Issue 1 • 2022
© 2022 The Royal Australasian College of Physicians

Only time: reflections on the importance of time in responding effectively to COVID-19

Dr Michael Ryan, Executive Director of the World Health Organisation’s Emergencies Program, and the recipient of the 2021 Cottrell Memorial Award has been at the forefront of managing acute risks to global health for nearly 25 years. He shares his thoughts on COVID-19 and the unique set of challenges we currently face as physicians.
Dr Michael Ryan joined WHO in 1996, with a newly established unit to respond to emerging and epidemic disease threats. He has worked in conflict-affected countries and led many responses to high-impact epidemics. He is a founding member of the Global Outbreak Alert and Response Network (GOARN), which has aided response to hundreds of disease outbreaks globally.
He served as Coordinator of Epidemic Response (2000-2003), Operational Coordinator of WHO’s response to the SARS outbreak (2003), and as WHO's Director of Global Alert and Response (2005-2011). Dr Ryan was a Senior Advisor on Polio Eradication for the Global Polio Eradication Initiative from 2013 to 2017 and then served as Assistant Director-General for Emergency Preparedness and Response in WHO's Health Emergencies Programme from 2017 to 2019.
He is currently the Executive Director of the WHO – Health Emergencies Programme, where he leads the team responsible for the international containment and treatment of COVID-19. He has come to attention in Australia and New Zealand because of his ability to speak the truth to power fearlessly and with great compassion.
Instead of delivering an oration in the usual format, Dr Ryan asked to be interviewed. Questions from several fellows and many children were collected and formed the basis of Dr Ryan's address. The session was moderated by Professor Don Campbell, President of the RACP Adult Medicine Division.
The inaugural question came from Mattie, an 11-year-old girl who asked: Should Australia send all of its vaccine medications to other kids in India so that their mums and dads do not die?
Dr Ryan responded by suggesting that Mattie should come and work for the WHO. He termed it a fantastic question that we are all asking ourselves today in a world desperately trying for equity. A terrible dilemma for everyone, especially the frontline workers today – ‘Is taking care of themselves before taking care of everyone else the right thing to do?’ What makes it even more difficult is that there isn't enough to go around. It has only been 139 days since the first person was vaccinated, and over a billion doses of vaccines have already been injected. The unfortunate thing is that 75 per cent of those vaccines have gone into the arms of people in just ten countries and there is a huge amount of inequity.
Dr Ryan then spoke about the COVAX initiative, a global initiative that tries to pull vaccines from countries with spare vaccines, so they can be shared with others who have struggled to access enough vaccines. He said that countries are now stepping up and becoming open to sharing, having seen the disease come under some control.
He commended the leadership shown by Australia in its public health care and overseas assistance. He felt Australia has shown commitment in working with the Small Island States by working with countries like Papua New Guinea and sharing knowledge, PPE, ventilators, and vaccines. It was doing the right thing by taking care of people in its backyard and its neighbours.
The next question was about the role an astute physician can play in making observations and drawing connections in today’s COVID-ravaged world.
Dr Ryan said that today when we look at an epidemic, we tend to increasingly look to technological solutions. We use AI-driven systems to pick up epidemics and automatically go to the machine solution or what we call innovation. But most epidemics, even today, are picked up very often by this stupid physician who notices that something is not right about a particular patient. They somehow make a connection with other similar cases to form a cluster then raise a red flag.
He went on to narrate a story from inside the COVID-19 origins story. In the first clusters picked up in China was a couple admitted to the hospital, one to the infectious disease ward and the other to a chronic disease ward for different conditions. The patient in the chronic disease ward developed some respiratory symptoms and had to be moved to the infectious disease ward.
The patient asked if he could be put in the same room as his wife. Until then, the hospital authorities did not know that both husband and wife were admitted to the same hospital as she had a different last name. They recognised similarities between both the cases and flagged that something unusual and risky was happening. It’s very interesting to note that the first step was an astute physician recognising and following up on the fact that two patients were presenting similar symptoms and were connected.
Another question from one of the older children was: What will the world look like two years from now?
Dr Ryan responded by saying that although it is the question on everyone’s mind, no one knows the answer. Six months ago, he would have said we'll be getting vaccinations by early 2021 and the disease should be under control by end of 2021. However, the virus has shown that it is full of surprises - the variants have emerged which have been driving transmission in some places.
He also said that this virus has a lot of kinetic energy. Once it gets into a community, it can rip through it like we just saw in India. Unfortunately, this virus is not done with us although we're done with the virus in our heads. He shared that, countries like Australia and New Zealand have managed to keep the disease at extremely low levels and the disease is dropping off in some other countries with higher vaccination levels. It shows that the end scenario of this disease is different if we can have strong public health intervention and drive vaccination levels up.
The next query to Dr Ryan was on what he thinks distinguishes nations that have responded successfully to the pandemic from those that have failed.
He responded by saying that no two countries seem to have done the same thing. But what is common between the countries that have done well has been their comprehensive approach. They worked on strengthening the healthcare system and engaging with their communities. Leveraging the power of communities to support their governments was another approach that worked well.
Dr Ryan spoke about a TV interview in which people from Sydney publicly thanked the people of Melbourne for what they did to save Australia. He said such simple acts of recognising the sacrifices of others go a long way in building morale and keeping spirits high.
This pandemic identified considerable loopholes in global health supply chains, he observed. In 2020, there were a series of fights around the world over material goods and PPE. We saw the horrors of frontline workers not being protected, and people dying in intensive care environments without ventilation and necessary oxygen. It was a breakdown of the whole system, not just of production and supply. The world was entirely dependent on a system that was simply not geared for a pandemic.
Dr Ryan shared that the WHO, with partners like World Food Programme, has put together a core supply chain management system and supplied over a billion dollars for equipment to 184 countries. It was very difficult in 2020, as they were competing in a global market amid constantly escalating prices and a tremendous amount of competition between countries. This has eased a little now where WHO is working with partners, trying to scale up the absolute PPE supply and the availability of diagnostics, in a sustainable way.
Commenting on the process of vaccine development, international collaboration, and COVAX rollout, Dr Ryan said it was amazing to see so many countries coming together to solve a single problem. COVAX is responsible for rolling out the vaccine rolled to over 100 countries and it has demonstrated that vaccines can be rolled out and administered even when they have to be preserved at -80°C.
COVAX has also been reaching out to governments with access to vaccines, to share some of their supply and ensure that the most vulnerable frontline workers are protected. Dr Ryan termed it an abomination that over a billion people are vaccinated but there are still places where the front-line workers dealing with this disease every day don’t have access to the vaccine.
A pertinent question was asked: Isn't it time patent protection waivers for key medicines like vaccines are implemented for the short term?
Dr Ryan said if it is not done now when will it be done? We are amid a global pandemic, and we are witnessing the horrors of people in intensive care units struggling to breathe. What else do we need to see to implement those waivers?
The next question was about the role WHO plays in promoting pandemic preparedness across nations.
Dr Ryan said that while the WHO has been working with many countries for a long time, the difficulty is that pandemic preparedness is not attractive. The world over, responding gets resources whereas preparing for disaster is not taken seriously. We, as a world, collectively did not invest, and we failed to prepare. The whole time, everyone failed to recognise that instead of preparing for the pandemic we were preparing to fail.
He opined that we are all paying a massive collective price for not seeing preparedness, health system resilience and community-based interventions as the core of our health system. We need to make sure that national action plans for public health security, which exist in so many countries but are never funded are now put into use. We have the systems, we know what to do but we do not do it because we see health and preparedness as a centre of cost and expenditure and not as a centre of investment and protection.
WHO Director-General Tedros Adhanom Ghebreyesus was quoted as saying 'vaccines complement, but do not replace the many tools we have in the toolkit'.
Dr Ryan was asked what he thought of the role of upstream drug therapies in the treatment and pre- and post-exposure prophylaxis?
He replied that we've seen new platforms like mRNA platforms and vector-based platforms in vaccine development and a tremendous amount of work going on in therapeutics. But the therapeutics we have right now are the older immunomodulators that aim to save patients in a crisis and are not directly aimed at stopping the virus. We don’t have any broad-spectrum antivirals that can be used to save lives while we develop the vaccines. There have been some interesting trials and innovative approaches but a game-changer drug has not emerged. Also, a lot of the trials have been too small to pick up any significant effects. Professor Campbell cited the example of the UK NIHR platform and asked how the WHO can help with the critical clinical trials infrastructure. Does WHO have the ability to coordinate that sort of response across nations?
Dr Ryan said that WHO has a platform called the Solidarity Trials, a platform for countries all over the world to work together using common protocols. Solidarity carries out the largest trials of drugs that have been carried out in terms of numbers. It also supports national investigators to connect with other researchers in the field. The Solidarity drug trials are ongoing and there are plans for further trials to test new second-generation vaccines coming onstream. The WHO is not a research agency by itself but acts as a facilitator providing support and technical assistance to countries who want to do good research.
The next question from a child was: Will they have to return to home schooling if COVID-19 spreads?
Dr Ryan remarked that the kids in Australia should consider themselves lucky and be proud of their health system which is working very hard to protect them. He observed that it is important to get this virus early and put in place preventative measures. And even if those measures involve home-schooling for a week or two, it's a small sacrifice to pay. The next question came from Olivia who wanted to know why it took so long for the world to recognise the severity of this pandemic?
Dr Ryan said that it was a question that he was still asking himself. He admitted that there was a slowness to react and that they lost valuable time in February. He gave the analogy of a dam and a valley. If you are down in the valley, you feel threatened easily and act at the slightest of threats. But if you are standing on the top of the dam or hill, it's hard to perceive the enormity of the threat. It is all about perspective. Countries, in general, did not recognise how serious this virus could be. Those countries which acted early are the ones that did extremely well against this virus. The countries which were caught unawares were hit hard but are slowly recovering.
When asked about what inspires and drives him on a personal level, Dr Ryan revealed that he doesn’t like injustice, and a lot of times, it’s about being in the ‘let’s do something’ club rather than the ‘something must be done club’. Especially in times like this pandemic, you will find many people telling you where you are going wrong, but you will rarely find people who will say let’s try and fix this.
In health and social justice, it is often about recognising that you as an individual can cause change, can make a difference. Dr Ryan went on to share his philosophy: if you want something to change, you have to be a part of that change.
Professor Campbell then asked him about words of advice he had for young Australian and New Zealand physicians thinking of working with the WHO.
Dr Ryan encouraged more physicians to do it because it provides a great opportunity to work with wonderful people from around the world. He went on to talk about the many great Australians and New Zealanders he worked with over the years.
Professor Campbell thanked Dr Ryan on behalf of the RACP and virtually presented the Cottrell Memorial Medal to him.