Journal Mobile


David Nabarro1, Katherine DeLand1

Author Affiliations: 

1Office of COVID-19 Special Envoy, World Health Organization

Correspondence to: 

David Nabarro, Chair of Global Health, Imperial College London, Norfolk Place, St Mary’s Campus, London SW7 2AZ, UK


Journal Issue: 
Volume 51: Supplement 1: 2021
Cite paper as: 
J R Coll Physicians Edinb 2021; 51 (S1): S2–3




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The COVID-19 pandemic is very complex. It affects all communities and all sectors. So we consider five perspectives: pandemic; people; public health; international progress; and the need for a unified global programme.


COVID-19 is a massive threat to global health, as well as to the economies and stability of all communities. By April 2021, the virus was reported to have infected at least 137 million people and caused at least 3 million deaths (both likely to be underestimates). It can occur anywhere and variants are inevitable. So capacity to detect outbreaks quickly and respond to them promptly is essential. Though the pandemic is slowing in the UK, it is still surging elsewhere: more cases were reported globally in April 2021 than at any time since the pandemic started.


People are the key to reducing transmission by: physical distancing especially indoors; wearing masks consistently; and practising effective hygiene. At the start of the pandemic the reported number of COVID-19 infections doubled every three days. Since then, the reproduction rate has steadily decreased, mainly owing to people meeting less and maintaining distance. As vaccines are rolled out, people should continue with these precautions as long as there is a significant risk of surges in infection. People are best able to protect themselves if supported by strong public health services – especially case finding and contact tracing. They need trustworthy information to choose the best available options, provided through transparent and consistent communication. In short, the virus is the problem; people are the solution.

Public health

COVID-19 has highlighted that well maintained public health services are needed to detect and control outbreaks, protect the most vulnerable, and communicate information based on the best available science. Countries that upgraded their public health services following the 2003 SARS outbreak have had an advantage in responding effectively to COVID-19. Places where investment in public health was reduced in favour of hospital-based services have faced greater challenges.

Public health and local services must also work together, notably in supporting people who need to isolate. In many countries, being identified as a contact and being required to isolate is a real threat to income, because the level of support from public health and related services is not sufficient for poorer people. The capacity to identify contacts and provide support and incentives for isolation needs to ensure that transmission is successfully interrupted.

In the UK, public health services have made exceptional progress in vaccinating half the population within three months. This has dramatically reduced deaths and permitted relaxation of restrictions on people’s movement. Nevertheless vaccination alone cannot end this pandemic in 2021; indeed that may not be feasible in 2022.

The greatest barrier is the extreme shortage of vaccines. This has many consequences – limiting roll-out, threatening global equity, and creating demand for vaccines which have not been assessed and verified for World Health Organization (WHO) Emergency Use Listing. The shortage also reduces the effectiveness of COVAX, the initiative set up in 2020 at the request of all governments to share vaccines around the world.

The second major barrier is the multitude of people who are reluctant to be vaccinated. Furthermore, given the millions of new cases being reported every week, it is inevitable that variants will continue to emerge. Eventually some will bypass the protection offered by current vaccines. Thus widespread and reliable genome sequencing is essential for prompt identification of variants – as part of the core public health capacity.

International progress and WHO’s role

Because the virus that causes COVID-19 is still new, governments and practitioners everywhere depend on WHO’s convening and analytical capabilities to decide how best to manage risk. The world needs a strongly backed and adequately financed WHO to support countries in tackling infectious diseases in accordance with the International Health Regulations (2005). Several governments are now considering an international treaty on pandemic preparedness and response to complement these regulations. The new treaty would underpin protocols for international travel and universal access to vaccines – challenges best navigated multilaterally by building on international agreements on human rights and the United Nations 2030 Agenda for Sustainable Development.

The need for a unified global programme

COVID-19 is a complex, long-term crisis. There is increasing evidence that the disease does not respond well to poorly coordinated efforts by individual governments. A unified, sustained global response driven by solidarity and determination to achieve equity is essential. The United Nations and WHO would serve the world well if they could together incubate a programme for COVID-19, drawing on experiences of the largely successful Global Polio Eradication Initiative of the 1980s and the subsequent Global Fund to Fight AIDS.

Without such a programme, the prospects of getting ahead of this pandemic are small, given the propensity of this virus to spread and to mutate. The challenges facing that programme include: establishing a central COVID-19 data repository; addressing the enormous variation in vaccine access, use and documentation; and rebuilding public health services where they are weak.

But the biggest challenge is that COVID-19 is a disease of poverty and inequity that we can only address through affirmative action that focuses on poorer people first. We know that, unless we take equity seriously, the poor and vulnerable do not feel welcome, and they do not or cannot attend for vaccination. Unless we tackle this pandemic fairly, and everyone in our world can benefit, the future will witness greater suffering and inequity. So, though it may appear attractive to ‘Build back better’, it is important not to go back to the gross inequalities of 2019. Instead, we need to ‘Move Forward – Fairly and Fast’. 

Financial and Competing Interests: 
No conflict of interest declared