Receiving the invitation from the University of Pretoria to visit the campus and be awarded an honorary doctorate filled me with immense joy. It wasn’t just any invitation, but an opportunity to visit one of the world’s most prestigious universities—a renowned institution with a forward-looking vision, actively tackling the ongoing challenges in South Africa and across Africa.

David Nabarro (third from right) with Vice Chancellor Tawana Kupe (second from left) with Faculty and students. Photo credit: University of Pretoria.

Upon my arrival, I was warmly welcomed by my hosts, the Faculty of Health Sciences. Their impressive standing in academia was evident across the four esteemed schools: medicine, dentistry, healthcare sciences, and health systems and public health. I had the privilege of meeting distinguished deans, engaging in discussions with vice deans and chairs of different schools. These initial interactions affirmed that my visit would be an extraordinary two-day window to learn from an academic community known for its excellence and innovative approach.

During my visit, I explored how this institution effectively engages with diverse entities to foster collaboration and create meaningful impact. This university functions as a vast ecosystem, recognising the importance of the intricate connections that it must establish and nurture with local authorities, government bodies, and stakeholders across various segments of the healthcare system.

Photo credit: University of Pretoria.

Shortly after my arrival on the 11th, I enthusiastically participated in the first of two significant sessions, where I had the privilege of listening to different researchers sharing their work and collaborative efforts. These sessions provided a valuable platform for me to absorb their insights and contribute my own perspectives. The discussions were filled with lively exchanges, extending from noon until 5 p.m. A notable aspect was the informality that fostered the perfect atmosphere for open and engaging dialogue. This kind of setting is something I truly cherish and actively seek during my travels, particularly when I can take the time to embrace and appreciate diverse perspectives.

Given my particular interest, I had the privilege of engaging in organised discussions regarding the spread of zoonotic diseases (those transmitted between humans and animals), as well as the viruses and other agents responsible for infectious diseases and pandemics. Notably, the latter group played a crucial role in characterising the COVID-19 Omicron variant when it first emerged. Additionally, I gained valuable insights into the various strategies employed to control malaria, especially in anticipation of the changing incidence of malaria in Southern Africa due to global warming and climate change.

Photo credit: University of Pretoria.

One aspect that impressed me greatly was the concerted effort to integrate various scientific disciplines and foster interdisciplinary collaboration. This approach ensures that the knowledge generated is directly applicable to the real-world contexts in which people live. For example, the university’s commitment to prioritising the wellbeing and capacities of the people who work in health care, and working with healthcare systems as living systems – influenced, and managed by people – was evident throughout. This reflects the principles of living systems that are so important at 4SD Foundation. The experts in the University understand that achieving equitable public health outcomes, where priority care is available for those who need it, not just those who can afford it, relies on health systems that function well with people’s needs at the centre. In this university the faculty are prepared to think hard about what makes a health system make a difference to the lives and livelihoods of people. They don’t see hospitals as the primary place for improving public health, instead, they recognise the integral role that communities play in health systems.

Overall, my visit to Pretoria university helped me appreciate its dedication to cultivating a holistic and multidimensional approach to research and application. While I realized that I lacked expertise with the local context, I offered some advice on maximising the efficiency of policies and procedures, ensuring optimal resource utilisation, and striving for outcomes that align with the aspirations of the people. A key aspect I emphasised was the importance of recognising the unique identities of different groups and investing in relationships that promote open sharing of ideas and knowledge.

I was able to delve into the five characteristics exhibited by living systems leaders:

1. Hold competing perspectives simultaneously
2. See the whole system differently to its separate parts
3. Feel into the pace, rhythm and readiness
4. See the system in relationship to its environment
5. Meet people right where they really are

These discussions underscored the significance of identity, relationships, and the act of sharing openly — all essential for building long-term, trusting relationships. The exploration of these themes served as a rich source of insights that resonated deeply. It became evident that the principles governing living systems could be harnessed to navigate complex challenges and pursue meaningful change.

Photo credit: University of Pretoria.

One particularly captivating aspect of my visit was witnessing the university’s engagement in the process of reconciliation and forgiveness, as well as observing how the broader society is structured. Through various art forms and exhibits, they vividly portrayed this transformative process. As we collaborated, I realised that there was much to learn from their profound understanding of trust and the characteristics of living systems, which they actively apply in their endeavours.

To conclude the day, we were deeply moved by the inspiring story of Dr. Bongani Mayosi, a brilliant cardiologist who tragically passed away at a young age. Dr. Mayosi had a profound realisation that heart health is profoundly affected by one’s poverty status—a stark reminder that poverty breaks hearts. It reinforced the pressing need to address the profound impact of poverty on individual well-being and overall heart health. It was a poignant moment to be in the presence of Vice Chancellor Tawana Kupe, who had played a pivotal role in developing Dr. Mayosi’s narrative. His involvement highlighted the university’s commitment to recognising and uplifting individuals who embody the values and actions required to drive positive change.

Being immersed in a society actively engaged in the process of reconciliation added another layer of significance to the experience. It underscored the collective effort to heal wounds, reconcile differences, and forge a path towards a more inclusive and harmonious future. Witnessing their willingness to identify role models who exemplify the necessary steps for progress was truly remarkable.

Photo credit: University of Pretoria.

On the final day of my visit, I had the opportunity to explore the Future Africa campus, a hub dedicated to interdisciplinary research on the African continent. I was particularly intrigued by two key initiatives.

• The first centered around understanding the interconnectedness of animal, human, and environmental health—an approach commonly known as “One Health.” I engaged in enlightening discussions with Professor Wanda Makota, delving into the critical relationship between these aspects and the implications for overall well-being.
• The second initiative focused on food systems, and it was truly exciting to witness the enthusiasm and innovative approaches demonstrated by the postdoctoral fellows in their pursuit of interdisciplinary collaboration. We dedicated time to exploring practical ways of making these initiatives a reality, recognising the barriers of the systems in which they work.

Later in the day, I had the privilege of attending the graduation ceremony where I received an honorary doctorate (click here to watch a recording of the event). The atmosphere was vibrant, with academics and the community coming together to celebrate their enormous achievements. The Vice Chancellor delivered a powerful speech, and the Dean shared a statement, emphasising the significance of their milestones. Witnessing the graduates receiving their awards was a moment of shared pride and accomplishment.

As I prepared to depart and return to Geneva, I couldn’t help but reflect on the invaluable lessons I had learned during my time in Pretoria. I was deeply impressed by the country’s resilience in the face of significant ongoing changes and its unwavering commitment to fostering collaboration across different scientific disciplines, sectors, and stakeholders. The collective community’s dedication to driving meaningful change through partnerships was truly inspiring. It became evident that our expertise and experiences held value in supporting activities in Pretoria and other universities. It was a realization that we were not merely observers, but active participants to support the change.

Overall, my visit provided an opportunity to offer capacity-building support, learn from others, and provide valuable feedback. I was honoured to witnessed first-hand the value that academics found in embracing the principles of living systems in their respective journeys. The living systems approach offered a fresh perspective and practical tools that enhanced their work and enriched their academic pursuits and I look forward to accompanying their change.

—

On Friday 5 May, 2023, the World Health Organization (WHO) downgraded its assessment of the pandemic, indicating that it no longer qualifies as a global public health emergency. The WHO approach was spelt out by the Director General during his opening remarks at a media briefing which can be watched here.

The background

On January 30, 2020, WHO’s Emergency Committee, constituted to advise the Director General as per the International Health Regulations (an intergovernmental treaty), had recommended that a public health emergency (PHE) be declared. This was before the disease had been named COVID-19 and when there were only 100 reported cases (and no deaths) beyond China.

The declaration that a health threat as a global emergency is a warning by WHO that the threat is extraordinary, affects multiple countries and requires a coordinated containment response. It is designed to encourage national decision makers to introduce special containment measures and arrange the release of extra funds. It indicates that low-income countries will need financial help to participate in the global response.

The present situation

On Thursday May 4, 2023, the Emergency Committee met for the 15th time to discuss COVID-19 and concluded that it was time for a change and made its recommendation to the Director General.

The Director-General said on 5 May 2023, the pandemic has been “on a downward trend for more than a year, with population immunity increasing from vaccination and infection.” That, he said, has allowed most countries “to return to life as we knew it before COVID-19”.

The present situation is that COVID-19 is still a pandemic: the virus is here to stay and that thousands of people continue to die every week. Nearly 3 million people were reported with COVID-19 in April 2023: there were 17,000 COVID-19-related deaths recorded. There is a residual risk of new variants emerging that could cause surges in illness and deaths.

High immunization levels, both from vaccination and previous infection, have helped dramatically reduce the severity of disease. So, while COVID-19 will continue to spread among people for a very long time, the threat level is lower and does not justify extraordinary measures to curb the virus’ spread. COVID-19 needs to be managed alongside other infectious disease threats.

What is WHO doing next?

• WHO is setting up a review mechanism: Now that the Public Health Emergency has ended, WHO is establishing a COVID-19 review committee under the auspices of the International Health Regulations (the current global treaty within the context of which WHO does its infections control work) to develop long-term recommendations for countries on how to manage COVID-19 on an ongoing basis.
• Advising Governments: WHO is advising Governments on actions to be taken now to deal with risks that could result from COVID-19 in the months and years ahead. Last week WHO published the fourth edition of the Global Strategic Preparedness and Response Plan for COVID-19, which outlines critical actions for national authorities. It highlights the importance of maintaining regular assessments of the spread of the virus (including for new variants), protecting people who are vulnerable with vaccines and boosters, the use of non-pharmaceutical measures (distancing, masking and protection) for reducing the likelihood of exposure among those who are more likely to experience severe disease (people who are older, immune-compromised, or affected by diseases that increase risk such as diabetes). It also emphasises the need to ensure that health workers and carers are able to reduce their exposure too. It includes recommendations on how to maintain safe health care, with the capacity to scale up if necessary, if there is a surge in people affected by the virus and experiencing severe illness.
• New Pandemic Treaty: WHO is also hosting negotiations between its Member Nations on the development of a new pandemic preparedness treaty to learn lessons from COVID19 and handle future mega-threats more effectively.

People are partners in the response

Simon Clark, Professor of Microbiology at the University of Reading, is quoted as saying that the message to the public should still be to take care and think of others. That means if you’re ill with a respiratory infection, like a bad cough, don’t put others at risk, especially not those who are vulnerable. If you pass on a COVID-19 infection, no one will thank you. Even if you are fit and young, COVID-19 can still be nasty and if you’re old and frail, it can kill you.

Mike Ryan, Director of the WHO Health Emergencies Programme, is quoted as saying, “It took decades… for the pandemic virus of 1918 to disappear,” when referring to the Spanish flu pandemic which is thought to have killed at least 40 million people.

So there is still much more work to be done even though the Public Health Emergency is over!

From his days working in South Asia, East Africa and the United Kingdom, to his leadership of Roll-back Malaria, the Scaling Up Nutrition (SUN) Movement, the #SDGs, food security crisis and #foodsystems transformation, as well as his response to Avian Influenza Pandemic and Ebola, David has alway placed people at the center of his efforts, promoting a living systems approach as a means to understand complex challenges.

David continues to be a powerhouse of inspiration globally as he creates learning opportunities for people through 4SD – Skills, Systems & Synergies for Sustainable Development where he serves as Strategic Director and at Imperial College London as Co-Director and Chair of Global Health at the Institute of Global Health Innovation. His role as COVID-19 Special Envoy and as a workstream co-lead of the United Nations Secretary-General’s Global Crisis Response Group, keep him and his dedicated team at the forefront of responding to some of the most critical challenges we face.

It is my nature and training to have a global perspective, but it can be easy to forget that there’s still a pandemic and can even feel isolating, like being among the few wearing a mask at the supermarket nowadays. But, joining 4SD’s Open Online Briefings, I am constantly reminded that we are a global community, that we share values and purpose, that the pandemic is not over, that we can all contribute to the solution, that we can always do better. In writing this new report on COVID communication strategies, I learned that the words we use, and how we communicate with the public to make meaning, really matters. I learned that radical transparency in public communications is critical, and that being honest when we are uncertain helps to build trust and fend off misinformation.

“How Language Shapes Change: Perspectives on the Most and Least Effective Communication Strategies and Tactics during the COVID-19 Pandemic” Download: English / Français.

The Briefings provide a safe space for sharing and they are the only place that I know of where there is real time information from people in-country across different continents – I can have a sense of what is going on that hasn’t been filtered through other kinds of media. How else would I hear the struggles of today from someone in Mozambique, Chile, Nepal, and the UK all in a one-hour session? The unfiltered nature of the Briefings allows me to hear the raw emotion in peoples voices and their concerns about what is really happening on the ground in that moment in their life. It anchors information in a way that we can’t hear otherwise. Issues ranging from long-COVID, to the recent earthquake in Türkiye and Syria, are all summarised delicately by David Nabarro; for me the Briefings are a touchstone.

The sensemaking and reflection which is part of what 4SD promotes, shares much synergy with this new publication, where the story is told by informants from Canada and beyond. I am simply the listener and narrator – the story is what I learned from the informants – all communications scholars and/or practitioners – and I can honestly say, this is one of the most interesting reports I have ever worked on. It provokes questions of  what will we learn, what could we have done better, and – perhaps most important –will we have the insight and courage to reflect on our mistakes and do some things differently going forward?

I hope that something in this report resonates with people who read it, and that something might change their own practice in how they communicate. In this world where we are all connected in one big complex system, and where the pandemic has exemplified our global connection, we must communicate with meaning, within and beyond our local/provincial and national bubbles.

We can all connect and communicate better with one another and be a part of the solution.

—

About this 4SD Reflection

This article is a reflection by Karen S. Palmer, inspired by the 4SD Foundation Open Online Briefings of Dr David Nabarro.

Participants of the 4SD Foundation Open Online Briefings are invited to share their reflections on how they are navigating complexities from their own perspectives. The views and opinions expressed in these reflections do not necessarily reflect the official policy or position of 4SD as an organization or it’s associated personnel. Any content provided by authors are of their opinion and are not intended to malign any religion, ethnic group, club, organization, company, individual or anyone or anything.

The importance of biodiversity for people’s health and wellbeing 

As humanity grapples with worsening climate change, successive COVID-19 waves, and deepening inequalities, it has become increasingly evident that many interconnected challenges threaten the well-being of people and the planet.  It is vital that damage to nature and loss of biodiversity are included in efforts to secure equitable and sustainable futures . 

Biodiversity provides humanity with food, water, medicine, a stable climate, and economic growth. Over half of global GDP is dependent on nature, and more than one billion people rely on forests for their livelihoods. But nature is in crisis. Accelerating climate change and the continuing destruction of nature threaten to undo the last fifty years of progress in development, global health, and poverty reduction, and to widen existing health inequalities between and within populations. 

Climate change and damage to nature are affecting the lives and livelihoods of an increasing number of people, especially those on the lowest incomes, through increasing volatility and uncertainty around weather patterns and the loss of natural resources. As systems disturbances accelerate, they bring additional threats to poorer people everywhere, especially for those who have least agency and respurces. They are especially vulnerable. 

 For example, climate change and damage to nature amplify existing gender inequalities and pose unique threats to the lives and livelihoods of women and girls. Changing weather patters reduce access to clean water: this leads to reduced yields of food crops and adds to the challenges faced by women.  Lack of water increases the challenges with management of menstrual hygiene.  School-going girls may feel unsafe, and some may not feel able to access education: this impacts on the power and agency of women and girls in communities.  

Climate change is affecting the behaviours of ecosystems, leading to changes in patterns of infectious disease and increasing risks to people’s health. Pathogens in the natural environment can spill-over to humans with potentially serious consequences: there are constant reminders of humanity’s vulnerability to outbreaks of zoonotic diseases such as those caused by Ebola and coronaviruses. SARS-CoV-2, the coronavirus associated with COVID-19, has caused the death of well over six million people since 2020. These vulnerabilities remind us that the human species is a part of nature’s world, and that nature needs to be treated with care and respect. Taking more than we give back, and not making space for species of animals and plants that preceded humans, creates an imbalance of resources on which people depend for life and livelihoods.  

Recognizing that humanity is dependent on the resources of the planet , and that this relationship has a direct impact on the health of both, underpinned recent negotiations towards a sustainable agenda for the world. These were initiated in 2012 and the outcome was agreed by world leaders in 2015. This 2030 Agenda for Sustainable Development (and its 17 Sustainable Development goals, or SDGs), acknowledged that the challenges faced by people and planet are layered, interlinked and universal. They must be faced not only in lower- and middle-income countries but in high-income nations too. They affect all aspects of our lives, including people’s physical health, emotional well-being, and livelihoods. 

Applying living systems approaches to the 2030 Agenda 

The 2030 Agenda for Sustainable Development, with its  SDGs has a broader set of objectives across a wider spectrum of socio-economic dimensions than its predecessor agreement, the millennium declaration, and the Millennium Development Goals (MDGs) of 2000. It is far more ambitious, recognizing that global challenges are universal and are interconnected. For example, the goal for health and well-being (SDG3) is linked with that for gender equality (SDG5), decent work (SDG8), and sustainable cities and communities (SDG11). In this way, the 2030 Agenda is a reminder that people are integral parts of all living systems. Splitting up global challenges and working on them separately, in siloes, is not the way to go. A focus on biodiversity targets alone, for example, might risk negative outcomes for people if human rights, sustainability, and equity are not adequately considered.  

The ways in which national Governments and community organizations respond to agreements reached by world leaders in global forums (like the United Nations General Assembly), have impacts on the lives of people everywhere, particularly those who are most vulnerable. Effective local and national responses depend on scientists, specialists and community actors making their voices heard in every possible avenue. They seek to ensure that decisions are driven through people’s engagement, with constant attention to re-generating and safeguarding nature in the face of climate change. People’s behaviour, beliefs, and willingness to act, together, all influence the prospects for people’s future wellbeing. It is more important than ever that people are at the centre of development efforts and no one is left behind.   

A ‘living systems’ approach offers a holistic way for all involved to work together when navigating complexity and negotiating contested issues.  It helps groups to work for transformational change through including all groups of people as partners, acknowledging power asymmetries and encouraging exploration of embracing perspectives.  Such an approach is helpful when addressing the consequences of COVID outbreaks, widening conflicts, accelerating climate change and damage to nature for the realization of the SDGs. Tens of millions of households are now experiencing the greatest cost-of-living crisis in a generation, and it is vital that responses reflect the expressed needs of those who are hardest hit, as well as an appreciation of what the the crisis means for them, and the support they need for health and livelihood security. 

The navigation of power asymmetries reqires an understanding of the political context from the perspective of the people themselves and the political realities that they encounter. This is vital if people who feel disempowered are to acquire greater agency. External experts may seek to position themselves as politically neutral, but most find that, in practice, they must pay attention to how their actions reflect the interests of those with the greatest influence.  

Living systems leaders become comfortable operating within this deeply political realm. They learn to be able to work with those who are making use of relatively limited power. They realize that people’s potential sources of power are not always the most obvious.  They accept that working within political processes may appear messy to those focused on specific outcomes: systems transformation is not a straightforward process. Negotiations may not immediately lead to clarity – indeed, being explicit about the choices to be made can lead to greater tensions, to suspicions, and to outright discord.  

One challenge faced by everyone is the tendency for all of us to share our perspectives with those with whom we expect to align.  This helps us build our own sense of community. However, we are more likely to succeed if we can work with all who are involved in an issue even if they have views which differ from ours – connecting with those with whom we have not worked with before. This can create the potential for the emergence of renewed energy and enthusiasm for unexpected and potentially  effective new collaborations. 

 Focusing on those most vulnerable so as to leave no one behind 

The health of all people is a recognized priority in public health and development, features strongly in the SDGs, and is an important focus within responses to outbreaks. It must be taken seriously when the well-being of populations is a central feature of national policies.  

To approach the SDGs with a people-centred and equity focus, with an emphasis on the interplay within living systems, requires seeing people as the primary actors in responses to public health challenges.  It calls for the engagement of the many stakeholders that have an interest. For example: food systems are more likely to transform if the full range of stakeholders can connect, engage, and explore options in a systematic way. Attention needs to be paid to the identities of, relationships among, and sharing between stakeholders as this increases the likelihood that they will trust each other and act together in a meaningful way.  

Responses to COVID-19 outbreaks have laid bare the necessity for a collaborative science-based living-systems-thinking. Such responses take account of the synergies across different issues: they help change the nature of the trade-offs that are faced when choices are made. Inter-disciplinary science and multi-sectoral working are essential and not an optional extra.  

It is important that the values adopted by all who are engaged in such collective approaches are made explicit: they are most likely to advance if those involved all acknowledge and respect human rights agreements, draw on multi-disciplinary science, appreciate the need to act across sectors, and approach health as an inclusive, whole of society, issue.  It is important to promote and protect the engagement, voices and interests of people with the least agency and greatest vulnerability when decisions are made.  This consideration applies especially to women, indigenous people, young people, older people, smallholder farmers, labourers and more.   

 Enabling health workers to lead for systems change 

Health workers have unique opportunities to lead by highlighting the challenges that are faced by people especially when their agency is limited. They can serve as advocates, making authoritative use of their experience and expertise. They can also be effective change agents, recognizing the importance of being authentic and accountable to those they serve. They are accountable when they engage openly with those they serve, taking stock and learning from what has been done, at all levels: it contributes to trust and impact.  

Their impact is increased if they widen their circles of engagement beyond the health sector and communicate in ways that reflect on where people really are. Honest, open, and consistent communication is essential and has proved to be especially helpful when partnering with people on responses to outbreaks of disease and other threats.  

 All groups in society have parts to play. Those with the responsibility to govern, for example, are expected to respond to the knowledge, experiences, and challenges of all in society including those at the frontlines of crises, especially women and indigenous peoples. When they lose their sources of income or are forced to evacuate their homes by extreme weather, they are at risk of becoming more marginalized and experiencing multiple forms of violence. Inclusive, multilateral, equitable actions will ensure that all within communities are able to access the resources they need, and that the most vulnerable are in a position to use them.  

 There is a unique leadership opportunity for health workers of all kinds to lead n the health consequences of climate change and biodiversity loss. Lasting change starts and ends with alliances being built within communities, and the deepening of trust between people and those who serve them. It is more likely to happen when people perceive they are partners in change, being listened to and perceiving that they are able to impact on the decisions made about them.  

 It is vital that all decision-makers are constantly reminded, by those they serve, that the biodiversity-climate-health nexus does not affect everyone equally. Who people are matters. Where they are matters. Whether they are able to engage in decision-making matters.  Whether they can participate as decisions are made, despite asymmetries in relative power, positions, and expertise, matters. It is important that climate change and biodiversity are included in conversations on health. It is at least as important that, as decisions about health and well being are made, there are accessible spaces in which people and their communities can engage in the decisions about health action.  

Tackling the emerging complexities that abound in our world, especially at the biodiversity and climate nexus, is extremely challenging. Navigating them in ways that optimise the health and well-being of those who have the least agency, power, and resources, is even more so. Health workers have a vital and central role to play. They are counted on to help maintain the structures, spaces, and opportunities for inclusive engagement, dialogue, exploration, and accountability. 

COVID-19 is an infectious disease caused by a virus that is easily transmitted between people. Outbreaks of COVID-19 are contained by preventing the virus from moving from person to person. As efforts are made to reduce the risks to populations, ways to encourage specific behaviours are considered.  In some settings, mandates for vaccination, wearing masks, physical distancing, and isolation, are being considered.  Yet decisions about the control of COVID-19 are never straightforward.  The virus is new and there is much that is not known both about its behaviour in populations and its impact on people.  What we do know is that the people worst affected by the virus are those who are vulnerable and the poor.

When decisions are made about how best to minimize threats posed by the virus, decision-makers need to know how it moves within populations, the risks and consequences associated with infection, and the effectiveness of preventive measures. This is the focus of efforts among scientists in different countries: their efforts are analysed by the World Health Organization (WHO) and used to develop the WHO’s recommendations.

Collaboration between scientists and policymakers

Responses to infectious disease outbreaks are best devised and delivered through public health systems that function well and adapt to changing circumstances.  The underlying values of public health should always be explicit. In my view these are about enabling all people to be as healthy as possible throughout their lives through offering health care that responds to their needs, with a focus on people who are hardest to reach and on leaving no-one behind.  This means connecting and partnering with those who have differing perspectives on how best to contribute as the pandemic is continuing to advance, wave by wave, across the world.

Multi-stakeholder collaboration with scientists and specialists can make the act of influencing policies more effective when they ensure that the well-being of all people is their central concern. Specialists may seek to position themselves as politically neutral, but most find that this is, in practice, just not possible.  Understanding the political context and navigating power asymmetries is vital in working towards restoring agency to persons who feel diminished or seeking to examine issues that have been set aside.

Specialists and decision-makers interact best for public health when they ensure that people are kept at the centre of all decisions.  For me there are six words that illustrate what this might mean in practice: cadence, consistency, connection, credibility, contracts, and conviction.

Cadence

Specialist advisers and decision-makers work best when they are adept at feeling into the pace and rhythm of their work, sensing whether things are ready to move or not. This means that – when they are together – they should seek to meet each other where they are and be comfortable with holding contradictory points of view.

Consistency

Being consistent when given a chance to communicate doesn’t mean maintaining a fixed opinion when it is not warranted. It does, however, mean making a point of being transparent, offering reasons for changes in position, and providing evidence to support them.

Leaders make difficult decisions every day.  They have to balance people’s health and well-being, the state of the economy, and the political space for shifting position. This will diminish when there is fatigue with responding but making quick decisions is part of the process and leaders must be vigilant and ready to re-evaluate and adapt those decisions if they notice things are not going to plan.

Connection

The steps involved in implementing public health directives are never straightforward: the implications of the directive must be spelt out clearly to make it understandable for different audiences.  This is where it may be difficult to combine the approach of the scientist and the belief systems of different groups of people.  If belief systems are influenced by ideology the interaction between science and politics can emerge as an issue:  it is important that all who communicate are authentic. This is where narrative and stories can help: they may better connect science and people than statistics and charts.  The narratives help with putting issues into context.  Here are some narratives which I use now:

1. When looking ahead, it is important to protect the vulnerable, prevent transmission and prepare for surges: This is a virus that is affecting everyone everywhere. It is a global issue. When thinking of public health policies, equity matters.

As with any kind of infectious disease, the starting point is to prevent people from being infected. We know that Public Health Social Measures prevent the transmission of the virus. Face-masking in closed or crowded spaces, frequent handwashing, ventilation, and fewer social interactions help prevent people from being infected.

The second is to protect those who are exposed from being seriously ill and dying. Vaccines have separated disease from death and help protect vulnerable populations. Immunity from vaccines seems to wane after six months or earlier depending on the person’s age or the type of vaccine they received. Keeping up to date on being vaccinated helps protect people from more severe symptoms, and even death.

Thirdly, surges seem to occur every three or four months. The window of time between surges is a moment to be used to prepare by putting systems into place at local, regional and global levels. During this time, listen to health workers who know what is happening and where it may lead. Bring together all stakeholders so they are well-integrated around a shared plan. Engage the people in their communities, connecting with them where they are, and to fill gaps in the response.

2. When planning responses, everyone involved should remember that the virus is the problem, and the people are the solution: Transmission starts and ends in communities. Responses should be locally integrated with central direction based on expertise and experience.

3. As the pandemic evolves all people are called on to be partners in the response: There are bound to be people with diverging perspectives. Avoid stigmatizing and demonizing any group even if they are a small number. Stigmatizing only pushes people further away and undermines social cohesion.

Credibility:

Scientists and policymakers need to earn people’s trust to be effective.

When dealing with COVID, the first part of being authentic is being clear that this virus is not going away anytime soon and threatens all of humanity. It is global and encompassing and we must ensure that no one is left behind.

People need to respond to COVID in a holistic way. The truth cannot be arrived at by only viewing its separate elements. Mandates and lockdowns on all people everywhere have had catastrophic effects in some cases and has had a knock-on effect on a vast spectrum of communities economically, politically, and also psychologically.

Thirdly scientists and policymakers need to avoid making any false promises or pledges. They need to be honest with people, and this matters when seeking to build trust. As the pandemic has evolved the world is faced with an infodemic. Misinformation has generated mistrust between people, as well as between people and governments.

Fourthly, the virus is new and there is so much that is not known. There is uncertainty about what variants are going to come next, or how they will behave. Being humble about this virus – acknowledging that there is so much which is not known and that scientists have to collaborate across national boundaries to help societies work their way through it.

Finally, being hopeful matters. My personal hope is that humanity will emerge from this pandemic a lot better, with a greater understanding of how to deal with multiple threats – including destruction of nature, mass migration, violent conflict, and more. Much ingenuity is needed for people to tackle them together, especially in poorer settings.

Contracts

Professionals involved in responding to COVID need to be clear with different audiences on what is at stake and what is important. The pandemic is still advancing.  The virus itself is changing. It is affecting people, businesses, governance, and nations. It is causing massive suffering. It is not going away anytime soon. After infection or immunization, individuals have some immunity but this fades over time. People should act in ways that prevent transmission and keep the virus at bay.  Concerted investment in a worldwide response is of vital importance, now more than ever: fragmented responses are less effective.

Multistakeholder platforms are established to inform integrated, people-centred responses.  Interdisciplinary scientists are welcome because their engagement permits deeper connections among diverse actors and stakeholders, especially if they focus on people as well as disease, and on connecting science with decision-making.  This can strengthen the ‘contract’ between society and the State and take trust and partnership to a new level.

Conviction

We have come a long way since the coronavirus was first discovered. We have adopted good habits to protect ourselves and to shield others. We have gathered tools and know what is required to fight this virus. We have seen communities come together and we have seen people connect with each other in beautiful ways.

There is hope for us to emerge from this as a more unified collective, and it all depends on how we manage this problem together with a concerted effort to increase levels of both political engagement and global investment.

The consequences that the pandemic has had on all other systems will only start to become apparent in about ten years’ time. The failure for concerted economic and political investment in an equitable response would leave us cleaning up the pieces for not just one decade but more realistically, for closer to two decades. Part of the learning curve of working in the science-policy interface involves finding out that we have made mistakes and then finding ways to do better. To do better, sometimes, it is necessary to think about the context within which scientific expertise is being offered.

I urge every scientist and specialist who has the opportunity to work with decision-makers, to make their voices heard in every possible avenue. It is still not too late for putting people back in the centre of the context.  It is people – how they behave, what they believe, and what they are prepared to do together- that could make all the difference. Only with people as partners can we protect those who are most vulnerable, prevent transmission of what is a dangerous virus, and prepare our systems for further surges, after all, it is the virus that is the problem, and people that are the solution.

Africa: from crisis to opportunity

The picture is grim. Millions of people displaced and driven into poverty by climate change, COVID-19 and international conflict. An escalating food crisis, resulting from crop failures and rising costs of living. Africa has been particularly hard hit by this. Ethiopia, Somalia and eastern DR Congo, among others, are facing major problems. High inflation reduces purchasing power and the family budget in many countries is now largely spent on food and energy. Due to the crisis, fertilizer has become too expensive, so that the extra kilograms of grain that farmers obtained from a kilogram of fertilizer are now lost.

Prolonged drought, heat, excessive floodings and epidemics of pests and diseases complicate food production for the 1.4 billion Africans. Nigeria – Africa’s most populous country – is facing increased insecurity, inflation and job losses. In addition, divergent views within the United Nations and other international forums disrupt the development of the African agri-food systems and undermine food security. These phenomena can fuel inequality, instability and mass migration to Europe.

For these reasons, it remains essential to support in Africa an agricultural policy that deals strategically and responsibly with water, fertilization, crop protection, available labor and sales opportunities. In order to meet increasingly pressing local food needs, above all local insights must be used to bring about a ‘transformation’ of Africa’s agricultural systems. Crucial to this is the sustainable intensification of small-scale agriculture in particular. Local food production (also on a large scale), local processing and shortening Africa’s food chains can significantly reduce the escalating transport costs.

However, technical solutions alone will not turn the tide. Political vision, will and power at all levels of government is needed to face the growing humanitarian crisis. It is also in our interest, the ‘Global North’, to respect and promote Africa’s self-reliance. At the level of the African Union (AU), Africa itself is in charge of agriculture and food supply. Africans are also increasingly taking the lead at national and regional levels on the basis of their own education, knowledge, skills and experience.

We must respect and encourage this ownership, because a paternalistic attitude of the West is no longer appropriate. Western ideas, which are still part of project proposals and conditions, no longer resonate in Africa. In addition, other major powers are now more in charge, leaving the West geopolitically behind.

Due to the colonial past of many member states and the current agricultural policy and the associated protection, the European Union does not always promote African agriculture. If the Netherlands and the EU want to pursue a sincere development policy based on current geopolitical events, they will have to leave the familiar ‘belittling finger’ at home. The free sharing of knowledge and skills, and entering into egalitarian trade relations must be given priority, based on a greater respect for African ownership and leadership.

Europe and other Western powers can help shape agricultural research, education and development with and for Africa. Preferably orchestrated by the African Union and national governments and where necessary with input from multilateral institutions, development banks and universities. The starting point must be the specific needs and potential possibilities of African farmers. Co-financed with proceeds from Africa’s wealth of primary raw materials, the living conditions of the rural population could improve dramatically. Africa is as big as China, India, the United States and most of Europe put together. In Africa food security is synonymous with human security. Investments, are not enough and resources are needed to address the growing humanitarian challenge–where big powers need to work more actively on peace, security, climate change mitigation and biodiversity conservation.

What has succeeded elsewhere in the Global South during the past fifty years must also become a reality in Africa. African ownership, confidence in one’s own abilities, international cooperation and mutual respect are sine qua non. The continent embodies gigantic potential and the political class increasingly has the means to crank up its economic engine. The joint formulation of a ‘Marshall Plan’ for agriculture – the cornerstone of the African economy – offers Europe a golden opportunity to pay off its colonial debt and offer the continent a better future.

This article is a revision of a column which was published in the December 2022 issue of the Dutch magazine Vork (https://www.vork.org). Thanks to Orlando de Ponti, Martin Smith and Kris Wyckhuys.

About this 4SD Reflection

This article is a reflection by Ad Spijkers following the 4SD Foundation Open Online Briefings of Dr David Nabarro.Ad worked as Representative of the Food and Agriculture Organization (FAO) of the United Nations. He is part of a group of Wageningen development veterans with extensive experience in Africa and Asia.

Participants of the 4SD Foundation Open Online Briefings are invited to share their reflections on how they are navigating complexities from their own perspectives. The views and opinions expressed in these reflections do not necessarily reflect the official policy or position of 4SD as an organization or it’s associated personnel. Any content provided by authors are of their opinion and are not intended to malign any religion, ethnic group, club, organization, company, individual or anyone or anything.

About this 4SD Reflection

This article is a reflection by Dr Oommen John following the COVID-19 Open Online Briefings of Dr. David Nabarro. Dr Oommen John is a physician researcher and digital health expert. He works at The George Institute for Global Health India and a Professor at Prasanna School of Public Health, Manipal Academy of Higher Education. He is an elected fellow of the International Academy of Health Science Informatics.

Trained as an internist, he has worked in primary care settings in resource-limited contexts across LMICS and has extensive field level experience in designing, implementing and evaluating innovative solutions and its applicability in health service delivery. He has served with WHO in Immunization Strengthening and Vaccine Delivery, Research and Development at WHO SEARO. At George Institute for global health India, he leads the India Health Accelerator Programme. His research involves evaluating the role of digital health interventions in improving clinical outcomes. He serves on the expert advisory panel for the Market Access Programme of National Health Authority, India.

He is a member of the scientific advisory committee at Foundation for Innovative Diagnostics (FIND), advisory board of Commonwealth Centre for Digital Health. He has contributed to WHO Digital Health Guidelines development group. Follow @Oommen_john and @GeorgeInstIN to keep up-to-date on social media.

After COVID-19 was declared a public health emergency of international concern, on March 11^th, 2020, it soon became clear that people living with obesity were more susceptible to severe SARS Coronavirus 2 (SARS-CoV-2) outcomes. We now know that the risk for hospitalization for people living with obesity is increased by 113%, whilst the risk of death is 48% higher when compared to individuals of normal weight.[i] Adding to growing concerns are the lockdown restrictions and mental health consequences of the pandemic that threaten weight maintenance and weight-loss efforts, with increased levels of physical inactivity worldwide. Obesity is thus considered an effect of the pandemic and cannot be ignored in both developed and developing countries that bear the highest burden of the disease.

We have nine years to meet the UN global development targets, also known as the Sustainable Development Goals(SDGs). We must act swiftly if we are to do so and fix the catastrophically off-track global obesity targets that are further threatened by the COVID-19 pandemic (SDG3.4, SDG3.8, SDG2). Why so? A lack of progress on obesity jeopardizes achievement of the World Health Organization (WHO) Triple Billion Targets that promises 1 billion people living healthier lives.

As an optimist, I do believe that within a crisis, lie seeds of opportunity. There is hope.

But what is the solution?

From the early days of the COVID-19 outbreak in Wuhan, I followed prevalence trends and response priorities. Having finished my MPH two years ago I never imagined living through a pandemic, at least just yet. Dr. David Nabarro’s Open-Online Briefings provided a platform for interactive discussions and a community to grow with. It exposed me to complex systems thinking – a framework to identify and account for interacting influences on COVID-19 and obesity that will be key to progress.

‘Holding the virus at bay requires following the well-established disciplines of disease outbreak control.  There are no shortcuts and no quick fixes. Different systems need to be woven together at a local level and be well supported by both national authorities and international programmes.  There is a need to do it all and do it well.’ Dr. David Nabarro rightfully says.

What is the missing piece of the puzzle? Youth Voices!

Young people have the innate capacity to see the ‘bigger picture’. They can discover complex interdependencies, including the components of a system that may affect and interact with each other. Their critical tendencies can help us identify barriers in implementing policies, including the incentives and stakeholders that need to be brought to the table. Youth have always been at the forefront of movements for justice and social change, including the Black Lives Matter and Climate Justice movement. They have shown their commitment to activities and improving lives for all.

‘Confronting Obesity: co-creating policy with youth’ (CO-CREATE) a project funded by the European Commission works for youth, with youth. By using a systems approach, the project addresses the unresolved challenges around childhood obesity. Just recently, the perceptions of 257 adolescents  (16-18 year old) on the drivers of childhood obesity across Portugal, Poland, Norway, the Netherlands, and the UK were explored.[ii] Collectively youth identified marketing, access to food (both availability and price), stress, anxiety,  depression, and low body positivity as factors contributing to the obesity epidemic. Not only did they identify such factors, but they also used a process of ‘mapping’ to illustrate how they are causally related to each other and obesity (see figure 1).

Figure 1 – Commercial Drivers of Obesity. Eur J Public Health, ckaa251, https://doi.org/10.1093/eurpub/ckaa251

We must listen to, and work with the important but often most neglected population group in obesity and COVID-19 research. It will build capacity and support decision-making on key issues that are ahead of us:

1. How to re-open schools safely, including the measures that are likely to receive collective support from students.
2. How to address the mental health crisis coming in COVID’s wake.
3. How to roll-out COVID-19 vaccination programmes, particularly amongst populations with low acceptability.
4. How to mitigate and prevent future infectious disease and pandemic outbreaks and the climate change emergency.

We have all lived with COVID-19 for a year now. The virus is here to stay for the foreseeable future. Equally, not one person has been untouched by confinement, and the hardships that the pandemic has given rise to. If not directly, then indirectly due to the lack of support from neighbouring countries during a local emergency. But this makes us powerful!

We are more united than ever, and It is time to take action as a collective. To engage and support one another for equity and justice for the planet. Every Body needs everybody to address obesity & COVID-19, and this includes youth.

Are you struggling to see systems and appreciate them? Dr. David Nabarro provides excellent guidance here. You can also watch the 4SD narrative on COVID-19 and systemic inequality here.

And remember – ‘Great things are not done by impulse, but by a series of small things brought together’.

[i] Popkin, BM, Du, S, Green, WD, et al. Individuals with obesity and COVID‐19: A global perspective on the epidemiology and biological relationships. Obesity Reviews. 2020; 1– 17. 

[ii] Savona, N., Macauley, T., Aguiar, A., Banik, A., Boberska, M., Brock, J., Brown, A., Hayward, J., Holbæk, H., Rito, A., Mendes, S., Vaaheim, F., van Houten, M., Veltkamp, G., Allender, S., Rutter, H. and Knai, C., 2021. Identifying the views of adolescents in five European countries on the drivers of obesity using group model building. European Journal of Public Health,.

About this 4SD Reflection

This article is a reflection by Claudia Batz following the COVID-19 Open Online Briefings of Dr. David Nabarro. Claudia is an emerging public health professional and a youth advocate with 2 years of experience in global and public health, Currently a Policy and Projects Coordinator at the World Obesity Federation and a Core Team Member of Young Leaders for Health.

At WOF, she supports the dissemination, communication, and utilisation of outputs from 2 EU consortium childhood obesity projects (CO-CREATE & STOP), and the development of youth-friendly materials, briefings, and resources to help policymakers and others seeking to implement obesity-related policies in their countries. Her previous role involved supporting the enhancement and delivery of the Strategic Centre for Obesity Professional Education(SCOPE).

Claudia is keen to improve health literacy and strives to elicit and bring the perspectives and skills of young people into the strategic design and delivery of health-related programs and policies through her engagements.