that such technological interventions should be supported by putting in placerobust mechanisms for providing continuous power and internet supply at CI such as safe
shelters. Alternately, these tools could be used during the preparedness and early warning
phases for planning and taking strategic decisions.
7. Conclusion
On the journey of the Sendai Framework of Disaster Risk Reduction and Agenda 2030, it isnoteworthy that emergency shelters have been very effective in providing refuge to at-risk
communities, and thus, reducing life loss to a great extent. It should be acknowledged that thiswas possible because concerted efforts were also made in direction of strengthening the early
warning mechanism, laying down evacuation protocols putting in place robust institutional
mechanism including the raising of trained and well-equipped response forces, enhanced
engagement of local community and organizations, etc. (OSDMA, 2014a, 2014b). Without thesemeasures in place, timely, safe and inclusive evacuation of exposed masses to safe shelter
seems challenging. Bosher et al. (2007) (as cited in McEntire et al. (2010)) highlight that while
engineered protective measures do offer a safer built environment in hazard-prone areas, often
the vulnerable people and communities lack the resources and ability to build such safe
structures on their own. In the backdrop of this, the presence of emergency shelters at thecommunity level is of immense importance in providing refuge to vulnerable communities
during any disaster. This is all the more relevant to developing countries where the individual
capacities of vulnerable households are limited. This dependence of the poor and vulnerable
population on community-level safe infrastructure is underscored by Wedawatta et al. (2016).
However, as the population is ever-increasing and considering the challenges of complex
emergencies, there is a need for a holistic approach of vulnerability reduction, which is not
merely dependent on engineered structures but also takes into consideration aspects of socioeconomic, demographic and exposure of a community and aims to address the systemic risks
and root causes of vulnerability. Moreover, the need for an all-of-society approach based on
consideration of multi-hazards cannot be overemphasized for a resilient and sustainable planet,
particularly during the current times.
The complex risk of COVID-19 pandemic and other hazards such as cyclones and ﬂoods
have highlighted the need for developing a better understanding of the dynamic, complex andsystemic nature of risk. To address the varied challenges faced by various local authorities,
communities-at-risk and other stakeholders in the management of these aspects of risk requirepreparing for and reducing the risk in its holistic form. The unforeseen challenges faced in the
management of the shelters during cyclones amid the pandemic, which have been discussed in
the paper could be addressed by undertaking different interventions, namely, engineering,administrative and individual interventions (CDC, 2020a, 2020b). These include engineeringinterventions whereby the emergency shelters could be made resilient to multi-hazards suchthat they ensure that no further harm or risk of the affected population is increased during theirstay in the shelters. Such interventions include all aspects undertaken concerning the design
and physical infrastructure of shelters toward risk reduction and management. The second setof interventions are administrative whereby policy, process and strategic decisions areundertaken toward the reduction of exposure of the vulnerable population, fulﬁlling the basic
needs of the evacuees, provisioning of emergency supplies, strategizing the layouts andrepurposing the available spaces, prevention the creation of new risks of evacuees at the
shelter. The third set of interventions are those that could be undertaken at an individual levelby the community-at-risk, other involved stakeholders to mitigate their own risk at the shelterssuch as practicing physical distancing norms, respiratory and hygiene etiquettes, etc. However,individual interventions need to be ensured through proper awareness generation, risk
communication and capacity-building measures.
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Corresponding author
Rajib Shaw can be contacted at: shaw@sfc.keio.ac.jp

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Review Article

Yoga and stress management during and post COVID-19 urban lifestylein Japan
Akiko Kato and Rajib Shaw
Graduate School of Media and Governance, Keio University, Japan

Abstract
When COVID-19 started spreading in Japan, the government announced national emergency in April-May, and requested people
to stay inside home for a prolonged period of time. This has caused significant stress in different groups of urban residents inJapan, where close contacts were the key issue. An online survey conducted with urban residents have pointed out that 78% were
under stress, and 18% were using yoga to relieve from the stress. Although the percentage of people conducing yoga was less, butthey wanted to continue it even after the COVID-19 is over. With some literature review, the paper argues yoga as an effectivemeans of stress and health management during as well post Corona time. This is especially relevant to urban lifestyle, since yoga
can be done by any age group, including physically challenged people. It is argued that yoga can also release stresses in different
disaster situation, especially in the evacuation centers.
Key words: COVID-19, yoga, stress management, urban lifestyle, healthcare
Asian Journal of Complementary and Alternative Medicine. Volume 08 Issue 3
Published on: 30/12/2020*Author for Correspondence: Graduate School of Media and Governance, Keio University, Japan
Cite this article as: Akiko Kato and Rajib Shaw. Yoga and stress management during and post COVID-19 urban lifestyle in Japan
Asian Journal of Complementary and Alternative Medicine, Vol 8 (3), 48-54:2020.

Introduction
In December 2019, an outbreak of coronavirus infection(COVID-19) was reported in Wuhan City, North Province,
People’s Republic of China, and has infected significant
number of people causing death, severe health problems,
impacts of economies, livelihood and lifestyles. Japan, with its
close proximity to China, high volume travel between the twocountries, high urban density and relatively higher percentage
of aged population is considered vulnerable to this global
pandemic from the initial stage [1, 2]. On April 7, 2020, theGovernment of Japan revised the state of emergency, judging
that “a situation has occurred that could have a tremendous
impact on the people’s lives and the national economy due tothe nationwide and rapid spread of the disease. Based on theprovisions of Article 32, Paragraph 1 of the Act on Special
Measures Concerning Influenza, etc.” Unlike other countries,
the state of emergency in Japan is not a forced lockdown, rathera request to its citizen to refrain from going out, maintaining
basic social norms and protection measures, reductionof economic and social. Before calling for nation wide
emergency, several prefectures including Tokyo Metropolitan
Government, Hokkaido (the northern island) has declared its
prefectural emergency and made the same request to its people
to observe certain levels of restrictions. This was one of thefirst attempt in recent years that the Japanese Government

has called for national emergency due to pandemic, which isconsidered as a biological hazard.
In addition to the economic stagnation, more than 100 million
people stayed in the home for more than a month including
all ages like infants, school children, working people and theelderly. In other words, the fight against this unprecedented
virus has resulted in the burden of lack of exercise and stresson healthy people, who did not have any symptoms of thevirus. The stress caused by refraining from going out causessocial and family problems such as domestic violence, andthe increase in suicides due to financial instability is alreadyanxious [3]. The stress and lack of exercise associated withthese self-restraint from going out, often termed as “corona
blue”, have become a problem not only for adults who workfrom home, but also for children who cannot go to school, andto elderly people who cannot go to day care services.
On April 22, 2020, two weeks after the state of emergency wasannounced, a government expert meeting discussed measuresagainst the new coronavirus and proposed to reduce contact
with people by 80% as “situational analysis” and “proposal”)[4]. The expert panel recommended 10 points for online
activities for muscle training and yoga. As a result, it becamea proposal to relieve the mental and physical stress using
yoga that can be done online at home and maintain wellness.
Different academic institutes, including Keio University has© Asian Journal of Complementary and Alternative Medicine, 2020

48

Akiko Kato and Rajib Shaw

also decided to introduce video yoga lessons as a mean tomaintain the wellness of the mind and body at homes when
students refrain from going out. In this way, yoga found its
new niche in urban lifestyle to combat the unprecedented largescale and long-lasting impacts of COVID-19. In addition, as
we are seeing multiple waves in COVID-19 in different partsof the world, including Japan (which is under third wave from
October 2020), the world may continue to be intermittently
and partially refrained from going out or banned from goingout for which will also cause prolonged stress.
In this context, the paper examines the importance andusefulness of yoga for effective stress management, withspecific focus on urban residents. With an online survey
conducted in Japan, the paper argues that in the urban lifestyleduring as post COVID-19, yoga can play an important role instress management, as well as overall health management.

Yoga and its effects on health andstress management
Yoga is defined as “stopping all activities of the mind and mind
(chitta)” (MOA 2017, p 4-5) [5]. This section describes the
medical science related argument for effectiveness of Yoga.
Our minds are influenced by the physical world and are in astate of confusion and suffering every day. Minds and thoughts
are constantly changing, and yoga is the task of completely
stopping change while controlling the changing mind. Withyoga, one can free oneself from the state of mind that istrapped in that suffering and binding (MOA 2017, p 4-5) [5].
By stopping the movement of one’s mind, one can reach astate of enlightenment and control it in a calm state. Yoga is tocalm one’s mind and free oneself from the painful conditionsof confusion. In other words, yoga is a mental activity aimed at
calming the mind and body. In addition to using various asanas(poses), pranayama (breathing), meditation (meditation), yoga
is a healthy and lively lifestyle with a balanced approach tolife [5]. It makes the most of the ability of yoga breathing(pranayama) and meditation to balance the sympathetic andparasympathetic nerves. The stress hormone cortisol has
emerged as the true nature of stress. It has been found that highlevels of cortisol secreted by long-lasting stress reduce theprocesses of nerve cells in the hippocampus of the brain. The
hippocampus is the part that controls memory and is involvedin emotions. It has become apparent that damage can lead todementia and depression. Yoga breathing is an effective way tosolve this [6]. Numerous researches have pointed out scientificvalue of yoga on health management.
In addition, the program “Mindfulness”, which was born basedon yoga meditation, is attracting attention as a method of
preventing mental illness caused by breathing [7]. Mindfulness
meditation and reduced breathing can help calm the amygdala
and manage stress [8]. Because the respiratory center is close

to the pituitary gland, yoga control of the pituitary gland calms
the pituitary gland and suppresses cortisol secretion from theadrenal cortex to reduce stress. Pranayama can reduce bloodflow in the pituitary gland and reduce stress.
It is said that serotonin levels are low in stress and depression.
Serotonin is a transmitter that suppresses the runaway of
noradrenaline and dopamine and balances the mind. The
serotonin nervous system exists as tens of thousands of cellbodies in the raphe nuclei in the midline of the brainstem, and its
axons project to a wide range of brain regions from the cerebral
cortex to the spinal cord, affecting various brain functions[9]. Therefore, mental stability can be obtained by increasing
serotonin. In particular, the spontaneous firing mode of serotonin
nerves has the following characteristics. Regular impulse firingcontinues at a few hertz during awakening, with slow-wave sleep
firing sparsely and irregularly, and REM [rapid eye movement
sleep] sleep with complete firing arrest. In other words, it works
on the cerebral cortex and has various functions such as making
one feel refreshed when wake up, making one’s body active
when wake up in the morning, suppressing the sensation ofpain, and working on anti-gravity muscles. When serotonin is
low, these functions do not work well, making it harder to getup and making it easier to feel pain in trivial matters. Serotonin
is said to increase through a regular life, exposure to light, andrhythmic exercises such as dancing and jogging [10].
[11] a professor of integrated physiology at Toho University
School of Medicine, conducted Zen yoga breathing exercisesfor people who had no experience in zazen and observed
the appearance of alpha waves [11]. Among the α waves (813Hz), the high-frequency α2 component (10-13Hz) increased
significantly, theta waves decreased, and β waves did not show
significant fluctuations. The point to note about the appearanceof alpha waves during awakening is that anyone who closes
their eyes immediately becomes an alpha wave-dominant brain
wave [12]. Therefore, we tried Zen yoga breathing even whenthe eyes were closed (note that the above data is in the openstate). Since the eyes are closed, a high peak of the α wave
is observed from the beginning. The α wave (corresponding
to the low frequency α1 component) disappears at about 7
minutes of the breathing method, and instead, at 4-5 minutesof the breathing method, a new α2 component appears and isgradually enhanced. That is, it was considered that the Zen
yoga breathing method changed the arousal state of the brain
waves and the cerebral cortex through a pathway in the brain
different from that by closing the eyes. [13]. It is rhythmic
exercise that further enhances serotonin neural activity inthe awake state. Yoga, the rhythmic movement of breathing,enhances the impulse firing of serotonin nerves.
Yoga seems to be used by wider variety of people andprofessionals from different section of the society. Tom Brady’s© Asian Journal of Complementary and Alternative Medicine, 2020

49

Akiko Kato and Rajib Shaw

health regimen would not be complete without a healthy doseof ancient Eastern wisdom. He is a hardcore lover of yoga,
which he gives credit for miraculous mental and physicalbenefits: “It’s great for flexibility, it’s therapeutic, and greatfor your attitude.” Sports personnel, including Major League
baseball players, soccer players, sumo wrestlers are foundto be using yoga increasingly for both their stress and healthmanagement [14]. In Japan, yoga is gradually introduced toelementary, junior and middle high schools as a part of extracurricular activities. Self Defense Forces in Japan, including
Maritime Self Defense team are also using yoga when theyneed to spend longer time in the

COVIDS-19 Stress Management
In the world, several countries like China, Italy, France, otherEU countries, UK, USA, Russia, Canada, Indian have taken
policies such as lockdown and refraining from going out atperiodic and spatial ways over last several months. This put
billions of people under house arrest for weeks and months at
home. This first-ever global experience of lockdown in March
2020 was repeated in the form of second and third waves
over the next few months. In other words, this research ischaracterized by studying the fight against stress caused by thehistoric number of people under house arrest for the first timein history, also to enhance a better preparedness for similardisasters in the future. This is related to stress management
method from the standpoint of disaster prevention and earlyrecovery. People, including celebrities in different countries
have been engaged in indoor family or self-activities likecooking, indoor exercise or workout, web concerts etc. torelease their stresses, and this can be viewed through numerous
social media posts over last several months.
There are several researches on COVID-19 related stresses.
The level of stresses varies from people to people, sometimes
based on the age, occupation etc. The importance of
psychosocial assessment and monitoring is highlighted by[15], and argues that the assessment should include queries
about Covid-19–related stressors (such as exposures to infectedsources, infected family members, loss of loved ones, andphysical distancing), secondary adversities (economic loss, forexample), psychosocial effects (such as depression, anxiety,psychosomatic preoccupations, insomnia, increased substanceuse, and domestic violence), and indicators of vulnerability(such as preexisting physical or psychological conditions).
Different tips are provided through different research forstress management during COVID-19. A few can be listed
as follow: healthy eating habit, creative physical exercises,social connectivity, practicing kindness, enough time forrest and relaxing, focusing on mindfulness etc. Integrative
consideration of COVID-19 also emphasizes on stressmanagement, and urged the importance of mindfulness

techniques such as meditation, breathing exercises, guided
imagery, etc. [16]. In a survey of around 1000 Chinese college
students, [17] have pointed out different types of stresses
during isolation in COVID-19 period. The study argued thatlong isolation can have negative consequence on the mental
stress among young generation, and have suggested six step
intervention strategy, including delivery of appropriate risk
information and enhancing knowledge on stress management
among others.
Role of yoga in stress management has also been emphasized
by several authors. [18] emphasized on the importance ofshortage of yoga trainer and argued that yoga practice isactively sought to achieve reduced anxiety and stress so that
improved sleep may positively impact immunity. They also
argued the importance of social media in spreading online
yoga and its usefulness in stress management and highlighted
the effectiveness of yoga in working from home stressmanagement. [19] also argued the importance of yoga and
Ayurveda as alterative public health approach for COVID-19
health management. Arguing that poor mental health condition
including stress and depression, are known to increase the riskof acute respiratory infections, the paper argued that several
measures for mental health are described in yoga therapy,
including pranayama (breathing exercise) which enhances lungfunction. Meditation is found to reduce inflammation markers
and influence markers of virus-specific immune responses.

Survey in JapanTo understand the stress issues among wider urban residents
in Japan, a questionnaire survey on stress management andyoga practice during COVID-19 period was organized by
Keio University and Yoga organization of Japan during 15thof May to 15th of June 2020. The survey was conducted online
using promotion through different social media and website.
A total of 336 people responded to the survey with different
age groups and nationalities (mostly Japanese, but also India,
USA and others, who are residing in Japan). Female % of the
respondents were higher with 63%. 51% of the respondents areof the age group between 20s and 30s, followed by 23% of 40s
and 50s, and 20% under 20s.
Figure 1 shows the results of the survey. It seems that 78%of the respondents are feeling some kind of stresses during
COVID-19. The stress is exemplified in the form of different
health impact like clod limbs, dizziness, less appetite,irritation, out of breath etc. Financial issue, fear of infection,
isolation from society, are some of the causses of stress.
People use different ways to release stresses like sports,
stretching, yoga, as well as reading etc. Around one third of
respondents used to conduct yoga before the pandemic, witha small percentage (18%) were conducting yoga for stressmanagement (Figure 2).

© Asian Journal of Complementary and Alternative Medicine, 2020

50

Akiko Kato and Rajib Shaw

Figure 1: Feeling stress and ways to release stress.

Figure 2: Performing yoga before and during COVID-19
Those who conducted yoga, usually does it once a week or
2-3 times a week (Figure 3). From the survey, it is found that
54% of people who practice yoga, do yoga by themselves,and 36% of people who practice yoga using online platform,
including you tube (Figure 3). Usual time is 5-10 minutes
and 10-30 minutes (Figure 4). The survey also showedthat 37% are doing yoga aiming at improving immunity,and 21% are doing it for stress management (Figure 4).
To a question whether they want to continue yoga after
COVID-19, 17% responded positively, especially for the
purpose of stress management. A minor percentage (2%)
intend to use yoga to improve cardiopulmonary function,
while 10% wanted to continue yoga to maintain being slim
and good physique.

© Asian Journal of Complementary and Alternative Medicine, 2020

51

Akiko Kato and Rajib Shaw

Figure 3: Performing yoga and meditation during COVID-19

Figure 4: Timing of performing yoga and meditation© Asian Journal of Complementary and Alternative Medicine, 2020

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Akiko Kato and Rajib Shaw

Discussion
Currently, not only Japan but the world is facing the onslaughtof new coronavirus infections. Each country has focused on
stopping the spread of the infection, even if it suspends its
economy, industry and education, and as a result, working fromhome by refraining from going out has become a norm, and ourlifestyle has changed significantly. Under the circumstanceswhere it is difficult to accept patients in hospitals because ofover-crowded healthcare systems, different virtual ways ofcommunication methods such as telework, take-out, online
shopping, mail order, etc. are getting popular. Social changeis accelerating due to the psychological effects of anxiety
and fear of being unable to meet people. In the future, even
if the epidemic of the new coronavirus infection is settled, itis thought that the lifestyle with physical distance as a new
countermeasure against infectious diseases will remain thesame. Therefore, it is required to propose changes in urban
lifestyles, focusing on people’s health and happiness, and how
to have a sustainable lifestyle in the future.
As a characteristic of urban lifestyle, there is a tendency tolike queues and crowds. Events such as parties, dining out,
museums, concerts, etc. are great pleasures of the urban
lifestyle, and while stimulating the exchange of different
cultures with exciting knowledge and technology, we seek
nature and relaxation in rural areas. However, during pandemic,
these events themselves were restricted, depriving people ofthe pleasure of going out. Physical distance has become a newmanner, and online gatherings, shopping, and browsing haveprogressed, depriving the characteristic enjoyment of urban
lifestyles. The drastic reduction in opportunities to express
oneself in relation to others has made it difficult to satisfy thedesire for self-approval from status appeals and group appeals,
and the altruistic value of branded products and luxury products
among consumers has also declined.
In addition, social infrastructure such as transportation,cityscapes, and lifelines support urban lifestyles. Even if
the houses are small in size in urban areas in Japan, many
people commute to work comfortably in an office building
equipped with air conditioning control. However, due to therequest to refrain from going out, the population of commutersconcentrated in the city decreased, and they were forced to stayin a small house. It doesn’t require long commute times anddoesn’t move. Under these circumstances, the value of urbansocial infrastructure has declined rapidly, and many companies
have lost the meaning of renting offices in buildings at highrent.
The concept of care and cure got its new position in urban
lifestyle due to pandemic. While people go to hospitals andhealth centers for getting cured, it is increasingly becoming
important to make proper health care measures which prohibits

disease, and also enhance immunity and reduces stresses ina busy urban lifestyle. From the above survey results, it isobserved that while there is a significant urban resident inJapan who were felling stress during the CVOID-19 pandemic,
not that many people were practicing yoga. The history ofyoga in Japan date back to the year 806 during Tang Dynasty,
however, the recent days yoga started when Tempu Nakamura
practiced yoga in 1919 and started teaching it. Yoga has been
popular among the female urban residents over years, which
has been mainly used as a mean to stay slim and fit. The yoga
movement in Japan got the boost with the start of International
Yoga Day in 2015 by Government of India, which promoted
yoga globally as a soft power tool. Yoga Organization of Japan
has been strongly promoting yoga among different age groups
and professionals, including national diet members.
It is interesting to note from the survey that those who were
doing yoga could find it to be effective means for stressmanagement. Similarly, yoga can also be effective against theharmful effects of lockdown and refraining from going out.
The benefits of performing yoga can be summarized as: 1)
one can practice yoga indoor and by alone, 2) All generations(elderly, middle-aged, elementary, junior high and high school,
infants) can practice yoga, 3) prevents the risk of illness due
to lack of exercise, 4) avoiding personal and family crises due
to stress, and 5) yoga is possible for people with disabilities.
The following points should be kept in mind when creating afuture COVID-19 yoga program: 1) regularly train your lungs
with breathing exercises (prevention), 2) eliminating lack of
exercise by asana (pose), 3) immunity boosting and stressrelease by asana, 4) relieve stress by meditation, 5) immunity
boosted by Ayurvedic diet, and 6) reducing economy classsyndrome due to asana. In addition, from the perspective ofdisaster prevention yoga, it is necessary to carry out yoga
programs from pre-disaster prevention. Performing yoga ona regular basis is a measure against COVID-19. In addition,
regarding disasters other than corona, it is necessary to makepolicy recommendations to create and disseminate a yoga
program to maintain physical and mental health and wellness
in the event of a disaster, especially in the evacuation centers.

Conclusion
The study focused on the urban residents during COVID-19
pandemic and looked at the stress people were facing. The
online survey pointed out that while significant percentage of
people are undergoing stress, only one fifth practiced yoga as a
stress management reliever. However, those who have practiced
yoga wanted to continue it even after the pandemic is over. The
paper also argues that in Japanese urban lifestyle, stress is asignificant part, with or without Corona. Therefore, practicing
yoga as a part of urban lifestyle helps in reducing the stress,enhances immunity against diseases and enhances physical© Asian Journal of Complementary and Alternative Medicine, 2020

53

Akiko Kato and Rajib Shaw

fitness. Since yoga and meditation can be practiced anywhereby any age groups, including people having disabilities, thiscan be a part of healthy lifestyle. Yoga can be considered asa part of “care” system, which will reduce the pressure on the“cure” systems in the hospital and health centers.

Author Contribution
A.K. contributed to survey, analysis and initial writing of thedraft. R.S. contributed to conceptualization, initial writing.
Both the authors have read and agreed to the current versionof the manuscript.

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Commentary

Reflection of Challenges and Opportunities within the
COVID-19 Pandemic to Include Biological Hazards
into DRR Planning
Emily Ying Yang Chan 1,2,3,4,5,*, Caroline Dubois 3,4, Ada Ho Yin Fong 4, Rajib Shaw 6,7, Ranit Chatterjee 7,8,
Ambika Dabral 7, Antonia Loyzaga 9, Yong-kyun Kim 10, Kevin Kei Ching Hung 1,3,5 and Chi Shing Wong 1,3
Collaborating Centre for Oxford University and CUHK for Disaster and Medical Humanitarian Response(CCOUC), The Chinese University of Hong Kong, Hong Kong, China;
kevin.hung@cuhk.edu.hk (K.K.C.H.); cswong@cuhk.edu.hk (C.S.W.)
2 Nuffield Department of Medicine, University of Oxford, Oxford OX37BN, UK
3 JC School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong,
Hong Kong, China; caroline.dubois@gxfoundation.hk
4 GX Foundation, Hong Kong, China; fong.adahy@gmail.com
5 Accident & Emergency Medicine Academic Unit, The Chinese University of Hong Kong, Prince of Wales
Hospital, Hong Kong, China
6 Graduate School of Media and Governance, Keio University, Fujisawa 252-0882, Japan; shaw@sfc.keio.ac.jp
7 Resilience Innovation Knowledge Academy (RIKA), New Delhi 110059, India;
ranit@rikaindia.com or chatterjee.ranit.8a@kyoto-u.ac.jp (R.C.); ambika@rikaindia.com (A.D.)
8 Graduate School of Informatics, Kyoto University, Kyoto 606-8501, Japan
9 National Resilience Council, Pasay City 1300, Philippines; aloyzaga@observatory.ph
10 Ministry of Interior and Safety, Sejong 30128, Korea; unkim68@gmail.com* Correspondence: emily.chan@cuhk.edu.hk; Tel.: +852-2252-8850
1

Citation: Chan, E.Y.Y.; Dubois, C.;
Fong, A.H.Y.; Shaw, R.; Chatterjee,
R.; Dabral, A.; Loyzaga, A.;
Kim, Y.-k.; Hung, K.K.C.; Wong, C.S.
Reflection of Challenges andOpportunities within the COVID-19
Pandemic to Include Biological
Hazards into DRR Planning. Int. J.
Environ. Res. Public Health 2021, 18,
1614. https://doi.org/
10.3390/ijerph18041614
Academic Editor: Paul B.
Tchounwou
Received: 30 December 2020
Accepted: 5 February 2021
Published: 8 February 2021
Publisher’s Note: MDPI stays
neutral with regard to jurisdictional
claims in published maps andinstitutional affiliations.

Abstract: COVID-19 has reinforced the need to revisit the integration of health within disaster risk
reduction (DRR) strategies for biological hazards in a system-wide approach. In November 2020,
DRR experts attended the Asia-Pacific Partnership for Disaster Risk Reduction (APP-DRR) Forumto share progress and learnings in the areas of health system resilience, data management, residual
risk management, risk communication, digital literacy, and knowledge product marketing. Advancements for health in DRR included the importance of multi-sectoral, multi-hazard action plans;
adaptation to technological advancements in data collection, dissemination and protection; promoting the health and wellbeing of essential and nonprofessional workers; and improving inclusivity
in digital literacy. COVID-19 has affected progress towards the Sustainable Development Goals(SDG) and created a unique opportunity within DRR to re-evaluate the adequacy of response mechanisms against concurrent, cascading or interacting risks of future biological hazards. Health emergency disaster risk management (Health-EDRM) is a new World Health Organization paradigm
that includes DRR at intra-, inter- and multidisciplinary levels. Scientific advancement under
Health-EDRM is necessary for health and non-health actors in DRR education and research. Continuous education on the multifaceted risk governance is a key to building awareness, capacity andaccelerating towards achieving the international DRR and the SDG targets.
Keywords: health-EDRM; disaster risk reduction; biological hazards; Sendai Framework; COVID19, pandemic

Copyright: © 2021 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms andconditions of the Creative Commons
Attribution

(CC

BY)

license(http://creativecommons.org/licenses/by/4.0/).

1. Introduction
The intersection between health, resilience capacity building and disaster risk reduction (DRR) planning and strategies has emerged as an interdisciplinary field of great importance for the protection of human health and wellbeing [1] since the publication ofInt. J. Environ. Res. Public Health 2021, 18, 1614. https://doi.org/10.3390/ijerph18041614

www.mdpi.com/journal/ijerph

Int. J. Environ. Res. Public Health 2021, 18, 1614

2 of 13several international frameworks, including the Sendai Framework for disaster risk reduction 2015–2030 [2], and more recently in World Health Organization (WHO) Framework for Health-Emergency Disaster Risk Management Framework (Health-EDRM) [3].
The ongoing COVID-19 pandemic has amplified the need to bring the health sector frontand-center in disaster risk management at national and international levels. A hazard isdefined by the United Nations Office for Disaster Risk Reduction (UNDRR) within the
Hyogo Framework for Action as “a potentially damaging physical event, phenomenon or
human activity that may cause the loss of life or injury, property damage, social and economic disruption or environmental degradation. Hazards can include latent conditions
that may represent future threats and can have different origins: natural (geological, hydrometeorological and biological) or induced by human processes (environmental degradation and technological hazards)” [4]. A pandemic is an example of a biological hazard,
which are hazards that may be either “of organic origin or conveyed by biological vectors”, would be further defined by characteristics such as “infectiousness or toxicity, dose–
response, incubation period, case fatality rate and estimation of the pathogen for transmission” [5], and may have amplified impacts in the age of globalization.
Globally, hazard management planning and response strategies have yet to reflect
the non-linear transition of biological hazards, particularly pandemics, which can emergein overlapping waves with different impacts, and the community must enter a response
phase before the initial recovery phase is completed [6]. As a result, the non-linear attributes of biological hazards have rendered the human community vulnerable to protracted
crises that persist and increase the community’s vulnerability to the cascading risks ofmulti-hazard that generate complex secondary events and interactions [7]. Many global
at-risk communities face cumulative impacts of concurrent geological and hydrometeorological hazard events like earthquakes and cyclones during the COVID-19 pandemic,
exacerbating existing issues of food insecurity and social security. Examples of multi-hazards with cascading risks include the cyclone Amphan landfall in India and Bangladesh,which disrupted clean water and sanitation systems, leading to barriers in adequate handwashing and hygiene, which has, in turn, exacerbated not only the spread of COVID-19
but other waterborne diseases [8]. The Philippines experiences an average of twenty tropical typhoons annually, which has added burden to the emergency situation of the country, leaving many communities to rely on their own resources for protection as local government resources are spent responding to COVID-19 [9]. In addition, many vulnerable
communities are affected by syndemics—the concurrent, cascading or interacting risks ofbiological hazards within the same individuals and groups, thereby aggravating disease
burdens such as COVID-19 and an array of noncommunicable diseases [10]. The inadequacy of available risk strategies catered for the nuances of biological hazards will undoubtedly challenge the resilience of community health and health systems.

2. Materials and Methods
This paper delineates the key issues as highlighted at the Asia-Pacific Partnership for
Disaster Risk Reduction (APP-DRR) Forum (December 2020) convened by the United Nations Office for Disaster Risk Reduction (UNDRR) Regional office for Asia and the Pacific.
This is a multi-stakeholder forum that includes governments, regional inter-governmentalorganizations, civil society organizations, international organizations and donor organizations. The purpose of the discussions is to monitor the implementation of the Sendai
Framework across the region and for stakeholders to share community-relevant insights
and identify key priority action areas towards DRR in the region [11].
The way forward for health system resilience building, data management, residual
risk management, risk communications, digital literacy, and knowledge product marketing were priority areas identified in this forum and are discussed in this paper.

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3. Results
3.1. Health System Resilience
When responding to a biological hazard, the health sector is expected to lead the immediate frontline response. In response to the multifaceted impacts of COVID-19, many
jurisdictions mobilized resources outside of the health sector to impose control measuresagainst the spread of the virus, which brought in travel, tourism, education, and othersectors. The most common measures included personal behavioral regulations such as
mandatory face masks in public places [12]; social distancing like city lockdowns, quarantine, and school closures [13–15]. Other measures include emergency international travel
guidelines, such as self-declaration of health status, and mandatory COVID-19 testing [16–18]. Although the Sendai Framework calls for the broader health system vigilance andresilience and to integrate disaster risk management across primary, secondary, and tertiary healthcare, there is a discord in how national responses are organized to respond to
COVID-19. Japan, for example, has a dedicated National Action Plan for Pandemic Influenza and New Infectious Diseases (2013) [19], which provides multi-sectoral, holistic andcomprehensive recommendations from the pre-outbreak to the recovery phase. The national action plan proactively monitors outbreaks in other areas of the world, and recommends international joint simulation exercises in the pre-outbreak phase. The plan contains recommendations to ensure continuity of medical care, of education, welfare-services, and business recovery mechanisms. The plan, however, does not consider concurrent, cascading or interacting hazards [6]. In contrast, Singapore’s national Pandemic
Readiness and Response Plan for Influenza and Other Acute Respiratory Diseases (2014)[20] aims to mitigate the mortality and morbidity consequences after the onset of the firstwave through rigid surveillance. The plan mobilizes essential services, case monitoringand isolation mechanisms, and infection control in hospitals so as to maintain healthcare
provision. However, the plan is developed by the Ministry of Health and heavily emphasizes the healthcare and public health approach, but is limited in considering the role andresponsibility of other sectors [6]. While these plans include guidance on post-epidemic
surveillance and the lifting of social and economic restrictions to return to normalcy, neither of these plans takes into consideration the mitigation or treatment of long-term physical, social and psychological impacts of a pandemic, which can include symptoms of anxiety, depression and even posttraumatic stress among healthcare workers or the wider
population [21]. In the case of COVID-19, there is evidence of post-viral syndrome, which
can include fatigue, myalgia, headaches and shortness of breath [22].
Most of these communities have a primary focus on building resilient health systems
and building capacity within health workers to apply DRR approaches in service delivery[2]. Nevertheless, there are broader aspects to consider:The capacity of the relevant health and non-health workers across the entire pathwayof care should be strengthened, from screening, testing, diagnosis, treatment, recovery and rehabilitation [6];Surveillance and information systems must be strengthened to ensure that data collected includes all populations and will enable the system to identify and protectgroups facing vulnerability [6];Public–private partnership models for health service provision should be exploredand promoted to maximize functionality and service provision, especially when government systems are constrained [6].

3.2. Data Management
Biological hazards affect population groups differently, depending on their exposure. Vulnerability will vary according to the nature of the hazard, existing mitigation andprotection systems, and any existing and inherent risks faced. Traditional groups facing
vulnerability include, but are not limited to, older people, groups living in rural areas,

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migrant groups, indigenous groups, and those with comorbidities, physical or mental disabilities. In order to assess impact inclusively, baseline pre-disaster data for health andsocioeconomic indicators should be made available to identify and minimize the impact
of determinants that may exacerbate biological risks [6]. To achieve DRR that is inclusiveof the vulnerable and the forgotten, risk assessments during emergency settings must
therefore include disaggregated data and analysis for groups facing vulnerabilities suchthat policies may holistically address the risks of the entire community.
Meanwhile, efforts will be needed to address the challenges in data storage, monetization of data, ethics related to secondary use of data, and implications on personal protection. While sharing timely and accurate data is necessary to the response and containment to a global pandemic, stringent protocols for the secure storage and distribution ofdata must be implemented, which consider access rights, encryption and continuous review of security, which take into account the evolving benchmark for security and technological advancements [23]. Global data platforms such as Google, Facebook, Uber andcell phone companies have in the past monetized data, for example, in making geolocation
data available to scientists for disease spread modeling or similar research. In the case of
COVID-19, such information has been utilized for contact tracing or controlling population access to public spaces. In addition, a clear protocol for the management of secondary
data is necessary to guarantee a balance between privacy and the usefulness of data [24].
Personal protection is important, and includes mechanisms for identity protection, protection against discrimination, understanding how personal data are used, and informed
consent prior to data collection, particularly if the information collected can reveal information related to the health of the individual or their family [25].
3.3. Residual Risk Management
The global response to COVID-19 has highlighted essential workers as a highly exposed group with unique needs. The categorization of essential services varies between
jurisdictions, across workforces from healthcare, social work, government services, agriculture, transport, waste management and others. However, despite society’s reliance on
essential workers, many have been unprotected, working under inadequate health andsafety conditions, and putting themselves and their families at risk [26,27]. In many communities, duties of care and protection have been undertaken by nonprofessionals suchas informal home care providers [28]. There is a gendered impact of increasing relianceon informal care, which is provided by women in many communities. School closures in
Asia, for example, are impacting professional women differently, who provide informalcare within families. Travel restrictions have caused challenges and uncertainties to foreign domestic workers, many of whom are women [29]. Informal care providers are often
not directly protected by legal measures for health protection or adequate infectious disease control training [30]. In Muslim communities, evidence has shown that women are
more likely to wear face coverings in public for religious reasons, but not in their houses
while caring for others, while men wear masks for hygiene both inside and outdoors [31].
In identifying and monitoring groups facing vulnerabilities, protection mechanisms can
support informal care providers through alternative means like the provision of material
resources such as personal protective equipment, medicines; information resources suchas home care guidelines; and appropriate training so that they may be able to care forother sick or at-risk groups while minimizing their risk and exposure [6,28].
Under COVID-19, health sectors across countries have resorted to the basic means ofservice and functionality. The International Labor Organization has published a policy
framework on protecting the workforce during the pandemic, which encompasses areasof employment stimulation, supporting enterprises, worker protection and social dialog
for solutions [32]. The International Monetary Fund has conducted research on the implication of fiscal policy measures on income inequality within and between vulnerable
groups, including essential workers [33]. However, there is little discussion, experiencesharing, and evidence-based lessons learned on the health impact this protract crisis has

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on essential or nonprofessional workers. With all the new challenges posed by megacities,
migration, rural urbanization and technological advancement, what constitutes “essential” workers in a community must be revisited and defined for relevant DRR planningand capacity building.
3.4. Risk Communication
Risk communication can only be made effective when taking the “whole of government, whole of society” approach [3]. The global impact of biological hazards highlights
the importance of effective communication between stakeholders at all levels, from theinternational level, among experts and policymakers, to the community level, within thegeneral public, within households, and among individuals. As the fundamental component to enhancing community cooperation, mobilization and resilience, risk communication should include a top-down approach from government or authorities that participate
in cross-country dialog to enable early and effective warning systems. These warning systems should trigger national or international standard operating procedures to mitigate
the impact as early as possible [3,6]. Communication also requires the bottom-up input of
the whole society to ensure that the information disseminated is tailored and relevant toall members of society and their protection. Efforts should be taken to extend this dialog
to groups facing vulnerability, such as indigenous communities, migrants and refugees,
for whom information transfer tends to be complex and indirect. The participation andengagement of local government, faith-based groups and religious leaders, as well as civilsociety groups, are essential in this process [6]. Moreover, it should be recognized that
resource information channels vary with user demographics, acceptability, and access.
Studies have shown that health literacy and risk perception are negatively correlated withincome, education and social status. The European Health Literacy Survey conducted ineight countries demonstrated that 50% of adults have problematic or inadequate levels ofaccess, understanding, appraisal and application of health or risk information [34,35]. A
study in Australia showed that people with low health literacy and people whose native
language is not English demonstrated poorer understanding of COVID-19 symptoms andprevention measures, more difficulty accessing government information, difficulty accessing prescription medication, and experienced greater anxiousness and financial difficulties [36]. Studies conducted in Australia and the United States showed that factors increasing vulnerability to COVID-19, such as age, underlying chronic diseases, and income
are also factors associated with the ability to access and understand health informationand decision-making [36,37]. During the COVID-19 pandemic and widespread lockdown,
digital media has become a convenient and rapid tool for people to gain information. It is
important that risk communication ensure equitable access and understanding by allgroups and mitigate against misinformation.
3.5. Digital Literacy
There is growing discussion on the use and functionality of digital tools for information-sharing, contact tracing, and communication. The rapid development of innovative information and communications technology (ICT) has enabled and enhanced the capacity for large-scale data collection, analysis and dissemination. As exemplified during
COVID-19, such systems have allowed individuals to remotely conduct normative dailytasks and maintain social cohesion despite extreme physical distancing measures [38]. ICT
allows sectors to continue their basic functions, such as the health sector using telemedicine for non-essential patients, the education sector using remote learning, and the business sector to promote teleworking. Furthermore, technology has enabled sectors to conduct extraordinary functions in the context of a pandemic beyond national jurisdiction.
For example, governments and private entities have implemented efficient surveillance,
reporting, or contact tracing through artificial intelligence other technologies that aggregate and share large-scale data; mapping disease spread for community protection [24].

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However, in adopting ICT measures, careful considerations must be made to ensure digital tools are inclusive to all members of the community. For example, barriers of accessand adaptability must be considered within ICT infrastructure to guarantee access to information and services among the elderly, disabled groups, lower-income households, or
those living in remote areas [6].
3.6. Knowledge Product Marketing
Updating and generating new recommendations and tools for DRR is a continuous
process. Outside of science, these tools can be used to develop effective public communication strategies and raising awareness for community preparedness [6]. The DRR community requires more tools and knowledge-sharing platforms to facilitate planning andstrategy development [2], and there is as yet limited availability of updated and relevant
DRR knowledge product specialization for biological hazards at a global scale such as the
COVID-19 hazards. This has hindered knowledge sharing, scenario planning, and crosssectoral learning. Although the WHO Thematic Platform for Health-EDRM was formed
in September 2016 to “coordinate activities, promote information-sharing, develop partnerships, and provide technical advice to strengthen the Health-EDRM research field”, asof 2020, there remains an urgent need to strengthen multidisciplinary learning and collaborative efforts to maximize the impact of such knowledge development. Active engagement in shared knowledge and building understanding of the complex nature of biological hazards will enable the DRR community to develop and facilitate scientific risk assessment mechanisms so as to build resilient systems in the future [3].
4. Discussion
The COVID-19 pandemic has had devastating human and socioeconomic impacts
worldwide. The global attention received for COVID-19 provides an opportunity for thehealth and DRR communities to reconceptualize knowledge and tools for disaster risk
mitigation, response and recovery. In November 2020, DRR experts from the Asia-Pacificregion attended the Asia-Pacific Partnership for Disaster Risk Reduction (APP-DRR) Forum to share progress, policy priorities and opportunities thus far for DRR in the region
with respect to the COVID-19 pandemic [11]. Experts shared learnings for risk governance, including health system resilience; data management; residual risk management,risk communication, digital literacy, and knowledge product marketing. Special academic
attention has been paid regarding the integration of biological hazards into DRR planning[6]. Although the Health-EDRM Framework was established to ensure that health will beconsidered within the DRR dialog at intra, inter and multidisciplinary levels, further efforts are required to ensure that both health and non-health actors in education and continuous education are included within DRR frameworks. Notably, and urgently, to include students and young professionals who will become key stakeholders in the next
decade in promoting awareness, scientific development, policy, and capacity at the intersection of health and DRR. Successful implementation of the Sendai Framework will require updated Health-EDRM and DRR tools that consider concurrent, cascading and interacting hazards. Cascading risks have a serious impact on national action plans, and theimpacts faced are becoming increasingly complex and interdependent. However, national
plans still tend to focus on the most probable impacts rather than on those that will bringthe most complex consequences that require heavily coherent and coordinated response[7]. Adaptive governance mechanisms are necessary for building interdependent resilience cutting across social, institutional, economic and ecological levels. Reinforcing continuous learning and innovation across the governance of different sectors will strengthen
DRR outcomes [39], systematic risks analysis and related action planning. Table 1 summarizes how the above discussion may expand into and impact DRR, related challenges
and suggested solutions.
The COVID-19 pandemic has demonstrated the ability for a biological hazard totravel across national borders and the need for governance structures mitigating against

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7 of 13transnational risks. There is a role for North-South, and South-South collaboration in
jointly developing technological, medical and social innovations, which can accommodate
local variation, that lead to creating incentivization for long-term multi-generational resilience [40]. Inter-sectoral coordination such as public–private partnership models forhealth service provision should be explored to maximize the functionality of service provision and the range of services available [6].
There is a large number of activities, priorities and stakeholders that must be mobilized, facilitated, and coordinated, not only in response to the pandemic and in the recovery phase but also in developing DRR plans against the next hazard that emphasizes acoordinated response across linked sectors rather than over-burdening one sector [6]. In
order to operationalize lessons learned in impactful, cost-effective and sustainable ways,
methods in cross-program planning, monitoring and evaluation can be taken from thearea of project management. This will involve viewing international development as atransformative public sector project when evaluating delivery constraints such as time,
cost and quality. International development and private sector projects are at risk of facing
similar challenges in poor stakeholder management, cost overruns, inadequate monitoring, and lack of understanding of local context. However, international development projects often have less tangible goals and certainly face higher socio-political complexities
that induce further transaction costs [41].

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Table 1. Opportunities for different areas to expand into and impact disaster risk reduction (DRR), related challenges and suggested solutions.

IssuesOpportunities to Expand into DRR

Challenges
 Weaknesses in current action plans that do Strengthen health considerations

not consider the entire disaster cycle or prewithin multi-sectoral national or inpare for concurrent, cascading or interacting
ternational DRR action plansrisks• Weaknesses in current action plans that do Improve hazard-related health out- not consider multi-sectoral impact or recomes by revaluating the resilience sponse
Health systems resilienceand vigilance of the health system as• Weaknesses in current action plans that doa wholenot consider post-epidemic long-term physiological or psychological effects National bodies are creating unique, siloednational action plans that lack complementarity

Suggested Solution
Develop multi-hazard, multi-sectoral and adaptive action plans for
DRR

Consider health systems-wide paradigm to care, beyond clinical care

Reinforce awareness-building andcontinuing professional education asa key component in policy development• Identify areas of improvement in ex Consider inclusivity and representa Security considerations in terms of data storisting data platforms (collection,
tion of vulnerable groups in building
age and management
storage, analysis, sharing) in terms
data management toolsof:- Inclusivity of vulnerable groups Incorporate the latest technological- Compatibility with other DRR infor- Ethical considerations for data use, monetiza- advancement and adaptive capacition of data, and personal data protection
ties for piloting secure data collection
Data management
mation platforms
and data management tools- Compatibility with technologicaladvancement
 Unique opportunity to collect robust
post-pandemic data across all popu Continuous education regarding syslations, to be used in recovery assesstems development and updates
ment research or for future hazards
 Define or redefine “essential”
 Develop policy and guidelines to There is no standard definition of “essential”
Residual risk management
groups, including part-time workers,
protect essential workers and nonworkers or nonprofessional workers
nonprofessionals (e.g., home care
professional workers

Int. J. Environ. Res. Public Health 2021, 18, 1614

9 of 13givers), and non-health sector workers
 Data and research in health impact
and needs of essential workers andnonprofessional groups including
needs in material resources, information gaps, or training opportunities Continuous education of stakeholders involved in policy update and development
Review or strengthen top-down gov- Limited evidence of barriers to inclusivity of Develop inclusive platforms for inernment approaches to early warn- populations or inclusivity of communication formation dissemination (e.g., used
ing systems
channelsby the elderly, disabled individuals)
Consider health literacy in disaster Limited but growing political will in manag- Community dialog to review and rerisk communication and decision- ing misinformation or in determining the re- search barriers of information accessmaking frameworks
liability of the information
and understanding Building awareness and appropriate
Consider demographic and healthpolicies for communities facing vulfactors (e.g., old age, physical disabilnerabilities and improving patterns
ities) in ability access to informationof communication under complex
circumstances
Use of novel technology to develop Complex access to digital tools for certain Build community dialog to promotetools for DRR data management (e.g.,groups (e.g., elderly, remote/rural groups, the use of digital tools and underinformation sharing, data collection,
low-income groups)
stand barriers to usage
tracking)
 Pilot novel and innovative tools for
Use novel technology to improve
telemedicine, robotic temperature
health DRR (e.g., diagnostics, telemonitoring, or automated dispenmedicine)sary Building awareness and appropriate
policies for communities facing vulnerabilities and improving patterns

 Research into health impact andhealth needs of a pandemic on essential workers and nonprofessional
workers, in order to build evidencebased policy and guidelines
Risk communication

Digital literacyLacking recognition or political will to protect the health and wellbeing of these groups(e.g., material provision, information dissemination)

Int. J. Environ. Res. Public Health 2021, 18, 1614

10 of 13of communication under complex
circumstances Update Health-EDRM and DRR
tools, in particular, to consider the Lack of political or institutional will for
multifaceted and adaptive nature ofmulti-sectoral planningconcurrent, cascading and interacting hazards
 Multi-sectoral participation in theKnowledge product mardevelopment of updated tools andketingguidelinesCollect evidence and lessons learned
for needs in addressing novel biological hazards
Developadaptiveknowledge products

tools

and

Begin a multi-sectoral dialog for DRR
Building awareness and identifying
knowledge gaps within communities
to encourage active research and policy development

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5. Conclusions
COVID-19 has impacted progress across the Sustainable Development Goals (SDG).
The economic impact has resulted in an estimated 71 million people pushed into extreme
poverty (SDG 1—no poverty); 80 million children under the age of 1 are estimated to missroutine vaccinations (SDG 3—good health and wellbeing); school closures will affect 90%
of students (SDG 4—quality education); cases of domestic violence will increase in 30% ofcountries (SDG 5—gender equality); and 60% of countries will experience prison overcrowding and further risk of spreading COVID-19 (SDG 16—peace, justice and strong institutions) [40].
However, the pandemic also creates opportunities to strengthen SDG, such as
strengthening partnerships under SDG 17 in developing shared warning mechanisms,
data sharing, multi-stakeholder partnerships in science to build evidence-based policy
recommendations. These partnerships can be built between sectors of a country, but alsoin North–South or South–South cooperation [6].
Opportunities and resources available during the response and recovery of the
COVID-19 pandemic may allow DRR stakeholders to examine and evaluate systemic
weaknesses in a holistic and comprehensive manner. To ensure that the global population
would be more sufficiently protected against future concurrent, cascading, or even interacting hazards, revisiting current DRR plans and strategies within the current frameworkof biological hazards will be instrumental. The COVID-19 pandemic has created a chance
to strengthen partnerships; build mechanisms for a coordinated response between DRR
experts and counterparts in health; and build health as a core component across disasterprevention, mitigation, response and recovery. Building understanding of the multifaceted and adaptive components of risk governance within people in their formative years
will allow the next-generation to accelerate towards achieving the targets under the Sendai Framework as well as the SDGs. Continuous education, notably of students and young
professionals, may be a key component when building awareness about DRR.
Author Contributions: Conceptualization, E.Y.Y.C.; methodology, E.Y.Y.C., C.D., A.H.Y.F.; writing—original draft preparation, C.D., A.H.Y.F.; writing—review and editing, E.Y.Y.C., R.S., R.C.,
A.D., A.L., Y.-k.K., K.K.C.H., C.S.W. All authors have read and agreed to the published version of
the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Acknowledgments: This article is a follow-up to the Integrating Biological Hazards (Including Pandemics) into DRR Planning Technical Advisory Document developed by RIKA and authored by
Rajib Shaw, Ranit Chatterjee and Ambika Dabral.
Conflicts of Interest: The authors declare no conflict of interest.

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The current issue and full text archive of this journal is available on Emerald Insight at:https://www.emerald.com/insight/1759-5908.htm

The impact of COVID-19
pandemic on public engagement
approaches to disaster
preparedness for foreign
residents: case of Tokyo
Metropolitan Area, Japan

Disaster
preparedness
for foreign
residents

Received 20 August 2021
Revised 1 January 2022
Accepted 24 January 2022

Bismark Adu Gyamfi and Rajib Shaw
Graduate School of Media and Governance, Keio University (SFC), Fujisawa-shi,
Kanagawa, Japan

Abstract
Purpose – Foreign residents in Japan are classiﬁed as one vulnerable group at risk of disasters. Therefore,various measures are in place to engage, educate and offer ﬁrst-hand experiences of disaster countermeasuresrequired to overcome systematic disaster preparedness problems. However, the need for Japan to prevent the
spread and infection of COVID-19 has necessitated measures that prohibit public gatherings and other social
activities. This study aims to look at how these arrangements have impacted public engagement approaches
to disaster preparedness for foreign residents within the Tokyo Metropolitan Area.
Design/methodology/approach – This study identiﬁes local organizations and examines their methodsof engagement that enhance the disaster preparedness of foreign residents in the Tokyo Metropolitan Area.
The activities are examined in the context of when there was no COVID-19 pandemic and the current state of
the pandemic. A change in activities attributed to the COVID-19 pandemic is then extracted and explained
through ﬁeld surveys and interviews with the relevant organization.
Findings – This study reveals that most disaster preparedness activities were best accomplished throughin-person engagements. Nevertheless, online engagements have become the alternative option because of
COVID-19 infection prevention. This change has widen the coverage of some activities but major setbacks
include events cancelations and technical and technological challenges attributed to using online platforms.
Research limitations/implications – This study did not examine the effectiveness of pre-COVID-19
pandemic engagement approaches and current changes attributed to the pandemic; many public engagement
literatures acknowledge success to include the number of participants, the abilities of organizations to ﬁnd
ways to effectively and positively engage their stakeholders for meaningful partnerships, the number ofclicks, access to a website and comments made online. Therefore, as organizations in this study have shown aglimpse of the above characteristics, there are indications of some level of effectiveness in their engagement
approaches even amid a pandemic.
Practical implications – To avoid such situations in the future, there is the need for the Tokyo
Metropolitan Government, local governments and associated organizations to develop public engagement
approaches that are ﬂexible to resist or cope with in-person, remote encounters, or sudden circumstances that
could potentially derail planned activities.

This study was facilitated by the kind support from the Keio University Taikichiro Mori Memorial
Research Fund 2021.
Conﬂict of Interest: The authors declare that they have no known competing ﬁnancial interests or
personal relationships that could have appeared to inﬂuence the work reported in this paper.

International Journal of Disaster
Resilience in the Built
Environment© Emerald Publishing Limited
1759-5908
DOI 10.1108/IJDRBE-08-2021-0095

IJDRBE

Social implications – The most effects attributed to the COVID-19 pandemic are the cancelation of many
disaster drill exercises, community disaster walks, training of volunteers for foreign residents’ assistance andmany hours of “Yasashii Nihongo” lesson. The cancelation of activities is a setback to the efforts of self-help
and mutual aid campaigns by authorities to reduce the impacts of disasters.
Originality/value – The spirit of inclusion has been an embodiment of disaster management approaches
in Japan for years for which policy recognitions have been tagged along the dimensions of public aid, self-help
and mutual aid. These are aimed at engaging the populace, especially foreign residents in disaster training
and exercises, language study and other communal activities for disaster preparedness. However, to preventthe spread of COVID-19, there have been a series of restrictions on gathering and inter-personal public
engagement activities in Japan. As foreigners are classiﬁed as the most vulnerable to disaster in Japan, it isimportant to understand how these restrictions will/are affecting the efforts of integration and disaster
preparedness, which are a crucial part of the Government’s effort to reduce casualties and damage in the
anticipated Nankai megathrust earthquake. Besides the results being useful for government interventions, italso adds to the knowledge of the repercussion of COVID-19 and how to plan for emergencies.

Keywords Public engagement, Local governance, Disaster preparedness, COVID-19 pandemic,
Local organizations, Tokyo Metropolitan Area
Paper type Research paper

1. Introduction
Public engagement is made up of “public” and its “engagement” in collective activities, andwhen put together, it can be deﬁned as “any individual, group of individuals, organization or
institution that has an interest in, or is affected by, the outcome of a decision” (Knowlton,2013). The processes of public engagement in decision-making are visible in many
endeavors such as governance (The Praxis Group, 2012), research (NCCPE, 2017), health(Welsh Government, 2020), infrastructure (House et al., 2017) and many others. The
application of public engagement strategies is, however, vital “when a decision is a known
concern of other parties or is likely to have a signiﬁcant impact on the parties” (Governmentof Alberta, 2014). These elements are consistent with disaster management practices, after
the realization that the changing scope of disasters is affecting all governments, societiesand people at different intensities such that “the ability of a system, community or society
exposed to hazards to resist, absorb, accommodate and recover from the effects of a hazard
in a timely and efﬁcient manner” (Joerin and Shaw, 2011) depends on collective effort of all(FEMA, 2011). The blatant acceptance of how disasters affect levels of society in different
manners, and the prerequisite need to involve all in the planning and execution of risk
reduction strategies, characterizes a “spirit of inclusion,” as attributed to public engagement(Knowlton, 2013).
The spirit of inclusion has been an embodiment of disaster management approaches inJapan for years but gained momentum after the 1995 Great Hanshin Awaji Earthquake.
Moments after the 1995 Great Hanshin Awaji Earthquake disaster revealed the importanceof community and public engagement in disaster risk reduction, as well the evidence ofvulnerabilities of foreign nationals in disaster events in the country (Cabinet Ofﬁce Japan,2018). These have necessitated policy recognitions tagged along “kojo (public aid),” “jijo(self-help),” “gojo (mutual aid in the neighborhoods)” and “kyojo (mutual aid between
strangers)” perspectives (Kitagawa, 2016). They are based on the fact that disasters cannot
be stopped entirely, but as ﬁrst responders, communities and residents play vital roles in
reducing the impacts and casualties if appropriate learning measures are created throughcommunities-led countermeasures. A successful implementation of disaster risk
management engagement at community levels highly depends on existing local structuresand stakeholders who have roots and are already connected within the communities (Shaw,2012). Hence, within Japanese societies, community engagement in disaster management

activities is exceedingly spearheaded by disaster prevention voluntary organizations (jishu
bosai soshiki), neighborhood associations (chonaikai), ﬁre control clubs (bosai kurabu),disaster volunteers (saigai borantia) and disaster reduction volunteers (bosai borantia).
These groups are somewhat intertwined in broader groups represented in semi- or not-forproﬁt organizations (Kitagawa, 2016). These groups, together with local governments, train,empower, obtain feedbacks, educate and give ﬁrst-hand experiences to dealing withdisasters and other auxiliary measures which augment disaster management planning andimplementation processes. To speciﬁcally deal with the plight of foreign residents andpotential disaster vulnerabilities, additional initiatives, such as the Multicultural
Coexistence Initiative (Tabunka Kyosei) and the Zero Information Refugee Project (Jōhōnanmin zero purojekuto), which aim to foster foreigner–Japanese integration and enhancedisaster risk communication, are fully incorporated in these community or public
engagement activities.
However, as the world continues to grapple with infections and impacts of the COVID-19
pandemic, one distinct characteristic to prevent its spread is by keeping social and physicaldistances while avoiding crowded areas. For this, Japan has declared series of state of
emergencies (SOEs) to curb the spread of the virus especially in the nation’s capital Tokyo,
because of its population and rate of infections. Each declaration comes with severe andtougher restrictions of public gatherings because of the detection of new variants of thevirus. On the contrary, all these SOEs are guided by the closure of many public places suchas schools, gyms, recreational areas and many others. Nevertheless, the same facilities are
essential to disaster management activities such as evacuation shelters, grounds for disaster
drills and exercises and other communal facilities aimed at promoting disaster preparedness(Shaw and Takeuchi, 2012). The need for continuous learning and understanding of disasterrisk reduction through preparedness is highlighted by Kaori Kitagawa, in her study“Disaster risk reduction activities as learning.” In the study, she points a new dimension ofdisaster risk reduction learning and engagement activities after concluding that previous
researchers on the subject matter focused on “curricula, instructional methods or program
designs for disaster risk reduction activities rather than the learning process of those whoare engaged in it.” To this fact, the study goes further to highlight the importance of
behavioral change by referencing Preston (2012, p. 5) to state that: “rehearsal is used toroutinize and familiarize individuals and families with preordained rules of behavior,” suchthat, behavioral changes for disaster preparedness include “learning through actual doing,”
as well as “learning from the consequences of the doing” (Kitagawa, 2021). Further from therecognition of engagements through structured learning curricula, additional studies
buttress the point of learning by practice in a way that partaking in disaster preparedness
activities increases preparedness efﬁcacy, improves risk communication and opens up a
discussion to clarify many uncertainties, especially in disaster simulations and exercises(Sun and Yamori, 2018). It is part of these reasons that many disaster preparedness and risk
reduction activities are undertaken at local communities but are fronted by localorganizations based on already established relationships required for clariﬁcations andeffective learning practices.
Therefore, what impact could COVID-19 have on local community organizations in theTokyo Metropolitan Area in the wake of existing engagement approaches? To understandthis, this study identiﬁes the structures for disaster preparedness in Tokyo Metropolitan
Area and the local governments, identiﬁes some relevant voluntary and other localorganizations that spearhead disaster preparedness for foreign residents in the local
government areas and examines the impact of COVID-19 prevention on their engagement
approaches through interview.

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IJDRBE

2. Local governments and eﬀorts in disaster management
Contrary to the federal governance structure in places such as Germany, where disasterprevention and response highly rest on the state (Lim, 2016), Article 92 of the JapaneseConstitution provides regulations concerning organizations and operation of local public
entities and are established under the “local autonomy” law. The local autonomy law
establishes and separates the procedures and activities of national and the prefectural/municipal (herein referred to as “local government”) authorities. The National Governmentis responsible for policies and affairs that require nationwide uniformity while local
governments are responsible for the day-to-day administration of settlements from towns tocities. The administration of local governments encompasses the handling of wide-scaleregional affairs, communication and coordination, education and environment and manyothers (Michihiro, 2010). The Basic Act on Disaster Management Act No. 223 of November
15, 1961, also reiterates the roles and responsibilities of local governments in disastermanagement. This makes it efﬁcient for disaster communication between local authorities,
residents and other local stakeholders because as pointed out by studies (ISDR/ITC/UNDP/
United Nations, 2010), local-level efforts in disaster management are a core component ofrisk reduction because local governments are able to: engage local communities as well as their citizens with disaster risk reduction
activities that align with the concerns, vision and government priorities;
 strengthen institutional capacities and implement practical disaster risk reduction
actions that may be peculiar to the status of the area; and devise and implement innovative tools, techniques and technologies for disaster risk
reduction, capable of scaling up to nationwide coverage.
These notwithstanding, managing disasters and vulnerabilities has increasingly becomechallenging because of the interconnected process, procedures and guidelines involved inmeeting the needs of stakeholders whilst reducing disaster intensities. The complexities ofthese activities have often resulted in shortfall measures that barely provide the neededmechanisms to reducing vulnerabilities. On the other hand, human nature and attitude to
exercising recommended safety protocols have also been a major issue in the risk
management frameworks (Radhakrishnan, 2020). Such a major attitude can be explained by
the study by Weichselgartner (2001). In the study “Disaster Mitigation: The Concept ofVulnerability Revisited,” emphasis is made on the need to rethink frameworks of disasters
such that the way we think about disasters inﬂuences where we look for solutions. As
echoed by other studies, making judgments about risk is not simple for individuals or any
member of the public, because there should be an assessment nature of the hazards and its
potential occurrence or impact, and match them with a range of alternative actions.
However, the appraisal of these is highly dependent on the way a person judges theconsequences of any particular action (Twigg, 2013). The judgment as alluded here has been
extensively examined by Solberg et al. (2010) to include thorough psychological, perception
and behavioral adjustments of individuals or groups of people. Hence concludes that manyfactors contribute to increased risk perception against disasters (Solberg et al., 2010) andinclude cultural and other social segregation of fragile groups such as females, the aged, theyoung, ethnic minorities, low-income groups or status (Dosman et al., 2001). Hence, trust,effective risk communication, education and training are key elements to reducing risk
perception and collective disaster preparedness (APEC, 2012; Twigg, 2013).
The recognition of these intricacies of capacity enhancement, coupled with pastexperiences of disasters in Japan, is what necessitates conscious disaster management

approaches at local communities through specially selected special days in the year
dedicated to disaster preparedness activities, volunteerism and others. The weeks from
August 30 to September 5 are declared “Disaster Management Week” with September 1
declared as “Disaster Prevention Day” while January 17 of every year marks “Disaster
Response Volunteer Day,” which is part of the “disaster response volunteer week.”
Furthermore, November 5 of each year is also declared as “Tsunami Preparedness Day.”
During these days, many community engagement activities are conducted including
disaster drills simulation and exercises, ﬁre prevention exercises, search and rescue
practices and many others. At the forefront of these activities are the local organizations.
3. Relevance of public engagement practices and approach
Public engagement is a concept highly recognized and implemented in many ﬁelds andcontexts because of its numerous advantages. The broader scope of its application has
equally generated diverse opinions as to what qualiﬁes or represents public engagement.
Thus, the lack of consensus has created an illusion of a precise deﬁnition or identiﬁcation.
For instance, to some scholars, public engagement is well identiﬁed when examined fromthe perspective of information communication mechanisms that exist between authorities
and the community. Deﬁnitions in this context encompass public communication, public
consultation and public participation. The communication aspect is a top-down mechanism
where information is sent from the source (usually from authorities) to the recipient (that isthe community) whereas public consultation constitutes the opposite, where authorities seekor solicit information/feedback from the community. The hybrid of these two instances
forms the participation component, where there is an exchange of information and ideas
between authorities and the public. The application of these components gives theimpression that the public is indeed engaged in a matter that concerns them (Rowe andFrewer, 2005). In other instances, the description of public engagements is prescribedagainst the backdrop of the type of decision to be made. Thus, the public is engaged
depending on whether the decision is directive, consultative or collaborative. Per thedeﬁnitions of the three decisions, consultative and collaborative in a decision-making
process suggest the public is engaged (Government of Alberta, 2014). From otherperspectives, public engagement is identiﬁed by the level of involvement of the public in thedecision-making process (Knowlton, 2013) whilst considering the context or the purpose of
the engagement, the structure of activities and the type of participants involved (Pytlikzillig
and Tomkins, 2011). Despite these varied opinions, many public engagements seek to offer
authorities the ability to empower populations to be able to make decisive decisions, bycollaborating and consulting with them to be better informed (IAP2 International
Federation, 2018).
In the process of public engagements, enormous knowledge is gained throughdiscussions or from just passive participation. In either way, deliberations during public
engagement fetch knowledge characterized by “informed (knowledgeable) opinions,attitudinal changes, rise in trust of institutions, and acceptance of resulting policies”(PytlikZillig et al., 2018. p. 21). However, these outputs from deliberations in public
engagement have been extensively associated with risk reduction and disaster
preparedness. Okada and Matsuda (2006) in their analysis of the participatory process indisaster preparedness argue that disaster preparedness “can hardly be sustained unlessappropriate knowledge is shared and transferred among the agents”; in that, people need togain knowledge on existing hazards and risks, gain know-how on how to survive disasters
and gain intrinsic local knowledge through knowledge sharing. Similarly, knowledge,
attitude and trust are examined as vital tools for disaster preparedness (Setiawan et al., 2020;

Disaster
preparedness
for foreign
residents

IJDRBE

Uslaner, 2016). Therefore, to understand the success of public engagement activities, somestudies rely on the number of participants (either active/passive), level of satisfaction,
inclusiveness level and others (Knowlton, 2013). However, Pytlikzillig and Tomkins (2011)
categorize the processes that lead to effective pubic engagement into “representation
criteria,” “process criteria” and “outcome criteria” such that there is representation of theaffected person, effective discussions and how the engagement improve existing situation.
Hence, any impediment to such process could derail the effectiveness of the process, andmay not achieve the intended purpose.
4. Situation of foreign residents in Tokyo Metropolitan Area
Population of foreign residents in the metropolitan area has increased over the years, and as
shown in Figure 1, this growth equally comes with changing composition in terms ofnationalities. Although Chinese nationals seem to be the dominant among this composition,other nationalities such as Vietnamese and Filipinos have gradually appreciated in numbers
in recent years. The increasing number and the changing composition have already been
researched to create challenges to risk information dissemination and accessibilities (AduGyamﬁ and Shaw, 2021a). Furthermore, their agglomeration in certain communities in themetropolis is also a potential element to exposing their risk levels in event of an earthquake(Adu-Gyamﬁ and Shaw, 2021b). These and many have initiated calls for a broader
engagement of foreign residents in risk preventions and information that consider language,
lifestyles and other factors of vulnerabilities (Ikuyo, 2020).
In Japan, COVID-19 is classiﬁed as a designated infectious disease, hence authorities
have the power and legal status to impose compulsory quarantine and other restrictions on
infected persons. Therefore, a stray from a persistent engagement practice could have ahuge impact on their livelihoods. Thus, of the total number of foreign resident workers in the
country as of 2020, 23.3% are technical trainees (thus come to Japan for a skill-building
program, sanctioned by companies involved), 20.8% work as “residents for work purpose”
6,00,000

551683521500486346

5,00,000

449042

Populaon417442
4,00,000

3,00,000

2,00,000

1,00,000

02015

Figure 1.
Population
composition offoreign residents inTokyo Metropolitan
Area

China
U.S.A.

2016

Rep. of
Korea
India

2017

2018

2019

VietnamPhilippines

Nepal

TaiwanMyanmarThailand

OthersTotal Populayion

Source: Authors, based on information from TMG (https://www.toukei.metro.tokyo.lg.jp/
gaikoku/ga-index.htm)

(thus those working in ﬁelds deﬁned under a so-called professional and other technicalﬁelds) and 21% as “activities other than those permitted by the status of residence (thuscomprising part-time jobs for international students and others) (Immigration Services
Agency of Japan, 2019), implying that in the event where COVID-19 infection prevention andother protocols are misrepresented, misinterpreted or misjudged, the rippling consequences
could be felt by individuals, families, organizations and communities as a whole.

Disaster
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for foreign
residents

5. Disaster preparedness engagement approaches for foreign residents inTokyo Metropolitan Area
The approach to engaging foreign residents in the metropolitan area is found within the
broad scope of the 2006 Multicultural Coexistence Initiative (Tabunka Kyosei) plan by
the Ministry of Internal Affairs and Communication. By implementing such a plan at the
local government level, the Tokyo Metropolitan Government (TMG) aims to foster
intercultural cohesion by embracing diversity while building a city where all residents
can participate and play active roles in the city’s development, as well as ensuring theirsafety. Such an approach includes providing platforms and collaborating mechanisms
for citizens, local organizations and other stakeholders. The organizations, together withlocal authorities, provide various information, including disaster preparedness toforeign residents in the respective areas (Tokyo Metropolitan Government, 2016).
As shown in Figure 2, disaster preparedness information creation and dissemination
are undertaken collaboratively by both in-person and non-contact mechanisms.
Furthermore, as indicated by the Japanese Disaster Countermeasures Basic Act (Act No.
223, November 15, 1961) Article 7.2., “. . . residents of the area under local government
are obligated to contribute toward the cause of disaster prevention by taking their own
measures to prepare for disaster and by participating in voluntary disaster prevention
groups, etc.” (National Land Agency Japan, 1997). Hence, other local and volunteer
entities engage foreign residents in disaster exercises, events, seminars and otheractivities to transmit disaster knowledge and other need learning experience toforeigners in the various local areas.

Figure 2.
Engagement
framework withforeign residents inTokyo Metropolitan
Area

IJDRBE6. Approach and methodology of this study
The study uses both quantitative and qualitative data collection and analysis intertwined
between the review of public documents, reports and ﬁeld interviews. By this, it identiﬁes
local organizations and examines their activities that enhance the disaster preparedness offoreign residents in the Tokyo Metropolitan Area. The activities are examined in the context
of when there was no COVID-19 pandemic and the current state of the pandemic. A changein activities attributed to the COVID-19 pandemic is then extracted and explained throughﬁeld surveys and interviews conducted between July and August 2021 with the relevantorganization.
6.1 Identiﬁcation of local organizations
The TMG recognizes 22 local international associations at the various local governments aspart of its efforts to create a multicultural and mutual assistance society. Furthermore, asnowball approach is used to identify other organizations with similar characteristics. These
groups offer consultation services to foreign residents, promote and teach easy Japanese
language (“Yasashii Nihongo”) and promote community cohesion through volunteering
activities between foreign residents and Japanese nationals within local communities in
conjunction with other agencies (Tsunagari, 2021). These activities are all essential todisaster preparedness for foreign residents in Japan (Ito and Tokarev, 2021). A literature
review from secondary data sources was used to build a general overview of activities of theorganizations before the COVID-19 pandemic but a few of the organizations were sampled
for interviews to extract speciﬁc changes in activities.
6.2 Detection of change in activities
From the general overview developed from Section 6.1 above, a matrix was developedwith rows that show activities of three international associations, against columns thatshow the number of times those activities took place within the 2020/2021 ﬁscal year
(from April 2020 to March 2021). They were then marked by representatives of theassociations as to the number of days or hours for the activity. Further explanations of
the activities are then sought through interviews. The results are analyzed qualitatively
and quantitatively. For other selected organizations, the literature review provided abackground for interviews concerning what may have changed because of the COVID-19
pandemic.
7. Results
7.1 Engagement of foreign residents by international associations
The activities of international associations in the Tokyo Metropolitan Area are mainlygrouped into categories that are deemed essential to the city’s vision of an inclusive andsafe environment for all its residents. Realizing the importance of language abilities indisaster knowledge and preparedness, Japanese language lessons and cultural events
dominate such activities. Figure 3 shows a list of the international associations and thetype of engagement with foreign residents. The shaded boxes represent an engagement
activity, while the blank shows none. About 90% of the associations conduct Japanese
language lessons for adults, while 59% combine adults and children of foreign
residents in language lessons. The remaining activities center on other educational
activities to support foreign residents. The issue of Japanese language education canalso be referenced as a means of breaking the language barrier which has consistently
contributed to disaster prevention lapses among foreign residents in Japan (Sakurai
and Adu-Gyamﬁ, 2020). “Yasashii Nihongo” or plain Japanese is one major learning

1
2
3
4
5
6
7
8
9
10
11
12
13

22

Tama City International Center

16
17
18
19
20

Multilingual information
sources

Homestay & visit

For foreign exchange
students

Language volunteers

Consultation service forforeign residents

Foreign language classes

Events

Lectures, symposiums

Volunteer teacher
training courses

Setagaya Intercultural Center
Association for Nakano International
Communications
Suginami Association for Cultural
Exchange
Association for Arakawa International
Communications
Itabashi Culture and International
Exchange Foundation
NPO Hachioji International
Association

21

15

Japanese language &study support forchildrenChuo Cultural and International
Exchange Association (CCIEA)
Minato International Association(MIA)
The Shinjuku Foundation for Creationof Future
Shinagawa-ku International
Friendship Association
Meguro International Friendship
Association (MIFA)
Global City Ota Cooperation
Association

Musashino International Association
Mitaka International Society for
Hospitality
Chofu International Friendship
Association
Machida Cultural and International
Exchange Foundation
Kodaira International Friendship
Association
Hino City International Friendship
Association
Higashimurayama City International
Friendship Association
The Kokubunji International
Association
Komae International Friendship
Association

14

Japanese language
classesInternational Associations

Disaster
preparedness
for foreign
residents

Source: Authors, based on information from TMG (https://www.toukei.metro.
tokyo.lg.jp/gaikoku/ga-index.htm)

approach adopted by TMG and is enhanced by international association as means ofengaging foreign residents to able to read or understand basic Japanese associated withsafety, disaster prevention, integration and mutual assistance. Thus, this concept uses
simpliﬁed Japanese to explain, guide and implement disaster management activities (Ito andTokarev, 2021). Before the COVID-19 pandemic, all these activities were conducted at thepremises of the associations, city halls and local community centers, except for consultation
services that could either be conducted in person or via email or telephone.
7.2 Foreign residents’ engagement activities by volunteer organizations
The study identiﬁed Tokyo Voluntary Action Center (TVAC) as a key player in thispurpose because it was established to promote and support volunteer activities forwhich the center provides consulting services for volunteers and civic activities for

Figure 3.
International
associations and their
engagements

IJDRBE

individuals and groups, and also conducts human resource development events. It
further provides hands-on experiences and training to groups and individuals in
disaster prevention and management, either directly or through other afﬁliated groups(TVAC, 2021). One major activity identiﬁed to collectively involve foreign residents’
preparedness against disasters in the Tokyo region is the “Disaster Walk.” This is where
various stakeholders made up of volunteers, NPOs, local governments and residents
gather, walk through the selected areas to identify disaster-prone spots within thecommunity and also familiarize themselves with important areas of the community suchas ﬁre hydrants spots, disaster shelter locations and stockpile warehouses in thecommunity (TVAC, 2020). Thus, a community is selected every time for these events,
and as shown in Figure 4 below, a route within the community is determined, membersthen walk along this route. This is vital for disaster preparedness, especially for foreign
residents who may not be too familiar with certain parts of their communities and may
not know other important elements of the community but can clarify throughcommunication with other participants.
7.3 Foreign residents’ engagement activities by the Bureau of Citizens and Cultural Aﬀairsof the Tokyo Metropolitan Government
As part of enhancing disaster preparedness based on the Japanese Disaster Countermeasures
Basic Act (Act No. 223, November 15, 1961), disaster prevention and preparedness drills areheld each across all levels of government, agencies and other organizations (The World Bank,
2016). However, the Bureau of Citizens and Cultural Affairs of the TMG speciﬁcally organizes
separate disaster drill events for foreign residents who per the language barrier or othercircumstances are not able to attend general events. This event takes place each year, andFigure 5 shows an example of such an event’s advertisement ﬂyer.
7.4 Change in approaches to foreign residents’ engagement
As seen in Figure 3, various methods are adopted to engage foreign residents in themetropolis. However, upon interviews with the selected international associations,Figure 4.
Community walkroute for disaster
preparedness

Disaster
preparedness
for foreign
residents

Figure 5.
Flyer of disaster drill
for foreign residents
in Tokyo area

the core activities that have a direct association with disaster preparedness are Japaneselearning course (under “Yasashii Nohongo” initiative), training of language volunteers
to assist foreign residents in time of need, Japanese language teaching volunteers who
further teach other foreigners “Yasashii Nihongo,” and lectures or symposium on many
topics including disaster preparedness and consultation services for everyday survival
in Japan. As depicted in Figure 6, the outlined activities were undertaken within the2020/2021 ﬁscal yearby the the Chuo Cultural and International Exchange Association(CCIEA), Meguro International Friendship Association (MIFA), and the Minato
International Association (MIA). According to the interview conducted, the pre-COVID19 pandemic era saw these associations undertake the following activities:IJDRBE

Figure 6.
Engagement
activities ofinternational
association forforeign residents intokyo metropolitan
area






Japanese language class: in person at the premises of the association and at the local
city halls.
Conduct consultations services: in person at the premises of the association or via
online/telephone.
Disaster preparedness and other communal events: in person at the premises of theassociation, at local city hall or communal areas.
Train volunteers: in person at the premises of the association and at local city hall.

However, Figure 6 again shows how COVID-19 changed these engagement approaches
because of pandemic restrictions of public gathering and SOEs declared in the metropolis.
For CCIEA, which conducts three different “Yasashii Nihongo” classes that amount toroughly36 months in total, 25 of those months had their classes canceled, with ten conducted
at a reduced number of participants. The situation is not different from the other two
associations with MIFA having eight out of 12 months’ worth of classes canceled. For theﬁscal year under consideration, MIA could not conduct any classes such that, thus, all its 12months of “Yasashii Nihongo” were scrapped. These notwithstanding, the assistance toforeign residents through consultations services remains unchanged. The reason for thissituation was that for people that need assistance, much of the requests can be made via
online or telephone with a limited in-person consultation. Furthermore, some in-person
activities like training of volunteers were moved online with some Japanese classes also
moved online via meeting platforms such as Zoom or Google meets.
In total, the associations conduct at least one to three classes each week, with each class lasting
1–3 h. Thus, an average of two classes per week, with 4 h average learning time. Hence, with 52
weeks in a ﬁscal year, each conducts at least a total of 104 Japanese language classes, accounting
for 416 h of studies. Hence, the three associations have an average of 1,248 h of studies. However,in perspective, CCIEA lost 400 h of study out of 576. MIFA on the other hand lost 128 h of study
out of 192. All of the 192 h of study were lost in the ﬁscal year according to MIA.
The loss in study and teaching hours caused by the pandemic is not peculiar to theinternational associations. By operation, the Disaster Walk event and the Disaster Drill
Rehearsal program for foreign residents by the TVAC and the Bureau of Citizens and Cultural
Affairs of the TMG, respectively, require a mass gathering of people and make use of public
facilities and services. However, a ban on the use of public centers and COVID-19 spread
prevention protocols meant that Disaster Walk could not take place in the ﬁscal year.
Furthermore, Disaster Drill Rehearsal was equally canceled this year by its organizers, andmany local governments also followed suit or conducted via online (NHK News, 2020).
Meeting to discuss assistance programs for foreign residents in event of disasters in theTokyo region, another event also organized by TVAC was also moved from in-person toonline. Furthermore, the training of disaster volunteers was also moved online or canceled. For
all events that were moved online, the following are the views expressed from the interviews:
 Japanese language classes are usually conducted by volunteers who are mainly
retirees in the cities. Therefore, moving from in-person to online limited the numberof volunteers because many are new to such online activities and faced manytechnological difﬁculties.
 In as much as there are reductions in volunteers, online presence also increases theaudience of the classes because those who did not ﬁnd time to time in-person wereable to attend. Also, participants of the classes are usually foreign residents who
reside in the respective cities. However, even though some move out of the city, they
still join classes of their previous cities.
 There are always some technical issues with online events and classes as it
sometimes becomes challenging to moderate, give the right experience or feel of asituation under description.
8. Discussion
Many scholars have given different methods and approaches to engaging the public inmatters that concern them (Matthew C. Nisbet, 2015), but outputs or results of theengagement may differ even within one method or among methods of engagement(Pytlikzillig and Tomkins, 2011). This notwithstanding, what is important is theunderstanding of the approach that suits the purpose, the context of the application andthe importance of undertaking such engagements (PytlikZillig et al., 2018). These three
instances align with this study in a way that past experiences with disasters in Japan
have alluded to the fact that a reduction in impacts highly relies on the efforts ofcommunity spirit and the ability to understand various aspects of disaster preparedness.
This situation becomes dire when it considers foreign residents and the role language
plays in both preparedness and actions in event of disasters as explained in the earlier

Disaster
preparedness
for foreign
residents

IJDRBEsections. Therefore, in line with the facts given by Kitagawa (2021), pre-COVID-19
pandemic engagement of foreign residents in the Tokyo Metropolitan Area can beclassiﬁed by learning approaches that focus on in-person or person-to-person
arrangements. A part of these in-person engagements yields an average of 1,248 h ofstudy and interaction time. Other in-person approaches also offer disaster preparedness
experiences associated with knowledge gained through active participation in a form ofdisaster drill rehearsals and disaster preparedness community walk. The contents
within these two identiﬁed approaches share similar characteristics described as publicdialogue and knowledge co-production (Matthew C. Nisbet, 2015). These arrangementsof engagement suit the purpose of offering theoretical and practical experience to foreign
residents whom many are novice to disaster preparedness protocols in Japan and themetropolis (Adu-Gyamﬁ and Shaw, 2021a).
However, an alteration to the approaches is taking place, this time in the context ofpreventing the spread and infection of COVID-19. As explained in Section 6.4, many of
the initial in-person arrangements have moved online or canceled. As empirically given,
online engagement has its negatives and positives (Smith and Gallicano, 2015). Whilesome see the method of online engagement as a cost-effective approach (Government ofAlberta, 2014), others argue the lack of emotions or commitment from the side of the user
(Smith and Gallicano, 2015). However, in this study, the demerit of the online approach is
the reduction in the number of volunteering as well as the difﬁculties of using some ofthe online tools by volunteers. In terms of the merits, the online approach has broadened
participation numbers as explained earlier (although no ﬁgures were able to be secured
from the organizations because of privacy concerns). Nevertheless, the major setback to
the engagement approach is the cancelation of activities because of the pandemic. Thus,
besides some accrued merits the changes may have brought, the effect of cancelation ofactivities is one thing with potential setback to the efforts of “kojo,” “jijo,” “gojo” and“kyojo.” That is, in all of these four elements of disaster risk reduction, a certain level ofJapanese language proﬁciency, disaster prevention protocol knowledge and risk
awareness are imperative. These are the content of activities that have been canceled
because of the COVID-19 pandemic.
Although this study did not examine the effectiveness of pre-COVID-19 pandemic
engagement approaches and current changes attributed to the pandemic, many public
engagement literatures acknowledge success to include the number of participants (Rowe andFrewer, 2005; PytlikZillig et al., 2018), the “abilities of organizations to ﬁnd ways to effectively
and positively engage their stakeholders for meaningful partnerships” (Kang, 2014), the numberof clicks on a website, access to websites and comments made online. Therefore, asorganizations in this study have shown a glimpse of the above characteristics, there areindications of some level of effectiveness in their engagement approaches even amid a pandemic.
9. Conclusion
The study sought to understand the engagement approaches of local communities andorganizations in assisting disaster preparedness of foreign residents in the Tokyo
Metropolitan Area and to ﬁnd out what impacts the COVID-19 prevention protocols have
had on the approaches in the 2020/2021 ﬁscal year. It identiﬁes organizations thatcollaborate with local governments and ﬁnds out that the pre-COVID-19 engagement
approaches were highly dominated by in-person encounters in the form of Japanese
language lessons under the context of “Yasashii Nihongo” at the premises of the involved
organizations, local governments’ city halls and other public places. Further in-person
activities were undertaken in the form of community disaster walk and disaster drillrehearsals. Therefore, it is revealed that an average of 416 h are dedicated to “Yasashi
Nihongo” per annum per organization, and per the sampled organizations, an average of
1,248 h are dedicated to Japanese lessons for foreign residents. However, to prevent the
spread and infection of COVID-19, the study ﬁnds out that most of these in-person activities
have been moved online. The change in approach from in-person to online has increased thenumber of participants who take “Yasashiee Nihongo” classes but has affected the numberof volunteers who support the activities because of managerial challenges attributed toonline engagement procedures.
The most setback to engagement activities attributed to the COVID-19 pandemic is thecancelation of many disaster drill exercises, community disaster walks, training ofvolunteers for foreign residents’ assistance and many hours of “Yasashii Nihongo” lesson.
To give a clue of the amount of impact, among three selected international organizations,
CCIEA lost 400 h of study out of 576 while MIFA lost 128 h of study out of 192. All of the 192
h of study were lost in the ﬁscal year according to MIA. The effect of the cancelation ofactivities is a setback to the efforts of “kojo,” “jijo,” “gojo” and “kyojo,” and in perspective,
the working composition and visa status of many foreign residents are highly sensitive tosudden in schedules and operations such that, should there be any misrepresentation,
misinterpretation of COVID-19 infection prevention and other protocols, authorities may
quarantine, forced restrictions should there be infections and this will prevent access towork and other public places. The rippling consequences of such situation could be felt not
only by the individuals but to families, organizations and communities as a whole.
Therefore, to avoid such situations in the future, it will be essential for the TMG, local
governments and associated organizations to develop their online procedures to a level ofeasy operation by all stakeholders or enhance other remote methods of public engagements
to avoid cancelations or derailment of planned activities.
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Disaster
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Article

Managing Compound Hazards: Impact of COVID-19
and Cases of Adaptive Governance during the 2020 Kumamoto
Flood in Japan
Takako Izumi 1,*, Sangita Das 2, Miwa Abe 3 and Rajib Shaw 4
International Research Institute of Disaster Science (IRIDeS), Tohoku University, Sendai 9808572, Japan
Independent Consultant, Sagamihara City 2520303, Japan; sangita.r.das@gmail.com
3 Kumamoto Innovative Development Organization (KIDO), Kumamoto University,
Kumamoto 8608555, Japan; m-abe@kumamoto-u.ac.jp
4 Graduate School of Media and Governance, Keio University, 2520882, Japan; shaw@sfc.keio.ac.jp* Correspondence: izumi@irides.tohoku.ac.jp
1
2

Citation: Izumi, T.; Das, S.; Abe, M.;
Shaw, R. Managing Compound
Hazards: Impact of COVID-19
and Cases of Adaptive Governanceduring the 2020 Kumamoto Floodin Japan. Int. J. Environ. Res. Public
Health 2022, 19, 1188. https://doi.org/
10.3390/ijerph19031188
Academic Editor:
Paul B. Tchounwou

Abstract: Japan experienced natural hazards during the COVID-19 pandemic as some other countries did. Kumamoto and Kagoshima prefectures, including many other parts of southern Japan,
experienced record-breaking heavy rain on 4th July 2020. While many countries were affected bycompound hazards, some cases such as the Kumamoto flood did not cause a spike of the COVID19 cases even after going through massive evacuation actions. This study aims to understand how
COVID-19 made an impact on people’s response actions, learn the challenges and problems during
the response and recovery phases, and identify any innovative actions and efforts to overcome various restrictions and challenges through a questionnaire survey and interviews with the affected
people. With an increase in the risk of compound hazards, it has become important to take a new,innovative, and non-traditional approach. Proper understanding and application of adaptive governance can make it possible to come up with a solution that can work directly on the complex
challenges during disasters. This study identified that a spike of COVID-19 cases after the disaster
could be avoided due to various preventive measures taken at the evacuation centers. It shows that
it is possible to manage compound hazard risks with effective preparedness. Furthermore, during
emergencies, public-private-partnership as well as collaboration among private organizations andlocal business networks are extremely important. These collaborations generate a new approach,mechanism and platform to tackle unprecedented challenges.

Received: 10 December 2021
Accepted: 19 January 2022

Keywords: COVID-19; flood; compound hazards; evacuation; volunteerism; adaptive governancePublished: 21 January 2022
Publisher’s Note: MDPI stays neutral with regard to jurisdictional
claims in published maps and institutional affiliations.

Copyright: © 2022 by the authors. Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).

1. Introduction
Compound hazards that combined natural hazards and the COVID-19 pandemic
have had major impacts on the community and the environment, and consequently increased the virus spread [1,2]. In such multiple-hazard crises, governments and other responding agents are required to make complex, highly compromised, hierarchical decisions aimed to balance COVID-19 risks and protocols with disaster response and recovery
operations. For example, the aggregation of evacuees into communal environments andincreased demand on medical, economic, and infrastructural capacity associated with natural hazard impacts also increases COVID-19 exposure risks and vulnerabilities [3]. In
India and Bangladesh, the number of COVID-19 cases drastically increased after the evacuation of more than 6.5 million, while the timely evacuation limited mortality as Cyclone
Amphan affected both countries in May 2020 [4].
As in the case of Cyclone Amphan during COVID-19, two extreme events that are
not related in origin but occur simultaneously or in succession are considered compound,Int. J. Environ. Res. Public Health 2022, 19, 1188. https://doi.org/10.3390/ijerph19031188

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multiple, or concurrent hazards [5]. They also have a characteristic of amplifying the impacts with the combined events and causing an extreme event when combined [6]. These
compound hazards make the preparedness and response efforts more complex and challenging for both hazards. Protocols to combat the COVID-19 pandemic include the practice of social distancing and self-isolation; however, the emergency response such as evacuation actions requires expanded planning efforts for evacuation and sheltering options
to limit possible virus exposure to evacuees and essential personnel [7].
Japan also experienced natural hazards during the COVID-19 pandemic. Kumamoto
and Kagoshima prefectures of southern Japan experienced record-breaking heavy rain on
July 4th, 2020. The rain caused devastating floods and landslides in many areas, which
killed 83 people, and destroyed 15,335 buildings according to the Fire and Disaster Management Agency (FDMA; data available online at https://www.fdma.go.jp/disaster/info/items/200709_ooame26.pdf; accessed on 16 October, 2020). Sixty-five people
died in Kumamoto prefecture alone. Kumamoto was the prefecture that was hit by a massive earthquake of 7.0 magnitude in 2016, which, according to an experienced volunteer
who answered during an interview, prepared the prefecture in many aspects of disastermanagement compared to some other parts of Japan. However, the flood of July 2020 presented a number of new challenges because of the ongoing fight against the pandemic.
The first severe COVID-19 positive patient was confirmed in Kumamoto Prefecture on
February 21, 2020 (source: Kumamoto prefecture’s website: https://www.city.kumamoto.jp/hpkiji/pub/Detail.aspx?c_id=5&id=36067; accessed on 16 October, 2020). Prior to
the torrential rain disaster on July 4, 2020, no positive patients had been identified in themunicipalities in the southern region of Kumamoto Prefecture, such as Hitoyoshi andYatsushiro, which were affected by the torrential rain. Surveys through interviews of residents’ actions immediately after the disaster revealed a low level of alertness to infectious
diseases in the early stages of public shelters when people were evacuated to temples,
public halls, and elementary school gymnasiums.
Although at the peak 2512 people were evacuated on July 12, it did not cause a drastic
increase in the COVID-19 cases resulting from close contacts at evacuation centers [8]. As
of July 14, only 49 infected persons had been reported in Kumamoto Prefecture, and no
infections were confirmed in the southern region of the Prefecture, including the areas
affected by the torrential rain (according to the data published on the website of Kumamoto prefecture; available at https://www.pref.kumamoto.jp/uploaded/attachment/112125.pdf; accessed on 16 October, 2020) Tashiro and Shaw [9] argued that thisinitial success could be related to the area’s culture (such as non-touch greeting and sanitation practice since childhood), food habits, and advance healthcare system. However,Japan has been managing the response to COVID-19 pandemic under a “Special Measures
Act to Counter New Types of Influenza” and not the “Disaster Countermeasure Basic Act”
that covers natural disasters [10]. Although efforts were made to tackle this unique situation through emergency revision of the management guidelines, both the preparation forand the response to the July 2020 flood were eventually affected by the pandemic in many
ways [11]. The evacuation centers in Kumamoto took various infection preventive
measures against COVID-19 such as hand disinfection, body temperature checks, zoningof people with fever, etc. [12]. Social distancing was strictly maintained among the evacuees, which reduced the usual capacity of the designated evacuation centers to a great
extent [11].
While many countries were affected by compound hazards and were forced to takeextra measures and efforts to tackle different types of hazards at the same time, some casessuch as the Kumamoto flood did not cause a spike of the COVID-19 cases, even after going
through massive evacuation actions. The Cabinet Office and Fire and Disaster Management Agency (FDMA) in Japan jointly announced the general principle in evacuation that“people in dangerous places must be evacuated in the event of a disaster, and that thisprinciple applies during the ongoing COVID-19 pandemic”. Such an announcement andrecommendation were made explicitly to prevent people from avoiding evacuation out of

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pandemic-related fears. At the same time, people were recommended and encouraged toevacuate to relatives’ and acquaintances’ places in addition to public shelters, or choose
places that were not likely to be flooded, sleep in a car that was parked on a safe ground,and even move to the upper floor at home. This method is referred to as “dispersed evacuation” [13].
This study aims to understand how COVID-19 made an impact on people’s response
actions, learn the challenges and problems during the response and recovery phases, andidentify any innovative actions and efforts to overcome various restrictions and challenges through a questionnaire survey and interviews with the affected people.
2. COVID-19 and Flood Response: The Need for Policy Integration of Compound
Risks
Based on the experience of compound hazard management under the COVID-19 situation, some research has emphasized the need for new policies and approaches to compound hazard management. Kruczkiewicz et al. [14] stressed that the existing frameworks
and guidelines do not apply to compound hazards, therefore, it is crucial to redesign theinstitutional regulations and structures including the funding mechanism to address compound risks. Ishiwatari et al. [10] argued that new approaches are needed to respond tofloods more effectively under the pandemic and future compound hazards. The new approaches should include engaging local organizations and communities, strengthening
risk communication with scientific knowledge, and coordinating multiple sectors. Yusuf
et al. [7] also highlighted that the pandemic-related factors should be incorporated into
emergency management policies and practices. Given the compound risks include not
only flood but also wild-fires, earthquakes, drought, food security, and rising temperature,various stakeholders need to cooperate and address these multiple-risks, and prepare forthe increase in compound pandemic–hazard threats. Simonovic et al. [15] discussed thatthe new approach has to focus more on disaster resilience, which can be a rather proactive
and positive approach, as well as action-based resilience planning, rather than focusing
on one hazard at a time. It is also vital to understand people’s behavior to communicate
what is resilience and how to prepare for and respond to these complicated events.
A literature search on the July 2020 Kumamoto flood was performed using CiNii (Citation Information by National Institute of Information) on September 15th with keywords “Disasters” and “COVID-19”, and it generated 142 results. However, few results
were yielded when the search was restricted to “the 2020 Kumamoto flood”, which was
the first natural hazard that Japan faced since the beginning of the COVID-19 pandemic.
Only eight articles were generated by searching “the 2020 Kumamoto flood” and“COVID-19”. Very few researches on the impact, linkage, and relation between the floodand COVID-19 in Japan were made.
Uchiyama and Danjo [16] addressed the effectiveness of a hazard map that showed
the areas expected to be inundated by the Kumamoto flood. It proved that a hazard map
could contribute specifically to developing an evacuation plan and drill. It also pointed
out the difficulty of gaining volunteers under COVID-19 and that this delayed the recovery efforts in Kumamoto. Kawata [17] emphasized the need for transforming the current
focus on disaster risk management and including the risk management from the cultural
perspective, which considers human lives, culture, customs, and behaviors, not only the
focus on the infrastructure and urban/city planning measures to prepare for a compound
hazard risk. This is called “cultural disaster risk reduction”. As such, a number of studies
highlighted the need for transforming the current risk management approaches to newones; however, the challenge is how the new approach should look and be developed. For
that purpose, it is crucial to collect the case studies of responses to compound hazards andanalyze them—what is missing and what went well, as well as how they could be widely
applied. This study aims to showcase the local initiatives taken to overcome the challenges
and continue the response and recovery efforts by local people without volunteers fromoutside of the affected prefecture, as well as the evacuation center management that

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avoided spreading the virus and keeping a safe environment for evacuees. These initiatives and approaches are considered “adaptive governance (AG)”. At the end, this study
highlights the importance of its concept as one of the potential approaches in a new strategy towards compound hazard response and recovery.
3. The Context of Frequent Flooding in Kumamoto and Attempts to Control Them
The Kuma River basin in Kumamoto prefecture is prone to flooding almost every
time there is heavy rainfall in the region (Table 1). A class-A river (a first class river designated by the Ministry of Land, Infrastructure, Transportation and Tourism in Japan, indicating rivers that are especially important to the national economy) of 115-km length,
Kuma River’s course begins in the mountain range in Kyushu. After running throughHitoyoshi city, Kuma village, and Yatsushiro city of Kumamoto prefecture with a strong
current, it discharges into the Yatsushiro Sea. Due to its location in South Japan, where
heavy rain is very common, severe flooding episodes along the Kuma River have happened many times in recorded history, and the worst of these were in the mid-60s. Whenthe area was affected by severe flooding three years in a row from 1963, the Construction
Ministry (a predecessor of the Ministry of Land, Infrastructure, Transport and Tourism or
MLIT in short) decided to construct a dam along the largest arm of the Kuma River as aflood control measure. The proposed dam, however, could have potentially affected thewater flow, which eventually could have affected the tourism industry and agriculture.
The central government, therefore, canceled the project in 2009 following resistance fromthe prefecture.
Three months after the July 2020 flood, an estimation compiled by the MLIT (available
online:http://www.qsr.mlit.go.jp/yatusiro/site_files/file/bousai/gouukensho/20201006shiryou2.pdf; accessed on 5 August, 2021) was revealed, whichshowed that the canceled dam could have reduced the total area of inundation by 60.7%.
The prefectural government has started to reconsider the proposed dam with design modifications following this revelation [18].
Table 1. Major floods along the Kuma River since the 1960s.

Kuma river overflowed along almost its entire length because of extremely heavy rainfall, flooding almost
two-thirds of Hitoyoshi city and breaking a part of the Hagiwara levee in Yatsushiro.
The same areas were affected along the Kuma river after a record-breaking rainfall on July 24. Over 5000
July 1982
houses were inundated and 47 houses were washed away.
August Heavy rainfall (664 mm in 4 days) brought by a typhoon towards the end of August caused the Kuma river
2004
to overflow along its mid-stream, forcing people of Hitoyoshi city and surrounding areas to evacuate.
Septem- The mid-stream of the river overflowed following heavy rainfall caused by a typhoon. In total, 119 houses
ber 2005
were inundated and over 750 families had to evacuate.
Continuous heavy rainfall for 5 days raised the water level all along the Kuma river, which overflowed inJuly 2006 places inundating 80 houses. Over 900 families in Hitoyoshi city, Yatsushiro city, Kuma village, and surrounding areas had to evacuate.
Heavy rainfall caused the Kuma river to swell and overflow inundating 33 houses. In total, 1087 families inJune 2008
Hitoyoshi, Yatsushiro, and Ashikita town had to evacuate.
The water level of Kuma river crossed the danger limit after heavy rainfall (566 mm over 4 days), forcing
June 2011
residents of Hitoyoshi city and surrounding areas to evacuate. At least 8 houses were inundated.
July 1965(Compiled by the authors based on the data from the website of MLIT’s Yatsushiro River and National Highway Office: http://www.qsr.mlit.go.jp/yatusiro/river/kouzui/index.html; 17 September ,2021).

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4. The Survey: Method and Key Findings
The online survey was conducted from March 2nd to March 11th in 2021, with thesupport of a survey company, to understand the impact of COVID-19 on the evacuation
action taken by the residents and the change in volunteerism under the Kumamoto flood,and identify innovative response and recovery efforts taken by local communities totackle the difficulties that they encountered during COVID-19 and the flood.
The questionnaire was constructed with a major focus on (1) the impacts of COVID19 and the flood, (2) evacuation, and (3) volunteerism. The questionnaire was distributed
and the respondents were identified by a survey company through their local networks.
The constraint of this survey was that only people who have internet access were able toparticipate in this survey. A total of 276 samples were collected from the people in sevencities/villages of Kumamoto prefecture that were affected by the flood of July 2020. The
data collected by the survey were compiled, digitized, analyzed using Microsoft Excel.
A breakdown of the target areas is presented in Table 2. The gender ratio of men andwomen was equal in this survey. The percentage of respondents in their 20s and 30s, 40s
and 50s, and 60s and 70s were 53%, 36%, and 11%, respectively.
Table 2. Target areas of the survey.

Areas
Kumamoto city
Yatsushiro city
Hitoyoshi city
Arao city
Tsunagi town
Sagara village
Kuma village

No. of Answers
195
43
14
16
4
3
1

Percentage (%)
71
16
5
6
1.4
1
0.4

In addition to the questionnaire survey, interviews and hearings with some volunteers and local affected people were conducted from July to October in 2020 to understandthe response practices made by the evacuation management committee and the volunteers. The interviews were also conducted with nonprofit organizations (NPOs) including
Young Men’s Christian Association (YMCA) and Peace Boat, who managed the evacuation centers at that time. Affected business owners who established a volunteer base, andlocal volunteers including students and business persons such as bankers were also interviewed. Through these interviews and hearings, innovative strategies and mechanisms
on not spreading the virus at the evacuation centers, and ensuring human resources toassist the response and recovery efforts, were identified and introduced in this paper.
4.1. Impacts of COVID-19 and the Flood
Ninety-three percent of the respondents reported that the pandemic impacted theirlives. The negative impacts on mental health, income, and social ties were relatively high(Figure 1).
In contrast to COVID-19, only 55% of the respondents answered that the flood impacted their lives. The largest impact was on mental health, and there was a wide gap
between this and second largest impact, which was on income (Figure 1). Regardless of
disaster type (pandemic or natural disaster), both COVID-19 and the flood had a serious
influence on mental health in particular.

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impact of COVID-19

impact of flood

Impacted my mental healthHousehold income was reduced
Impacted my healthSocial ties were reduced
Interaction with our neighbors was reduced
Lost a job
Unable to obtain further education
Lost family members
Others (e.g., injuries/damage on houses )
0

10

20

30

40

50

60

70

%
Figure 1. Impacts of COVID-19 and the flood.

4.2. Evacuation
Of the 276 respondents, 43 (16%) evacuated before the flood. Because heavy rains
occurred from midnight to early morning, it may have been difficult to evacuate duringthat period of time. Among the respondents who evacuated, 80% answered that the riskof COVID-19 infection impacted their decision to evacuate. The greatest impact was thatit took time to make the decision to evacuate.
Thirty percent of those who evacuated went to other places perceived to be safer instead of going to the designated evacuation center. Among them, 67% evacuated to a car
and 25% evacuated to the home of a friend or someone they knew. These locations might
have been chosen because of the evacuation situation at the time of the Kumamoto earthquake in 2016.
The respondents reported that “access to food and water” was their biggest concern
when deciding whether to evacuate to an evacuation center (Figure 2). Their second mostimportant concern was exposure to COVID-19 and “caring for children”. However, theoptions included three COVID-19 related concerns—“COVID-19 infection”, “cannot takeenough preventive measures against COVID-19”, and “cannot enforce sufficient social
distance at the center”. When these numbers are summed up, COVID-19 related concerns
appear to be as important as “access to food and water”. These concerns most likely stemfrom prior experience at an evacuation center or their understanding of the general conditions at the centers. Many people hold negative images of evacuation centers.
Gaining food and water
Caring for children
Caring for family members requiring special attention
COVID-19 infection
Using public toilets, washrooms, and baths
Securing privacy
Concern about safety and security
Caring for pets
Cannot take enough preventive measures against COVID-19
Tackling heat and cold
Concern about my chronic disease
Cannot enforce sufficient social distance at the center
Others

55.8
23.3
11.6
25.6
16.3
14.0
4.7
18.6
9.3
7.0
2.3
18.6
2.3

0

10

20

30
%

Figure 2. Concerns of the respondents at the time of evacuation.

40

50

60

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The major problems encountered at the evacuation centers were “not enough foodand other necessary items” (a major concern of evacuees regarding the evacuation centers
before their evacuation) and “lack of privacy” (Figure 3). These problems were not related
to COVID-19 but were rather common problems encountered at evacuation centers in Japan. In addition, around 20% of the respondents considered “using public toilets, washrooms, and baths” and “having to wear a mask all day” to be major problems. Only 12%
considered having some social distancing at the evacuation centers to be a major problem.
This finding indicates that the infection prevention measures, especially the practice ofsocial distancing, had been taken at most of the evacuation centers; thus, people did nothave to worry about it.
Not enough food and other necessary items

25.6

Using public toilets, washrooms, and baths

20.9

Need to be considerate when taking care of children

16.3

Unable to provide enough support to my family who required special care

2.3

Was not able to secure enough privacy

25.6

Unable to take adequate preventive measures against COVID-19

14.0

Difficulty adjusting to heat and cold

14.0

Unable to enforce sufficient social distance at the center

11.6

Unable to care for my pets adequately

11.6

There were times that I did not feel safe

7.0

Had to wear a mask all-day

18.6

Difficult to have a conversation with my family and people I know

11.6

Others

7.0

0

5

10

15
%

20

25

30

Figure 3. Major problems at the evacuation centers.

With regard to the reason why the respondents did not evacuate, 74% answered thatthey did not evacuate because they thought it was possible to secure their safety without
evacuation. This indicates that 26% of those who did not evacuate considered not evacuating unsafe, but, for various reasons, still hesitated to evacuate. Improving or solving the
problems at the evacuation centers may reduce this hesitation to evacuate and, thus, encourage more people to take necessary action as quickly as possible. Concerns about
COVID-19 infection was the second most cited reason (9.4%) for not evacuating, whichshows that the pandemic did affect people’s decision to evacuate. Only 1% thought thatthe evacuation itself was too much of a hassle.
4.3. Volunteerism
Among the 276 respondents, 11% (30) received support from volunteers. The small
percentage was primarily due to the shortage of volunteers because of COVID-19-related
restrictions. For instance, the volunteers were limited to Kumamoto prefecture to avoid
spreading the virus (Website of Social Welfare Council https://www.saigaivc.com/202007/;
accessed on 2 November, 2020).
Volunteers provided different types of support during and after the disaster (Figure4). During the first week, the need was mostly to assist in distributing food, provide emergency items, and cleaning houses. After the first week, the need shifted to cleaning houses
and providing urgent mental health support. After about a month, the focus was distributed to various types of support at the same time.

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Cooking and distributing food
Cleaning rubble and houses
Receiving emergency items
Medical support
Sorting out the items and clothes provided
Mental health support
OthersDid not receive any support during this period
0

5

10

15

20

25

30

35

40

45
%

1 weekwithin 1 monthafter 1 month

Figure 4. Support provided by volunteers.

Twenty-three percent of the respondents participated in volunteer activities. However, 77% (214) did not participate in any volunteer activities. The most cited reason for
not participating was that they were “worried about COVID-19”, which again shows alink between the pandemic and the shortage of volunteers. Fifteen percent did not participate in any volunteer activities because they were also affected by the flood.
5. Discussion with Case Studies of Evacuation and Volunteerism
The survey findings showed that COVID-19 and the flood had severe negative impact on mental health, income, and social ties. In addition, the compound disaster caused
by COVID-19 and the floods had a significant influence on the areas of evacuation andvolunteerism. This section further focuses on these two areas, introducing case studies
collected mainly through interviews and observations at the time of the flood.
5.1. Evacuation
The survey findings revealed that COVID-19 had a major impact on the decision toevacuate. Respondents took more time to make the decision and many evacuated to places
other than a designated facility. Thirty percent of the evacuees went to other places out offear that they or their family members could be exposed to COVID-19.
Evacuation centers also had to take various preventive measures to prevent further
spread of infection [13,19], following existing guidelines and the newly issued instructions
from the government. The WHO [20] has pointed out that it is crucial that all preventive
measures are carried out at evacuation centers, such as hand hygiene, wearing masks,
social distancing, etc. It was also strongly recommended by the Japanese government toavoid the “three C’s” that is, “closed spaces, crowded places, and close-contact settings”,
in the response to disasters in the midst of the pandemic [13]. The evacuation process andits management during COVID-19 and the flood were more complicated and challenging
than the management of a single crisis. Some of these special measures taken in Kumamoto are described below.
5.1.1. Controlled Entrance and Setting Hand Sanitizers and Thermography
The entrance and exit at the evacuation centers were strictly controlled. The designated evacuation centers, which are usually gymnasiums of public schools, have morethan one door, through which people can come and go according to their needs. However,in 2020, only one door was used for both the entrance and exit, so that only those who had

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permission could enter after a temperature check and hand sanitizing. A thermograph
was placed in the reception area (Figure 5), as well as bottles of hand sanitizers.

Figure 5. Hand sanitizer and thermography at the registration tables.

While it is not uncommon to have hand sanitizers at evacuation centers, their placement at the entrance as well as at the common spaces, with monitoring by the management to ensure their proper use, was a measure taken for the first time. In most evacuation
centers, hand sanitizers were placed in areas such as mobile phone charging stations(Figure 6) and library corners, apart from the reception at the entrance.

Figure 6. Hand sanitizers at mobile phone charging areas.

5.1.2. Social Distancing within the Evacuation Centers
In addition to setting preventive items, social distancing is also an effective measurefor preventing viral transmission [21]. However, an evacuation center is often overcrowded and there is a high risk of COVID-19 infection [19,22]. To ensure adequate social
distancing in order to prevent the spread of the virus, the evacuees were asked to stay
only within a makeshift designated area marked by light materials such as cardboard or
plastic floor mats. In some evacuation centers, the evacuees were dispersed throughout
the facility, including available classrooms.
5.1.3. Dispersed Evacuation
The social distancing measures described above reduced the capacity of an evacuation center to nearly 30%. It was therefore crucial to designate more evacuation centers toaccommodate the remaining evacuees, and, also, identify isolation facilities for infectedindividuals [23]. In order to increase the number of evacuation centers, non-traditionaland non-designated evacuation centers such as hotels, other accommodation facilities,
training facilities, and other potential places for evacuation were identified and people
were encouraged to use them. This method is referred to as “dispersed evacuation” [13].

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To implement “dispersed evacuation”, municipalities became responsible for securing asufficient number of designated evacuation centers in order to prevent secondary disasters.
Furthermore, it is also crucial that the evacuation of people to neighboring towns andcities through advanced agreements among neighboring municipalities is considered incase there is a shortage of evacuation centers. As of July 9, 2020, there were 403 evacuees
from Kuma village in Kumamoto Prefecture, of whom it was only possible to accommodate 131 at four designated evacuation centers in Kuma village. Because the number ofdesignated centers was insufficient, 272 evacuees were accommodated at the centers outside the village with support from neighboring municipalities [13]. Such efforts and initiatives to carry out evacuations to wider areas, beyond a traditional evacuation patternthat includes only designated centers in the evacuee’s residential village, can expand thecapacity to cope with large-scale disasters.
5.1.4. Some Issues That Call for More Attention
The preventive measures described above had some negative effects too. For instance, the measures limited exchanges among volunteers and evacuees, especially older
adults who were assigned in small numbers to small classrooms. There was very limited
opportunity for conversations or brief exchanges between evacuees and volunteers. The
primary focus of all the extra measures was to prevent the spread of COVID-19 and keep
the evacuees protected till they could be moved to individual temporary houses. This, inturn, may have forced some of the evacuees to keep their problems and discomfort tothemselves, blocking the way for timely solutions.
Another important issue that came to light in the recent years was the environment
at the evacuation centers. In June 2013, based on the experience of the Great East Japan
Earthquake and Tsunami in 2011, Japan’s Basic Act on Disaster Countermeasures wasamended, and “Securing a good living environment at evacuation centers” was added. It
became a responsibility of municipalities for securing a certain level of living environment
at the centers, not only securing sufficient number of evacuation centers [24]. However,
the issues such as “improvement of environment at evacuation centers” and “divergenceof evacuation places” have been left unsolved until present [25]. Murosaki (2020) has
pointed out that a general negative image about evacuation centers being “distant, unclean, and no-space” often causes the hesitation to evacuate. These issues have existed formany years, and the COVID-19 situation exposed them further. It is urgently required toreview these issues and take actions to improve the situation [26].
5.2. Volunteerism
The survey findings indicated that a very limited number of people (11%) received
assistance from volunteers. This finding can be explained by the severe shortage of volunteers due to travel restrictions during COVID-19. The first respondents during the initial weeks were individuals and organizations from within the prefecture [11]. The survey
also showed that people did not participate in volunteer activities because they were “concerned about the possibility of COVID-19 infection” (57%). Only 15% answered that it was
because they were also affected by floods.
Volunteer support is crucial in disaster response [25,27]. Volunteers provide a significant resource for emergency management [28]. There are several types of volunteers.
Waldman et al. [29] categorized them into spontaneous volunteers and affiliated volunteers associated with emergency-related voluntary service organizations. Spontaneous
volunteers participate in volunteer activities from outside the affected areas and do nothave any formal training in disaster response [30]. If they do not have any formal training
and are from the same community or neighboring areas, they are called “informal volunteers” who work outside of formal emergency and disaster management arrangements[30]. The communication and coordination among spontaneous or informal volunteers
and affiliated volunteers are ineffective, and affiliated volunteers have concerns about theInt. J. Environ. Res. Public Health 2022, 19, 1188

11 of 16level of safety and liability associated with the work of spontaneous volunteers [28]. Whittaker et al. [28] indicated that those who work outside of systems tend to be viewed as
nuisances or liabilities, and their efforts are often undervalued.
An “on-call civilian firefighter” is an example of a volunteer who has been trained. Ifthey are from outside of the affected area, they are “expert volunteers” (e.g., health workers) or “formal or affiliated volunteers”. Because disaster risks are increasing, it is expected that the need for and expectation of spontaneous volunteers will also increase [31].
It has become necessary to estimate the minimum manpower required for the cleaning
and reconstruction work at each disaster-prone area, and create a sort of roadmap towards
ensuring spontaneous volunteers from within the area itself [11].
During the Hanshin-Awaji earthquake disaster in Japan in 1995, a large number ofvolunteers came to the affected area to provide assistance; however, it was not possible tounderstand the needs of the affected people and effectively coordinate responses. Basedon the lessons learned from these experiences, disaster volunteer centers (VCs) that aim
to understand the needs of the affected people and coordinate the activities of volunteers
are being established by the Social Welfare Association in the affected areas in collaboration with nonprofit organizations (NPOs) and volunteer organizations [32,33]. In addition, an NPO support center is often established to share tasks with VCs. While an NPO
center collaborates with VCs, there is no clear division of work and responsibilities between VCs and NPO support centers [34]. In the case of Japan, most of the volunteers areusually spontaneous (coming from outside the affected areas/no formal training) or informal (coming from the same communities or neighboring areas/no formal training); however, they normally work after being registered as volunteers at disaster volunteer centers.
COVID-19 prevented volunteers from participating in support activities such as
helping to clean houses and removing rubble, distributing necessary items, and cooking
and distributing food [35] as these activities can interrupt social distancing [11]. In the caseof the flood in Kumamoto in 2020, the affected people were allowed to accept support
only from local volunteers (https://www.saigaivc.com/202007/); accessed on 2 November,2020). The challenge of how to ensure the necessary support previously given by volunteers for relief and recovery assistance has emerged during the pandemic. Through interviews with affected people and volunteers, this study identified four new strategies forincreasing volunteer support, in order to overcome this challenge.
5.2.1. Establishment of Volunteer Base by Business Owners
The recruitment of spontaneous volunteers was limited to those within Kumamoto
prefecture, which did not ensure sufficient support personnel for the restoration of evenordinary homes. Therefore, restoration activities for hotels, stores, shops, etc., in the centerof the city were aided not by volunteers dispatched from volunteer centers but by relatives, acquaintances, and those who in normal times had been business partners of theshop owners. Within Hitoyoshi City, private volunteer bases were set up, and stores performing restoration work began to appear and function as new hubs of activity. One man
established a private volunteer group at his store’s site. He manages a wholesale store
selling a distilled drink from Kumamoto. This one-storied shop was flooded up to theceiling. The center welcomed supporters from partner businesses, banks, etc., and placed
containers at the site. The volunteers removed debris from disaster-struck stores, clearedaway mud, and cleaned up.
At the volunteer base, drinks and ice were provided, a rest area was set up, and alarge number of electric fans were operated to prevent heatstroke from working in theblazing sun. Due to the shortage of volunteers because of reasons described in the previous sections, there was very little expectation of volunteers being dispatched from official
volunteer centers. Therefore, this private volunteer base was set up by a storeowner sothat the efforts could be carried out by themselves. The volunteers were requested to wear
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to pay close attention to not spreading the virus. Moreover, the information of who
worked where and with whom were saved in case someone became infected.
5.2.2. Recruiting Support Staff under “The Kuma Recovery Project”
To deal with the shortage of volunteers, a group of local organizations, in cooperation
with the business community and other stakeholders, started a project called “The Kuma
Recovery Project” a month after the 2020 flooding. Their objective was to connect threeparties: (1) areas where volunteers were needed for cleaning work, (2) potential volunteers, who were mostly people who lost their business or jobs to the disaster, (3) contributors and fund providers.
There were certain criteria for people who could apply as volunteers. The potential
volunteers could apply through the website, where a list of work sites and dates wereposted. Based on the date and place of work, bus rides were provided. After a day’s work,
the volunteers were given a small amount of daily allowance from the fund created by thecontributors. The website regularly posted updates of the recovery work performed under
this project.
5.2.3. Involving Local Students in Relief Activities
The experience of the flood in 2020 during COVID-19 highlighted the challenge ofvolunteer service operations under the pandemic and the need for unconventional approaches to gain support for disaster relief. For instance, local students in Kumamoto prefecture were recruited to replace volunteers and were paid a minimum wage to provide
the services normally provided by volunteers. Recruitment was carried out by the “Kumamoto Support Team,” a private organization set up by volunteer members from Kumamoto Prefecture after the Great East Japan Earthquake and Tsunami in March 2011 toestablish a support system to provide sustainable relief assistance. This organization became a general incorporated association in July 2020.
The organization used donations received from across Japan to manage volunteer
activities by paying a daily allowance to university students who participated in the relief
activities. Students who had lost income from part-time jobs due to COVID-19 were employed by the organization. In addition to a daily allowance, participating students were
given meal coupons for use at restaurants and shops affected by the flood as part of a new
initiative to help restaurants and shops affected by income loss. The initial budget was
obtained through crowdfunding, with approximately JPY 20 million raised across Japan,
exceeding the target amount of JPY 6 million. The total number of students who worked
under this system had exceeded 1450 as of September 28, 2020 (Source: Kumamoto Support Team website: https://kumamoto-team.net/; accessed on 5 July, 2021).
5.2.4. Crowdfunding to Support Response and Recovery Efforts
At the time of the flood in July 2020, a private organization, “Student Disaster Volunteer Support Association” was established by university and NPO staff who had been
carrying out support activities for the response and recovery effort after the HanshinAwaji earthquake in 1995. They started crowdfunding to gain support from student volunteers who were active within the prefectures affected by the flood because it was difficult to receive support from volunteers from outside the prefecture due to COVID-19.
These funds were mainly used to support the transportation and material costs ofsupport activities and to cover activity expenses with the goal of promoting the proactive
participation of student volunteers. However, the funds did not cover a daily allowancefor the volunteers, which was different from the support given by the “Kumamoto Support Team”. Applications for participation in the volunteer activities were accepted fromuniversities with the requirement of forming a group of three or more people, not by anindividual. Fundraising through crowdfunding targeted a maximum of JPY 200,000 per
activity, and a total of JPY 5,000,000 for 25 projects. Within 2 months, a total of JPY

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6,869,855 was raised, and the number of supporters reached 795. As of June 2021, there
have been 24 completed or ongoing projects. Through this scheme, budgets were secured
through crowdfunding to contribute directly to the response and recovery activities, andto enable groups to start the activities as soon as possible, not covering a daily allowance
to individuals.
5.2.5. Revival of Traditional Systems
The first case of the establishment of a volunteer center by business owners succeeded in gaining volunteer support from their own business networks, without relying
on the volunteers dispatched by official volunteer centers. This is considered a case ofreactivation of a traditional mutual help system in communities. Other cases are newschemes to provide immediate necessary support to the affected people developed on the
ground, which aided in overcoming the shortage of manpower and financial resources
and fueled relief and recovery efforts.
Due to the difficulty of ensuring enough volunteers, two different types of mutual
aid systems arose eventually: (1) flexible changes to disaster responses under the pandemic, not only to follow a traditional response, but rather to innovate and apply new
mechanisms, exemplified by the cases implemented for operating evacuation sites andsecuring necessary support from the volunteers, and (2) the revival of traditional systemsof mutual aid that existed for a long time in the region [35]. The experience of compound
hazards in Kumamoto showcased not only new and innovative mechanisms and initiatives, but also the potential for the revival of traditional and the emergence of new mutual
aid systems in the community that grew under the pressures associated with the nonarrival of volunteers on the mutual aid systems that existed before the disaster [36].
6. Conclusions
The findings from the interviews conducted for this study bring forth some important issues that can be crucial in the management of compound disasters of a similar
nature in the future. The findings show, that while concerns for COVID-19 was the main
reason behind the dilemma on whether to evacuate or not for most respondents (80% felt
their decision to evacuate was impacted by COVID-19), once they were in the evacuation
center, their major concerns were ensuring privacy, food, and necessary items (25.6%each). Only 14% of the respondents expressed concerns over protection against COVID19. In other words, the findings show that COVID-19 infection was a much bigger concern
before the evacuation than after, indicating some success of the measures taken at theevacuation centers. Some of these measures were instructed in the government guideline,
but many were not—they came about as a response to certain issues that were createdbecause of the complexity and uniqueness of the situation.
Similarly, concerns for COVID-19 affected the local residents’ decision to volunteer
at the early recovery stage. In this study, 77% of the respondents refrained from volunteering for this reason. Spontaneous volunteers from outside the prefecture could not access the affected areas because of travel restrictions in order to control COVID-19. This
unprecedented situation severely affected the recovery process in the early weeks, andthe strategies described in the previous section to overcome this serious issue show theimportance of a participatory multi-stakeholder platform. These new strategies, including
the reactivation of a traditional system to overcome the challenge of a shortage of volunteers can be explained as “adaptive governance (AG)”. An AG approach is put forward
as an alternative method of managing complex social–environmental problems including
disasters [37]. AG calls for new governance systems that are “less rigid, less uniform, lessprescriptive and less hierarchical, and promise a more innovative but effective way of
dealing with complex environmental problems” [38]. One proposed innovation for more
flexible and participatory methods of governance is through the multi-stakeholder platform, defined by Steins and Edwards [39] as: “Decision making bodies (voluntary or statutory) comprising different stakeholders who perceive the same resource management

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problem, realize their interdependence for solving it, and come together to agree on action
strategies for solving the problem.”With an increase in the risk of compound hazards, it has become important to take anew, innovative, and non-traditional approach. Generalized guides are often not applicable to complex situations where several issues overlap. Proper understanding and application of AG can make it possible to come up with solutions that can work directly on thecomplex challenges during disasters.
This study eventually leads to the following conclusions:












The COVID-19 infection was the second common concern at evacuation centers next
to gaining enough food and water before people decided to evacuate. However, themost serious problem at the evacuation centers that people actually experienced wasinsufficient privacy, not COVID-19-related issues. This revealed a long-term problem
and concern at evacuation centers. The general conditions at the evacuation centersneed to be improved urgently to motivate people to take the necessary action at an
emergency. At the same time, it is important to share the information on the safety
and preventive measures taken at evacuation centers to eliminate “evacuation hesitation” for concerns related to infection.
Income loss and mental health damage were most common impacts caused by
COVID-19 and the flood. Therefore, financial support and assistance to recover frommental health damage are required at the recovery phase.
Due to a lack of volunteers, it was difficult to access the necessary support normallyprovided by volunteers at the response and recovery phases. However, new mechanisms and initiatives to overcome this issue have evolved. The effectiveness of suchinnovative approaches should be further examined, and the experience should beshared widely.
A spike of COVID-19 cases after the disaster could be avoided due to various preventive measures taken at the evacuation centers. It shows that it is possible to manage compound hazard risks with effective preparedness including timely communication and coordination.
The preventive measures, however, restricted the interaction among the evacuees
and management personnel to a great extent. This may have forced some evacuees
to keep their problems and discomforts to themselves, which could lead to various
serious issues including disaster-related deaths. Provision for alternative ways ofcommunication and interaction need to be included in the evacuation centers considering this experience.
During emergencies, public–private partnership as well as collaboration among private organizations and local business networks are extremely important. These collaborations generate a new approach, mechanism, and platform to tackle unprecedented challenges.

In recent years, the risk landscapes of the world have been increasingly complex. As
stated earlier, governments and other responding agencies are having to make compromised decisions in the midst of multiple, overlapping emergencies, due to the lack of aconsolidated roadmap towards the management of compound hazards. The changing climate has been adding to the complexity of these risks, making the need for a possible
roadmap increasingly urgent. AG will be a key to managing compound hazards to overcome difficulties, especially during the recovery stage, that require a longer time and effort.
This study was conducted based on the experience and case studies in Kumamoto.
The response and recovery efforts towards and from compound hazards, as well as theireffectiveness, differ from country to country. For instance, the mass evacuation in somecountries caused a rapid increase in COVID-19 cases. There should be innovative responses and recovery actions towards COVID-19 and natural hazards specific to each

Int. J. Environ. Res. Public Health 2022, 19, 1188

15 of 16country. Furthermore, different challenges and problems need to be identified under different environments. Therefore, further studies, analysis, and comparison of the effectiveness of risk management on compound hazards need to be conducted based on the practices in different countries.
Author Contributions: T.I.: conceptualization, methodology, analysis, writing—original draft. S.D.:
writing—review and editing, validation, formal analysis. M.A.: data curation, validation, formal
analysis. R.S.: conceptualization, methodology, supervision. All authors have read and agreed tothe published version of the manuscript.
Funding: Fukuzawa Research Fund of Keio University; JSPS KAKENHI Grant Number JP19K02035
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Informed consent was obtained from all subjects involved in the
study.
Data Availability Statement: The data presented in this study can become available on request fromthe corresponding author. The data are not publicly available due to legal and privacy issues.
Conflicts of Interest: The authors declare no conflict of interest.

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