Lankan WHO Covid envoy extols SL’s ‘bounce back’ capacity and established public health system

Dr. Palitha Abeykoon, former Director, Health Systems Development, WHO South-East Asia Regional Office and Senior Advisor to the Sri Lankan Ministry of Health, was recently named the WHO Director General’s Special Envoy to facilitate the COVID-19 response in Southeast Asia.

Counting many years at the WHO, Abeykoon served as the advisor in human resources for health in Nepal where he helped to set up the Institute of Medicine, the country’s first medical school, and later in Indonesia to establish the Consortium of Health Sciences and five new schools of public health. He also worked as the WHO South-East Asia Regional Advisor on Human Resources for Health and later was appointed the Director of Health Systems Development. He also served as the WHO Representative to India and led India’s polio eradication effort. He has published widely in many international health journals.

In an interview with Randima Attygalle, the respected senior professional who has long been a building bridges of goodwill in the regional health sector, discusses the road-map for the fight the pandemic in which health security and sustaining livelihoods cannot be undermined.

Q : What advantages do you think your appointment gives the Sri Lankan health sector and the region?

A: For the past one year, I have been working closely with the WHO, with the Ministry of Health and different groups in the country. I believe my present appointment will help me give further thrust to this engagement and extend it to the highest level, to the WHO Direct General’s and Regional Director’s offices, and also to bring messages down to the local level. This way I hope I could be even more relevant and useful.

As a Sri Lankan who has worked extensively in the region coupled with my experience in the local public health sector, I believe I’ll be able to add value not only to our own setting but to the other countries in the region in a number of ways.

Q: What is your mandate?

A: Our Region has a 2.4 billion people and I will try to do justice to their priorities. The Director-General has appointed six Special Envoys on COVID-19, to provide strategic advice and high-level political advocacy and engagement in different parts of the world. The Special Envoys work in close collaboration with WHO Regional Directors and WHO country offices to coordinate the global response to COVID-19.

In coordinating this response, one of the key responsibilities is to promote health security and to take the WHO DG’s messages to stakeholders in the government, the private sector and most importantly to the communities and individuals. The envoys also have to help ensure that the WHO guidelines are implemented correctly. We have weekly meetings with the WHO Chief and his technical staff on COVID-19 where we discuss pandemic-related common regional issues.

The DG strongly believes that we could be strong ‘supplementary voices’ for our respective regions, to be able to communicate fast with him and take his voice downstream as quickly as possible because of the contacts we have already made over the years and are expected to make in the short term.

Q: As a health professional who had held many international positions and steered several health projects in the region, do you think your latest appointment is more challenging than those of the past?

A: Every situation where you have to work with large groups of people has its own challenges; but the main difference between what I did then and this position is I suppose the fact that those days I was working within the WHO, in an established system and a structure. Therefore the responsibilities were according to a plan with agreed outcomes which we made with the different countries.

But what we are going through now is a pandemic with a spectrum of issues and a high level of unpredictability. This is a complete novel situation we have to grapple with. It has affected the entire world, and ever since the pandemic broke a year ago, we have been learning something new every day. We continue to learn about the virus, how it circulates, its changing nature, new management strategies both in terms of the preventive and clinical aspects of management. Yet, we do not know enough.

Now we have the new dimension of the vaccine. Nowhere in our history did we have a situation where a new vaccine was developed with the strictest of controls to the stage of administration in just one year. It is an amazing scientific achievement! There is considerable hope with the advent of the vaccine although it is not going to solve all the problems immediately. Thus, there are many challenges and my role would be to facilitate the overall system development.

Q: What are the immediate concerns of the Special Envoys in terms of COVID-response?

A: Right now we have three main concerns. We are looking at how best to make COVID vaccines equitably distributed because we have a serious problem where all rich countries seem to be purchasing all the vaccines produced, leaving very little for the poor countries. This is a sad story. In fact two days ago the Director General referred to this as a “catastrophic moral failure”.

Up to now, 50 countries in the world including India have started immunization and 70 – 80 million doses have been administered to their people. One of the things we are supposed to do is to work with regional bodies and the manufacturing countries to advocate that all countries get at least part of the vaccines produced in an equitable manner. Otherwise there will be health problems and also political issues when one section of the world is deprived of a vaccine with the other part grabbing it all.

Many countries have entered into bilateral agreements with manufacturing countries. Sri Lanka as well as some other countries in the region such as the Maldives, Bhutan and Bangladesh have also entered into such agreements with India. Some other countries have bilateral agreements with manufacturers to buy vaccine stocks. For example, Myanmar has an agreement with the Serum Institute of India which is licensed to manufacture the Oxford AstraZeneca vaccine (named Covishield) in India. The Institute by itself cannot sell outside India, and hence we have entered into an agreement at an official protocol level.

Q: Sri Lankans are anxiously awaiting the arrival of a vaccine. Where do we stand right now in terms of our preparedness to import an effective vaccine and when can such a vaccine be expected to arrive here?

A: The GAVI Alliance (The Global Alliance for Vaccinations and Immunization) which is a global health partnership of public and private sector organizations dedicated to ‘immunization for all’, has developed a facility called COVAX. It is co-led by the WHO and the Coalition for Epidemic Preparedness Innovations (CEPI) and aims to accelerate the development and manufacture of COVID-19 vaccines, and to guarantee fair and equitable access for every country in the world.

At the moment COVAX has been able to procure about two billion doses and by the end of this month they may be able to raise it to three billion doses. The COVAX facility will give vaccines to the poorer countries free of charge. We are likely to get enough to vaccinate about 20% of the population, prioritizing the front-line health workers and the other most vulnerable segments in society including the elderly and those with chronic illnesses.

But all of the four million doses will not come immediately or in bulk. It will come in batches and by end February we may receive the first supply of a COVAX vaccine. Through the rest of the year we may able to get the balance depending on the availability of the vaccine supply. The vaccines through the COVAX facility are likely to be the Pfizer vaccine and the Oxford- AstraZeneca vaccine, which may come through the Serum Institute of India or another facility.

Q: Do we have adequate cold chain facilities here at home to store the vaccines?

A: Yes we do. Only the Pfizer Vaccine requires storage facility of minus 70 C. Even for that we have identified sufficient storage space and necessary logistics.

Q: What does WHO feel about Sri Lanka’s preparedness and response efforts and what key areas should be strengthened to face the COVID threat in months to come?

A: There are several pillars on which the drive to fight a pandemic rest: the leadership, technical, behavioural, and management. Sri Lanka generally speaking, has handled all these pillars reasonably well.

Our sound public health system which is time tested and had faced epidemics has been applauded. It is a system which is primed to face emergencies and disasters. Secondly, we are also fortunate to have good leadership at multiple levels and tiers. We have used probably the best scientific evidence that a pandemic of this scale requires.

Thirdly, we have had a lockdown at the initial stages which some believed to be ‘too harsh’. But the idea of a lockdown at the onset of an epidemic is to suppress the virus. The suppression also meant time to strengthen the health system so that in the event of an upsurge, the system is well geared to cope. We did that reasonably well – detecting, isolating, quarantining and at the same time strengthening the health system by expanding the bed capacity, ICUs etc.

The success of a good public health system involves the input of multiple professionals and a scientific approach. On the whole, our response to the crisis has been driven by and large by science and evidence. Sri Lanka has one of the best track records with regard to immunization and I am sure we will be able to organize the vaccination programme very well.

Another attribute similar to Thailand, which also has done well, is that we also adopted ‘a whole of society’ approach. This means all groups came together- the government, professional bodies, the private sector, academics etc. in countering the crisis. It is largely the countries which did not have this ‘whole of society’ approach, among them developed countries such as the US, which suffered notably.

In general our people’s behaviour, with the exception of a small segment, had also been good during the pandemic. We also need to applaud our people for sacrificing some of the most important religious and cultural events of their calendar, irrespective of the faith, to protect one another.

Having said that, it is inevitable that sometimes complacency creeps in when the public is too confident. This contributed to the second wave but with the lessons learnt, we should be able to prevent a large third surge.

In terms of strengthening our system, we need to give more teeth to the proven interventions we already have in place and bridge the gaps. There could be better communication among multiple stakeholders. Now we generate a lot of data through various platforms and agencies. This includes clinical data, epidemiology data, laboratory data etc. We need to collate all this data better and redesign a data-driven campaign. This could help us further fine-tune our surveillance mechanism. In that case we need not block large areas of population. We also need to bring in more technology to move forward.

The other crucial need of the hour is to look after our frontline health workers. A good number of them are fatigued and they also face the threat of infection. We should not allow a ‘burn out syndrome’ to creep into our health sector. This has to be managed well. I think the forces cadres are handling their systems well. We need to take good care of those who take care of us in the best possible manner and make them feel that they are valued and respected as an integral part of our COVID management mechanism.

Q: What is the immediate forecast of the WHO and their advice in moving forward in this new normalcy?

A: Generally speaking the vaccine will be a game changer but certainly not short-term in the next three or six months. Countries will have to adopt the same measures they have been adopting stringently over the past year- the fundamentals such as wearing masks, regular washing of hands, social distancing etc.

The WHO also urges vigilance to prevent another cycle because what might happen then is that the capacity of the health system can get overwhelmed. Why countries like America and European countries got into trouble was because this surge came quite fast at a time when their health systems were not resilient enough. Once that happens the game changes very quickly.

We have to make sure that we do not create any situation which would lead to another wave. Preventing super-spread events where large numbers of people get together is crucial. This is going to be a difficult year; however if we manage this year well, we should be on the path to recovery.

When you tighten the controls by locking down and isolating areas, naturally there are spillover effects on the economy and education of children. Like most other governments we too need to be mindful of these two crucial factors. So now we have the issue of balancing: how do we save and protect lives as well as livelihoods? This is going to be the biggest challenge.

Good communication which will contribute to the desired behaviour of people is important because it is essentially the behaviour of people that is going to make or break the next six months of the epidemic. We have to make sure that people take ownership of the situation, empower the communities to take responsibility – this is the challenge from now on.

Q: There is a serious issue of COVID myths vs Scientific Facts. What is the role of the health sector in disseminating correct information to the public and also the role of media in this regard?

The pandemic response has to be driven by science. The role of the health sector in sharing correct information is crucial and the role of mass media in disseminating that knowledge in an acceptable and an ethical way becomes equally important. Media has to be conscious of conveying credible information without sensationalizing. Their reports must be interesting and factual. This approach may not be attractive to some media organizations, but that, and certainly not controversy, is the need of the hour.

Education per se does not necessarily make people rational; we cannot stop everyone from subscribing to non-scientific measures. In any setting there will be pockets believing in myths. Sometimes, out of desperation, people are driven to such trappings. Hence the responsibility of media and the health system is not to spur the public to subordinate essentials with such behaviour. Media cannot afford to create a false sense of security by encouraging people to displace well known scientifically established facts with unproven phenomena.

Q: What are your proposals to the Health Ministry and other local stakeholders in strengthening access to correct information on the pandemic with necessary transparency?

A: It is ideal if we have one designated ‘face’ as a national spokesperson for COVID-19 as in the case of Thailand. This can avoid confusion and contradictions. We could have one designated person or a panel of people who speak the same language in this regard.

It is also important for the Health officials to give more time to the media. Both print and electronic media should also have designated journalists trained in this subject, so that there are specialists who can produce a balanced report.

Q: From the lessons learnt during the pandemic, how can our health sector be strengthened to face future catastrophes?

A: Most importantly, we have to make certain that our healthy security is strengthened with strong and resilient public health systems that can prevent, detect, and respond to infectious disease threats, wherever they occur in the world. According to the ‘Swiss cheese model’, in a complex system, hazards are prevented from causing harm by a series of barriers. Each barrier has unintended weaknesses, or holes – hence the comparison to Swiss cheese and this term is frequently used by patient safety professionals.

The prime subjects of health security should be the most vulnerable groups such as those with chronic illnesses, the elderly and the disabled. Health security should also pay attention to nutrition, that the children are immunized even in times of epidemics or pandemics and that pregnant women have access to anti-natal care.

Moreover, international Health Regulations articulate certain obligations of a nation. One key regulation is the immediate notification to the WHO at the first sign of any infection, particularly, those diseases which can be transmitted to humans by animals. This is why there is a controversy surrounding Wuhan where the first case of COVID-19 was reported. WHO investigations are being carried out to determine if there was any lapse in this regard by the Chinese officials. Within the WHO system there are ‘incident managers’ for immediate referrals of this nature.

Q: What do you think are the inherent ‘Sri Lankan strengths’ as a nation in fighting this pandemic from a cultural and a social perspective?

A: We can take shocks and bounce out of shocks. This has become part of our nation’s DNA. Our people are generally helpful and in a crisis all pull together. This level of mutual help and support, we may not see in many countries. Also our health literacy is very good. We also have a strong history of volunteerism. We donate eyes, blood, kidneys etc. more than in many parts of the world. We are one of the very few countries in the world with a 100% voluntary blood donation service. We are still very much an altruistic nation, a major plus which we should sustain.