Coronavirus: The Story of Risk and Resilience (Part 3)
By: Mike Promentilla
Tags: Coronavirus, Pandemic, Risk, Philippines, Resilience

Massive testing is thus one of the key factors to effective NPIs, which was underscored by the World Health Organization director-general, Tedros Adhanom Ghebreyesus: “Test, test, test…Without knowing, without testing, it’s like moving blindfolded.” The improved testing capacity with rapid tech-enabled tracking and contact tracing (e.g., QR Code, Bluetooth) could also be effective as demonstrated in Taiwan, South Korea and New Zealand.

As shown in Chart 15b, Vietnam is a classic example of how important massive testing is. In Chart 14, the US has a higher number of testing than South Korea and Vietnam, but its positivity rate is lower relative to the size of the outbreak. This is also the same case with Italy. Thus, we should not look at the data on confirmed cases and the data on testing in isolation. Both sets of data will give a better context and richer picture.

The number of confirmed cases is not enough to give us the real picture of the extent of the outbreak. To understand the epidemic and evaluate how successful we are in our response in terms of testing capacity, we need to know the extent of testing by which these cases were discovered. Testing capacity is not all about the total number of tests. Timing and a high rate of testing will do more to flatten the curve if testing was done as early as when there are fewer infections. We can clearly see the effect of testing early or late, and the test positivity rate by checking the path (similar to Chart 15b) taken by South Korea, Italy, and the US.

Other factors may also be considered for a cost-effective strategy to flatten the curve. For example, Japan and Thailand did not have the numbers of testing as extensive and massive in comparison to that of Vietnam, South Korea, or Taiwan.

Japan focuses on cluster containment by testing the infected and tracing the clusters of the original source. Everyone in the cluster is then isolated and treated as necessary. On the one hand, Thailand managed to suppress the epidemic because of its strong primary health care system and its investment in the health security capacity in areas such as monitoring and tracking cases of infectious disease, epidemiological training, and electronic surveillance reporting. Thailand also has strong community participation through volunteerism.

Another compelling case to study is that of Cambodia, whose testing capacity is also limited. Both leaders of Cambodia and the Philippines have downplayed the risk and maintain unrestricted travel linkages with China at the very early stage of the pandemic. To date, Cambodia seems effective in its strategy to contain the outbreak by instituting some stringent measures.

Since the pandemic is not yet over, it would be difficult to generalize which specific strategies really work against this coronavirus given the many unknowns, and the lack of transparency and lack of testing capacity in many countries. We need context. Only time will tell.

But one thing is for sure, resilience against this pandemic in Asian countries such as Vietnam, Singapore, South Korea, Taiwan, and Thailand could be attributed to their level of preparedness and the strong healthcare system. Most of them share similar approaches to combating the outbreak, based on rapid and coordinated response born of lessons learned after the deadly severe acute respiratory syndrome (SARS) epidemic of 2003 and 2004, and the Middle East respiratory syndrome (MERS) in 2015.

In summary, it is clear that the strategy to win the first round of the battle against this coronavirus is Test, Track/Trace, and Treat.

These are the seven key actions to win this battle:

1. Act quickly and decisively based on the best available data and evidence.

2. Massive testing and rapid contact tracing to assess the problem at hand.

3. Isolate and quarantine (suspected, probable, confirmed) infected people or clusters to prevent the spread.

4. Border control and non-essential travel restrictions to prevent case importation from outside.

5. Strengthen healthcare systems to manage the epidemic and other looming disasters and treat patients.

6. Continue practicing physical distancing and personal hygiene to lower the risk of contagion.

7. Face masks for everyone to lower the risk of contagion.

With these key action plans in place, the government should start providing clear guidelines on multiple metrics or criteria to be used on when and where to relax the control measures. Detailed guidelines should be in place to identify the sectors and areas where businesses can be opened to revitalize the local economy. For example, physical distancing protocols should be clear such as how many persons and what activities are allowed in a certain place or event. The metrics should also be clear on when and where to re-impose restrictions as deemed necessary. These should properly be communicated to the citizens before the government lift or modify the restrictions of either ECQ or GCQ.

Mall goers observe physical distancing while queuing at a mall in Quezon City on May 17, 2020. Source: Photo by Darren Langit/Rappler ( https://www.rappler.com/nation/261197-malls-to-be-closed-physical-distancing-not-observed-coronavirus-lockdown )

2nd Phase: Recovery and Resilience Phase

This is our mid-term strategy. Our planning horizon will range from six months to 18 months after our government decided to ease the restrictions of ECQ gradually. The main objective is to build resilience against this epidemic while minimizing economic and social costs. While we are transitioning into the new normal, the government should start crafting the strategies and policies toward economic recovery and social welfare reforms.

Do we have an evident economic recovery and social welfare development roadmap to cushion the blow caused by this pandemic crisis?

To date, the Department of Finance outlines the four pillars of the socio-economic strategy against COVID-19.

Besides, the National Economic Development Authority (NEDA) is reviewing the technical document entitled “We Recover as One”. This outlines the three phases of the government’s response against COVID-19, namely (1) response, (2) mitigation, and (3) transition to the new normal.

NEDA is also studying the feasibility of adopting the UNDPs’ COVID-19 Integrated Response that is framed around three objectives: prepare, respond, and recover phases. The three immediate priorities of the UNDP plan are health systems support, inclusive and integrated crisis management and response, and social and economic impact needs assessment and response.

Academic institutions drafted policy recommendations on social protection and economic recovery plans such as that of UP School of Economics, ADMU Department of Economics, and DLSU Angelo King Institutes.

This is the time where collaborations among government agencies, academe, industry sectors, and civil society will be more needed for economic recovery in times of crisis.

Risk-informed development: from crisis to resilience

Indeed, economic progress and national development are impeded by shocks and crises, such as that of a pandemic. It is thus important to look that exposure to risk and development are not separate, but essentially the same thing viewed from different angles.

The United Nations Development Programme (UNDP), in collaboration with the Overseas Development Institute (ODI), published a report that underscores a risk-informed development approach. It allows for development to become a vehicle to reduce risk, avoid creating risks, and build resilience.

There is a need for systematic assessments of complex threats and risks, opportunities, uncertainties, risk tolerances, perceptions, and options to ensure that development is sustainable and resilient.

Disaster risk reduction and management (DRRM) core tenets can also be applied to the COVID-19 crisis management (Djalante et al., 2020). First, it is imperative to provide more knowledge and science provision in understanding disaster and health-related emergency risks. Second, to extend disaster risk governance to manage both disaster risks and potential health-emergencies, particularly for humanitarian coordination aspects. Third, to strengthen the community-level preparedness and response.

Thus, we should also start building community resilience through a strong epidemic-ready barangay healthcare system. In this recovery and resilience phase, we have to start also building resilience to our institution and infrastructure as we anticipate the possible scenarios on how this pandemic will progress. We should be prioritizing the vulnerable groups of our society, i.e., created by our fragile socio-economic system.

We have to remember that poverty can fuel the spread of the disease and amplify the risk of the epidemic. But COVID-19 can also create or deepen such impoverishment. Poor households often lack disposable cash and do not have the capacity to stockpile food, basic supplies, and medicine. Hunger, malnutrition, pneumonia, and other forms of health-related shocks and co-morbidities compound vulnerability to this epidemic.

We can thus anticipate those crowded urban slums as potential hotspots for the spread of COVID-19 disease. We need to target these areas of extreme poverty through health interventions alongside other forms of sustainable development that would offer a longer-term solution. This is to prevent the spread of future outbreaks and reduce vulnerability from impoverishment.

In addition, limited resilience capacities have amplifying effects as well. Of course, healthcare systems need strengthening along with other critical infrastructures. We may need safety nets such as universal basic income (UBI) for social protection, and to reinforce decent employment standards that provide protection for the most vulnerable workers.

Strong governance will also play an important role in building resilience. We must ensure smooth and transparent coordination among government agencies, and among the national, regional, and local government units (LGUs).

CO-INFORM: Metrics for Risk and Resilience Management

With these considerations, decision support tools such as the CO-INFORM can provide an evidence-based approach to target emergency interventions. These metrics can be used to calibrate policies in managing the epidemic in the country. Chart 16 provides an example of indicators that can be used for CO-INFORM. Please refer to Part 2 of the article for details of the conceptual framework. Chart 17 describes a sample output from the use of these indicators as metrics.

The anticipation of possible pandemic scenarios

This pandemic would continue until effective vaccines become available, and 60–70% of the population becomes immune. In the meantime, some countries like the US are doing antibody tests to reveal the extent of the outbreak. According to the US Center for Disease Control and Prevention (CDC), this strategy includes using serology testing for surveillance to understand better how many infections with SARS-CoV-2 have occurred. The seroprevalence survey could also be useful to guide control measures such as physical distancing. However, some experts warn us to use this strategy with caution, as this may give us a false sense of security. We should also be wary of the sensitivity and specificity of such a test. Even a small error in testing could have unintended consequences for health policy. Such tests like any other tests should be implemented with the proper context for this strategy to be cost-effective.

This coronavirus may have to be around, and infect us in the next 18 to 24 months before any level of herd immunity gradually develops across the world. One report from the University of Minnesota Center for Infectious Disease Research and Policy (CIDRAP) describes three possible “wave scenarios” for the future of the ongoing COVID-19 pandemic.

The worst scenario (Scenario 2) among the three scenarios is similar to what happened during the 1918 Spanish influenza pandemic and the 2009 H1N1 flu. Our first wave of the epidemic, which we are experiencing right now, will be followed by a larger wave in fall or winter, i.e., six to nine months from now. After this larger wave, one or smaller subsequent waves may occur in 2021.

We should plan for this worst scenario, including no vaccine availability or herd immunity.

As you can see from Chart 9 (see Part 1), I imagined that the weekly death rate (9 months from Lockdown Day Zero) attributed to COVID-19 will have lower peaks even though the larger second or the third wave may occur in this coming November or January of next year. Why?

“…because I wish and choose to be an optimist.”

I am optimistic that we have learned from our shortcomings fast enough to act decisively this time and start investing in resilience. I am optimistic that our economy will gradually recover. I am optimistic that our society will be preparing and adapting to the new normal. I am optimistic that our government will do the right thing.

Our government should develop strategies to ensure adequate protection for healthcare workers when disease incidence surges.

Our government officials should also develop concrete plans, including triggers for reinstituting mitigation measures, for dealing with disease peaks when they occur.

Lastly, risk communication messaging should incorporate the proper context that this pandemic will not be over soon and that people need to be prepared for possible periodic resurgences of COVID-19 over the next 2 years.

By the time this second or third wave hits us, are we prepared and ready to suppress or mitigate this epidemic while we are on the path to economic recovery?

A transparent and fair socio-economic stimulus package should be both effective for both the short and long-run. Provide bailout to citizens. Shift to “glocalism” as deemed appropriate. Prepare for a digital economy.

We need to start studying the viability of adaptive cyclic exit strategies from lockdown. We need to build a disaster-proof supply chain and industries that can adapt rapidly and continue to operate under stress. Large enterprises need to protect their workforce and reinvent themselves and be agile to adapt. Likewise, micro, small and medium enterprises (MSMEs) must learn how to leverage the fourth industrial revolution (FIRe) technologies to be agile and flexible to adapt to the new normal.

These are just some of the issues we have to address in the second phase.

Here again, is my fearless forecast.

We will still be in a crisis mode for the next 12–18 months.

We must not be complacent. We need to have these 7Cs to combat COVID:

1. Crisis leadership.

2. Communication with the correct context.

3. Collaboration among government, industry, academe, and civil society.

4. Coordination among National, regional, and local government units and agencies.

5. Community engagement to build resilience.

6. Calibration of policy.

7. Civic duty.

3rd Phase: Reimagining and Restructuring Phase

This is our long-term strategy.

The planning horizon will be from 19 months onward, and for the next five and ten years. The main objective is not only to thrive and flourish in this new normal but also to reimagine the society of the future.

COVID-19 pandemic, which could last for two years, is more than just a global health crisis. It has the potential to bring social, political, and economic upheavals we have not imagined to happen so soon. It will leave a scar. Indeed, it is not just a health crisis, it is a humanitarian and development crisis.

Crisis & Opportunity — Opportunity is always present in the midst of a crisis. The Chinese word for crisis carries two elements, danger, and opportunity. Source of image: https://peakwatch.typepad.com/decline_of_the_empire/2010/02/crisis-opportunity.html

We can thus use this crisis as an opportunity to build a better society that leaves no one behind.

COVID-19 pandemic catalyzes our transition to the new normal in the era of circular economy and the fourth industrial revolution (FIRe). It exposes the weakness of our institution and our way of life. It challenges the status quo.

This is the phase where we start crafting our strategies that will transform our society by introducing systems reform to our institutions and critical infrastructures. We should be anticipating not only for a “black swan” event but also for the crash of “gray rhinos”.

A black swan event is extremely rare, severe impact, and the widespread insistence it was obvious in hindsight

In hindsight, a black swan seems around the corner. But are we ready for a crash of grey rhinos, events that are highly probable with high impact?

For example, it is time to envision the agri-food systems of the cities of the future. I am part of the team at the National Academy of Science and Technology (NAST), working on the Food System Vision 2050 of Metro Manila. Leveraging urban farming and artisan farming, we can strengthen the local food supply chain that nourishes and nurture the health of the people and the planet. We can start envisioning the future of other sectors as we speak.

We continue building resilient infrastructures and antifragile healthcare systems. We continue building antibodies against the coronavirus and also start preparing for the next pandemic or disaster.

We continue investing in community resilience. We grow more adept at managing disruption and become more skilled at resilience-building. We can create and take advantage of new economic and social opportunities that we have never imagined before. Building resilience offers us the capacity to recover after the crisis and grow even stronger in times of relative calm. This is the resilience dividend. This is antifragility in the making.

This is also the time to invest in holistic visions such as that of OneHealth, EcoHealth, and Planetary Health. This is the right time to ask ourselves:

How would you reimagine our society five years from now, ten years from now?

What is the future of education and work? What is the future of our cities? What is the future of humanity on Earth?

These are just some of the questions we need to think deeply to find out what is our preferred future in the post-COVID world.

Our government should begin with an end in mind. Our government’s think tank should start engaging policymakers, experts, and stakeholders on strategic foresight initiatives to plan for the long-term future. This is the right time to demand from our leaders a better future.

Concluding remark.

Let me end this article with a classic public health parable which I recently read from the book “Upstream: The Quest to Solve Problems Before They Happen”.

You and a friend are having a picnic by the side of a river. Suddenly you hear a shout from the direction of the water — a child is drowning. Without thinking, you both dive in, grab the child, and swim to shore. Before you can recover, you hear another child cry for help. You and your friend jump back in the river to rescue her as well. Then another struggling child drifts into sight… and another… and another. The two of you can barely keep up. Suddenly, you see your friend wading out of the water, seeming to leave you alone. “Where are you going?” you demand. Your friend answers, “I’m going upstream to tackle the guy who’s throwing all these kids in the water.”

What is the moral of this story?

It is just natural that these times of uncertainty, we react to problems at hand. We deal with emergencies, put out fires, and so on. This is not enough. We have to turn this crisis as an opportunity to learn and fix the system, the root cause of our problem. Otherwise, we will be trapped in this vicious cycle.

This metaphor on a stream of flowing water thus provides us a different perspective of approaching complex problems and finding sustainable solutions.

With both eyes wide open, let’s hope for a better future. Let’s move forward by going back upstream to solve our problems before they happen.

This is our story. The story of risk and resilience.