Leadership to prevent COVID-19: is it the most important mitigation factor?

The word pandemic has an ancient heritage coming from the root “pan” (all) and “demos” (people) meaning that it affects us all. Underscored in this adage is both a responsibility and imperative for nations and leaders to synchronize their capacities to fight a common enemy to all of world's citizens.

Success of both political leadership and pandemic mitigation are intertwined: so are failures

Recently, concerns were raised about the blurred political leadership responding to the novel SARS-CoV-2 disease that was observed in multiple countries both in developed and developing countries [1]. COVID-19 has created significant challenges for leaders at all levels across the world to address the two overarching priorities; respect and promote scientific advisories aimed at mitigating the pandemic, maintaining societal and economic functions [[2], [3], [4]]. A third priority also emerged in developed economies about upholding individual freedom of and consequently individuals being charged to make informed and socially beneficial decisions about individual contribution to disease control, irrespective of an individual being directly affected by the crisis [2,3]. It is possible that the notion of individual liberties as overriding collective societal responsivities may have been corralled by the advocates of economic security over health security.

From a disease control perspective, leaders that make policy errors by prioritizing economic progress and personal over pandemic mitigation has been the major limitation to global pandemic mitigation [5]. As outlined in the first comprehensive recommendations on pandemic mitigation and succeeding scientific discourse assert that pandemic mitigation is a combination of simultaneous synchronized approaches [[6], [7], [8]]. It is a combination of imperfect individual interventions, and combination makes them more effective. Focus on one approach or action by one country would not be sufficient.

The failure of pandemic mitigation has dire consequences to the economy, national security, political security and by extension for future health security because we are facing a novel pathogen with lot of unknowns [9]. Maintaining jobs and economic output are equally important as pandemic mitigation, but we know how to do this better than how to manage a pandemic derived from a novel pathogen. We know how to revive the economy and create jobs. Despite the unequal development trajectory of our nations, as was done by the Marshall Plan after the World War, collectively we do have the resources to achieve a vibrant economy and development. But, mortality and psychological impact of COVID-19 on individuals are irreversible. By ignoring science and the threat posed by the pandemic, we endanger the very platform we can use to rebuild our economies, leading to further exacerbation of the socio-economic disparities between nations.

The multifactorial blow of the COVID-19 outbreak on global health and economy remains to be fully elucidated. Moreover, the socio-economic and psychological impact of travel restrictions and lockdowns, which were imposed to reduce cross-border viral transmission, cannot be underestimated. A recent study projected that by the end of 2020 the impact of aviation losses might negatively reduce the World Gross Domestic Product up to 1.6%, while job losses may rise up to the value of 25–30 millions [10]. In retrospect, the data flow commotion between the Chinese government and the World Health Organization (WHO), at the beginning of the pandemic, might have been partially responsible for the delayed governmental responses in several Western countries.

Ignoring warnings and opportunities is not leadership!

The WHO characterized the COVID-19 pandemic as a Public Health Emergency of International Concern with a purpose so as to accelerate a response, and showed decisive leadership by enhancing international partnerships through its Solidarity Fund/Trial, and the COVID-19 Supply Chain System [11]. The Solidarity trial facilitated recent developments such as the beneficial effect of low-dose dexamethasone therapy in critically ill patients with COVID-19 [12]. The WHO initiatives upgraded data and expertise sharing and boosted partnerships with countries and private foundations including financial support programs, and medical supply donations. However, gradually, it became apparent that the production of effective therapies against COVID-19, and the development of robust protective strategies (i.e., vaccines) would require governmental collaboration to overcome funding, and technical difficulties.

Building up new platforms for molecular processing and developing standardized technologies for manufacturing novel medications requires effort, time, and multifaceted collaborations between active privateers and governments. Currently, the diversification in the development of vaccinations by pharmaceutical companies including launching “national vaccination products” cannot be excluded but may facilitate public's confusion and produce questionable scientific results. Therefore, combining projects and collecting our resources in a global effort to overcome the COVID-19 threat should have been a political priority.

While the current pandemic is not a political issue per se, unfortunately, its death toll reflects war time statistics; hence inspirational and serious political leadership is required. Furthermore, as shown by countries such as Taiwan and New Zealand, the fact that the majority of COVID-19 deaths are preventable makes a powerful tool for inspiration and to unite the population. The fight against the pandemic is not solely a matter of scientific development but it is first and foremost about saving lives and protecting the less privileged members of our global community.

Pathogens are elusive but overcoming them is human endeavor

The world today has the science, wealth, and communication infrastructure to address the COVID-19 crisis than during the challenges of the past. While the COVID-19 crisis global in magnitude, all things considered, COVID-19 pales in comparison to the challenges faced by global leaders of modern times including Sir Winston Churchill, Mahatma Gandhi and Nelson Mandela. Churchill, Gandhi, or Mandela did not have the historical perspective on the issues they were addressing as we do now to deal with disease outbreaks. From historic account of pandemics, and recent disease outbreaks such as Ebola, SARS, and Zika, we have the platform to discern the natural history of a novel pathogen and mount and effective response. We learned major determinants of COVID-19 in weeks from epidemiology, source, and enabling factors and a test was made available in weeks. Our social media embedded telecommunication system is capable of embarking on a risk communication with global reach in minutes. Collectively, the richest nations have more resilient financial capacities to address the global crisis sufficiently.

Sir Winston Churchill, an eminent leader during the Second World War, motivated his people both at home and overseas to comply with unpleasant realities by stimulating their emotional and intellectual reflexes, while integrating crisis management logistics based on common sense practices. Gandhi's concept of non-violence and his high moral standards would align perfectly to COVID-19 crisis management. Non-violence translates to prevention and if not possible reduction of excess mortality and morbidity. Moral standards would give preference to life over economy and personal liberties as well as upholding the concept of philanthropy. Nelson Mandela bridged a polarization, division, and suppression that existed in a society through generations to become a rainbow nation through truth and reconciliation. This approach would help us avoiding ostracizing the country of initial report of the disease or individuals who may have unknowingly transmitted the disease. As the past President of Zambia told the attendees of the fifth International Conference on AIDS in 1989, on the origin of HIV, “what is important now is where it is going, and not where it came from”. These political and logistical merits are in greater need now.

Successful local solutions are by extension global gains

Given the interconnectedness of our economy, less COVID-19 anywhere is less COVID-19 everywhere. By increasing compliance with available mitigation tools such as the use of face coverings, our preparedness for a vaccine introduction can be greatly enhanced. Despite evidence for face coverings, our face covering compliance rates vary between single digits to near total [13]. Face covering has become a perfect indicator to measure the existence of pro-mitigation leadership [14].

For leadership to be globally effective, they should be effective locally. To achieve this, leaders should tactically address the short and long -term socio-economic and public health burden that a pandemic can impose. Second, leaders should develop a framework for recovery of economic and societal functions not just for one country but for all. Finally, COVID-19 management experience should be put to use to inform a framework for global collaboration to contain or respond to emergencies, climate disasters and disease threats.

Initiatives such as the PEPFAR, GAVI, and GFTAM were propelled by political leadership, indeed, with sufficient scientific advocacy underpinning their genesis. Of note, PEPFAR, established by a republican President Bush, the initiative received unequivocal bipartisan support from both sides of the U.S. political ideology. COVID-19 has not benefitted from such political stewardship, not because of the lack of scientific advocacy, but because of an emerging anti-science mindset among leaders of multiple populous and prosperous countries. Although the confusion on the origins of AIDS derailed South Africa's AIDS control efforts for a while, such challenges were not widespread. For COVID-19, unfortunately there are many leaders who trump science and take a narrow view focusing exclusively on personal liberty and economic growth. And countries with such political dynamics have been less successful in pandemic mitigation as in Brazil and the United States.

What has been lacking with COVID-19 is strong global synchronized consensus leadership that galvanizes all the above-mentioned capacities at our disposal today. The countries with leaders who recognized and took proactive decisions are reaping the benefits of those actions. But the countries that sacrificed their liberties with stringent and coherent actions are still being challenged by the inaction or suboptimal actions of others where SARS-COV-2 has become endemic as the potential for reseeding of SARS-COV-2 prevails.

Decisive governmental initiatives and the development of health care flexible platforms and credible public health responses during pandemics, and global economic rebuilding are urgently needed. Transparent and compassionate decision making could enhance the generalizability of therapeutic solutions and preventive measures against a highly transmissible infectious agent, without affecting the diversification in pharmaceutical industry planning, addressing thus at the same time putative stakeholders’ concerns. The aphorism “A COVID-19 anywhere is a COVID-19 everywhere” reiterates the need for concerted and synchronized action that transcends narrow.

How to boost political leadership?

Courageous political will that nurtures bold public health measures and rapid innovations is the universal mantra for reprieve from COVID-19's impact. There is much to learn from the leaders in New Zealand, Taiwan, and South Korean in standing up timely crisis response.

Respond with science. People are more likely to believe science than a person. The evidence-based cancellation of the Umrah and Hajj 2020 to international pilgrims in Saudi Arabia due to COVID-19 stands as an example and was viewed favorably by the entire 1.9 billion Muslim population of the world. 19

Risk communication delivered in time with facts is a single overriding tool to manage a crisis. When facts emerge from the leadership, risk communication achieves two goals; reduction of panic and misinformation and improvement of trust by the population in their leadership.

Transparent coordination of efforts. Stay at home orders and lock downs can be most effective if they are implemented in a coordinated framework without questioning its utility and alternatives provided. China contained the resurgence of COVID-19 on multiple occasions with repeat lockdowns complemented by universal testing, treatment, and sustaining social support systems.

Role modeling to boost compliance with face mask advisories is a necessity and contention of its utility should be relegated to science.Pandemic is not the time for generating controversies on commonsense interventions such as face masks.

Strong leadership is not exemplified in isolation and denial, rather in valuing and exploring inter-dependance to identifying, harnessing diversity of global capacities and redirecting them to match current needs. Gloves produced in major rubber growing countries can benefit the entire world, as do vaccines produced in developed countries. COVID-19 related unemployment can be proactively addressed by task shifting to production and services related to COVID-19 mitigation such as contact tracing services, or mask production. School bus-service can be reversed as distribution vehicles for school meals.

Global leaders can create a platform to utilize the philanthropies of individuals and corporations. PEPFAR's public private partnerships provide a model for such innovations.

Practice soft diplomacy through timely assistance. Countries with large military transportation capabilities can use their infrastructure to significantly reduce the cost of transportation of COVID-19 related repatriations and distribution of COVID-19 commodities domestically and to support countries that are in need.

Five skills for adaptive political leadership during pandemics

Rally behind the science: first and foremost, to succeed in pandemics is to respect and rely on science. This approach can prove beneficial to leaders' rapport with the population. Science is consensus based if not evidence based. Individual opinions are subject to bias.

Listen to and speak to the community. Development of community advisory body is the smartest approach to reach the community. This body should include with members who cover the major elements of societal functions from religious leaders to trade unions and civic societies. They can serve as a sounding board of the population they serve. If these entities are corralled with appropriate consensus can emerge and they can also serve as ambassadors of the message.

Walk the talk. A lot can be learned from the advertising industry. Humans by nature are followers. When scientifically sound and consensus based novel approaches or changes are introduced to a community, confusion abounds. Leadership with considerable media presence, can be a force of change in social marketing of new ideas such as the use of face coverings.

Foster Collaboration. Pandemic mitigation is a all hands-on deck approach. A pandemic by virtue of being global, there is no win without global collaboration. Collaboration can help share data, ease the uptake of emergency declarations, and sharing of commodities in short supply. Crisis management requires redirection and repurposing of several elements that support societal functions. Collaboration and inclusiveness does not make a leader weak, it is just a marketing strategy with tangible benefits.

Finally, learn as you go. Use crisis as a learning opportunity and prepare for future events.

Conclusion

In a fragile situation, such as COVID-19, it is not the lack of solutions, rather the ineptness of its leaders that fails the society. Capricious leadership and divisiveness are likely to fail in pandemic mitigation which can in turn lead to their own political downfall. Open and public communication is mandatory although sometimes unpleasant. Learn to follow the science. Build redundancy in preparedness. In times of crisis, what the leadership talks and does makes a huge difference to the population they serve more than in peaceful times. Help your communities and societies in their struggle and adaptive phase. In an information-based era, the values exhibited by the leaders of today will not go unnoticed and remembered by generations to come. We all want to be remembered for our good deeds, how we helped our fellow citizens, neighbors, and loved ones to thrive in these tiring times.

Declarations

All authors declare no competing interests.

All authors have equally contributed in drafting this manuscript.

No financial support was received for this study.

No patients were included in this study.

Known facts:

The reasons for success and failures of pandemic mitigation, chronicled during the 1918 influenzas pandemic and with COVID-19 and portrayed as ‘a tale of two cities or countries’, is directly linked to leadership inertia, delayed action, and travesty of science.

Countries that succeeded in pandemic mitigation had forward thinking agile leadership who rallied behind science, with swift and synchronized implementation of mitigation measures.

Countries with proactive leadership that implemented early mitigation and corralled their population towards compliance do not have a protracted and destabilizing wave of COVID-19 outbreaks.

New findings:

Success of both political leadership and pandemic mitigation are intertwined. Leadership will fall with failure of mitigation-sooner or later.

Ignoring opportunities is not leadership.

Pathogens can be elusive, but smart leadership will prevail.

Given SARS-COV-2 transmission dynamics, any successful local leadership has immense global implications.

Reliance on science, communicating with the community, leading by example, fostering collaboration, and learn as we go are key leadership skills that can help manage repeat COVID-19 waves and mitigation fatigue.

Impact on clinical practice:

As we are still in a pre-vaccine stage, strong and proactive leadership will help re-implement adaptive pandemic mitigation measures to avert the stress on health care system.

The concept of ‘learn as we go’ enables health care system to be forward leaning and preparedness oriented rather than reactive. Through collaboration and a all-hand on deck approach, leadership should be able to fill the gaps in needed surge capacity.

Good leadership principles will help boost the morale of both the community and health care system to face future waves of COVID-19 more sustainably.