Our COVID Future: The Long Crisis Scenarios

Our COVID Future: The Long Crisis Scenarios

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COVID-19 marks a turning point in the 21st century.​ Levels of uncertainty are off the chart, making predictions impossible. ​But if we can create plausible stories about different futures, we create a foundation for decision makers, campaigners, and communities to influence the process of change.​

Working in partnership with Local Trust, our new venture, The Long Crisis Network, has created scenarios that imagine what could happen, allowing us to explore what different pathways into the future could look like.​

We start with the nature of the risks we face in the long crisis of globalisation – a turbulent period in which risks proliferate across borders as rapidly as opportunities. We then explore the difference between high and low resilience systems, and what it takes to respond to a crisis when events are running out of control. 

The COVID-19 pandemic is the latest and greatest of a series of shocks to global systems. It has three layers – a public health emergency that will continue for two years or more, an economic disaster that will take at least five years to unfold, and a crisis of polarisation and insecurity that could take a generation to play out fully.

Drivers of Change

Two drivers will shape how societies respond to the emergency. Will a crisis force people to work together or will it divide them? And will the response be centralised or distributed? These drivers frame four scenarios:

1. In the Rise of the Oligarchs, the dark phoenix that emerges from COVID-19’s ashes is a government of the few. It’s polarised, xenophobic, and corrupt.

2. Big Mother sees government take charge. The response is ambitious but uninventive.

3. Fragile Resilient is a future where things fall apart – with chaos tempered by innovation.

4. Winning Ugly sees an uneven process of renewal. No obvious victory but a steady increase in a society’s ability to organise, learn, and adapt.

We compare these scenarios across four dimensions: who has power? What do they mean for prosperity? What impact do they have on people and places? And what are the pathways from one scenario to another?

Finally, we explore the implications of the scenarios for the way forward. How do we move from Them and Us to Larger Us thinking? What do we need to do now to promote positive outcomes in the short, medium, and longer term? Who are the actors in a Larger Us movement? And which strategies are mostly likely to be effective in the future described by each of the scenarios?

The Scenarios

The unknowns on the public health, economic, and insecurity layers of the COVID-19 emergency are compounded by equally deep uncertainty about how we will react. ​

At all levels, we face choices between collective action and polarisation. ​Millions of lives, billions of people’s futures, and trillions of dollars depend on whether we act collectively in the face of crisis or instead polarise when under threat.​ The response can also be centralised or distributedIn the rapids, does the captain steer the ship alone or does she also empower everyone to row?​ Four scenarios reflect these choices.

Scenario 1 – Rise of the Oligarchs

Divided | Corrupt | Xenophobic

Like a dark phoenix from the ashes, the winner from COVID-19’s crises is a government of the few. It’s inequitable, illiberal, corrupt, opaque – and ineffective.

No-one thought that it would be this bad: the spread of the pandemic, the economic pain, or the damage to people’s lives. But through it all, the powerful – in politics, business, and the media – protect their own. 

People are angry, but also scared and compliant. Stranded between apathy and the latest conspiracy theory. Risk takerslive at the bottom, not the top of the pile.

International co-operation withers and geopolitical tensions proliferate. In a world of closed borders, racism and xenophobia flourish.

Scenario 2 – Big Mother

Statist | Ambitious | Uninventive

Government is BACK and it’s here to help

Politicians are expected to deliver: a vaccine, an income, a future.To keep the lights on both literally and figuratively. People are told what to do by a state that promises to look after them. Lockdowns are sporadic but behaviour is constantly monitored and regulated.

The social contract is clear, but the strain is showing. The government has plenty of answers, but seldom the most imaginative ones

And it continually increases expectations while elbowing others aside. When it gets it wrong, people feel betrayed and anger surges.

Scenario 3 – Fragile Resilient

Chaotic | Vulnerable | Innovative

Repeated waves of COVID-19 – and a financial crash, food system crash, energy crash, trade crash – overwhelm the capacity of a state that finds itself in the latter, more frenetic, stages of a game of Tetris. 

Amid intensifying levels of drama and chaos, national politics increasingly becomes a competition for what is left of the spoils. Bubbles inflate and burst. Fortunes are made – and lost.

At the grassroots, there’s a surge of innovation as communities fend for themselves. Like Italian towns facing the Plague or developing countries today, people are fantastically inventive when making the best of a bad job.

Scenario 4 – Winning Ugly

Distributed | Function not Form | Learning | Emergent

No-one said it was going to be easy.

No obvious sign the battle was won. No heroic moment of victory. Instead, an extended – and at times seemingly endless – attack on the pandemic. One that started in hospitals, moved into communities, and was driven by a collective willingness to learn and adapt.

The economic trauma was profound, but institutions held. Not just the organisations, but our ability to organise. To draw on reserves of community cohesion. To replace failed leaders with a new generation.

At first, we just threw money at the problem. But over time, this created space for smarter approaches to proliferate and for the emergence of a narrative that promotes collective action to tackle other urgent risks such as climate change.

Towards a Larger Us

If these four disparate scenarios make one thing clear, it is that we are at a point at which the future is up for grabs. Them and Us thinking could drive us further towards breakdown – but a Larger Us movement still has everything to play for. A future where the toll of the pandemic is still heavy, but our capacity for collective action grows.

For the full story of our four scenarios and more on the long crisis of globalisation, read the report here – Our COVID Future: The Long Crisis Scenarios

Protecting our Critical Global Infrastructure

Protecting our Critical Global Infrastructure

Earlier this week, we published Shooting the Rapids – COVID-19 and the Long Crisis of Globalisation. In the final section, we present a plan for collective action at the global level with four elements: 

  • Firefight better – getting the emergency response right to overcome the most serious problems. 
  • Make people feel secure – not only to defuse risks of violence and conflict, but to create the psychological conditions needed to support collective action.  
  • Protect the critical global infrastructure that we absolutely cannot afford to lose.  
  • And a New Deal for a New Generation – education, jobs, and climate protection. 

In this post, we wanted to say a little more about what we mean by critical global infrastructure and why we need to identify and focus on it. 

Shooting the Rapids is a sequel to Confronting the Long Crisis of Globalization – a Brookings report from 2010 (written with Bruce Jones). And the Long Crisis was in turn developed from a paper that Gordon Brown asked us to present at the Progressive Governance Summit in April 2008.

Prime Minister Gordon Brown with other World Leaders during a press conference at the end of the Progressive Governance Summit, 5 April 2008; Crown copyright.

Brown hosted the summit to try and build a like-minded coalition to manage risks in an increasingly tempestuous international environment. But the initiative was dismissed as a “frothy indulgence” by critics in his own party. They advised him to forget the global and get in touch with “Labour values” by offering “common sense” answers to the everyday problems of British voters. 

But 2008 was not a good year for progressives to try to retreat into their shells. As Robert Cooper once said, “we may not be interested in chaos, but chaos is interested in us.” Northern Rock, an upstart British bank with a “reckless business model,” had collapsed in February. The “run on the Rock” was the first in the UK in 130 years. By the time the Progressive Governance Summit was held, signals of broader systemic trouble were blinking red, as chatter grew about an impending “credit crunch.”

As we would soon discover, the global financial system was rotten to the core and Brown’s time as leader would be defined by his attempts to prevent it from collapsing (much lauded) and the subsequent revenge taken by British voters for the pain the crisis caused them, driving him out of office and his party far away from power. 

The summit was a tense, and often strange, affair. Our job was to kick off a summit on global governance (see our paper), but it was long delayed as the discussion on the economy ran on and on.  

My strongest memory is of Dominque Strauss Kahn’s intervention. Yet to be unmasked as a sex pest or worse, the head of the IMF told leaders that he’d been shaken by a financial crisis unlike any he’d expected to encounter in his career. Now it’s over, he said, we must learn lessons and make sure it never happens again.  

But it wasn’t over. It had hardly begun. Lehman Brothers collapsed 163 days later, with the global economy came frighteningly close to total breakdown. So:

  • The world was unprepared for a crisis – financial and economic systems were not resilient. 
  • Leaders called the peak of the crisis far too early – and were tempted to declare victory and move on. 
  • In September, with floodwaters up to their necks, they rallied – revelling in the “drama, media attention, and sense of purpose” that an acute emergency brings.  
  • But – again – they moved on, leaving the Eurozone to fester, trust in institutions to collapse, and societies to polarise in a way that left societies less prepared for future crises. 

In this new crisis, we can already detect the same patterns of denial, panic, emergency response, and a failure to sustain action.  

The danger of a premature declaration of victory is especially acute at the moment, as governments convince themselves that infections have peaked and they are past the worst, that economies can be restarted and will recover, and the bounce in popularity that many have enjoyed will be sustained. 

Maybe this rosy scenario will come to pass. But – as we demonstrate in the first section of Shooting the Rapids – levels of uncertainty are frighteningly high, the route out of lockdown is perilous, many countries are only just starting their journey with the virus, and it is hard to see economies going back to normal anytime soon.  

Moreover, the ‘consequences of the consequences’ are only just starting to unfold. We could soon see a secondary wave of impacts on food systems, energy and trade, sovereign and corporate debt, and banking systems, be hit by an unrelated shock such as a major earthquake, or experience fallout from political instability and insecurity. 

“The ‘consequences of the consequences’ are only just starting to unfold.”

The future could look very ugly, in other words, if we again discover that this is the Northern Rock phase of the emergency and Lehman Brothers lies ahead. 

This matters for the international system and what it should be focused on. The run up to this week’s World Health Assembly was dominated by calls for an independent enquiry into what went wrong. Many countries are also switching into ‘lessons learned’ mode. 

But we should be more focused on the mistakes of the future than the mistakes of the past. On understanding which of our global systems could fail in the next phase of the crisis and acting now to shore them up. 

In Shooting the Rapids, we identify some priorities:

  • Keeping global food supply chains open, using models that emerged from the 2008 food crisis.  
  • Stabilising global energy markets and helping major exporters cope with the pain that collapsing prices is causing their citizens. 
  • Maintaining trade routes at a time when protectionist forces are stronger than at any time since the 1930 Depression and there are rational reasons for onshoring.    
  • Tackling systemic financial risks and making sure the global communications infrastructure can withstand attack.  

In each of these areas, we need strong international leadership, the strategic discipline to focus on what is most important and jettison what is not, and minimum viable alliances that “can begin to manage a risk or solve a problem – and then expand participation as momentum builds.” 

This work is not glamorous. If it’s effective, it will go mostly unnoticed (the unfortunate “paradox of prevention”).  

But it is essential that we act now to protect the “institutions and systems that we cannot afford to lose as we navigate the long crisis of COVID-19.” 

Shooting the Rapids: COVID-19 and the Long Crisis of Globalisation

Shooting the Rapids: COVID-19 and the Long Crisis of Globalisation

Back in 2010, a report entitled Confronting the Long Crisis of Globalization, which we co-wrote with Bruce Jones, was published by the Brookings Institution. Today, we release a new report exploring the link between the Long Crisis and the COVID-19 pandemic. Read the full report here – Shooting the Rapids: COVID-19 and the Long Crisis of Globalisation.

Introducing the Long Crisis

The Chinese government first reported “cases of pneumonia of unknown aetiology” to the World Health Organization (WHO) on 31 December 2019. A week later, the new virus responsible for the disease outbreak was identified. Tightly connected global systems quickly spread the virus across the world, and by the time WHO declared a global pandemic in mid-March, 114 countries had reported cases.

Governments everywhere have scrambled to contain not only a public health emergency that could lead to millions of deaths, but also the biggest economic crisis since the 1930s. Below the surface, a profound political, social, and cultural transformation is also underway. 

The signs of strain on both decision makers and the public are clear. As the crisis unfolds, people are struggling to maintain good mental health in the face of such wide-reaching upheaval, new inequalities are being created between and within countries, and government officials are left playing what “feels like a game of whack-a-mole”. 

Meanwhile, in the midst of a pandemic that pits all of humanity against the virus, we face decisions at both local and global levels about whether to act in self-interest or in the collective interest. 

This is the world in the age of coronavirus, the latest in a series of shocks typical of the “long crisis” of globalisation.

A decade ago, in Confronting the Long Crisis of Globalization, we warned of a turbulent period for globalisation in which risks would spread and multiply across borders just as rapidly as opportunities. Now, as we prepare to face the global risks presented by COVID-19, we are building on that first piece to explore what we do and don’t yet know about the crisis, set out a playbook for collective action, and present a plan for international co-operation.

Shooting the Rapids: Key Findings

Today, as we find ourselves in an especially perilous stretch of the river, the metaphor of  ‘shooting the rapids’ is more relevant than ever before.

As we navigate the whitewater of a major systemic crisis like COVID-19, there are many routes we can take, but it’s still the river – not us – that decides the speed and direction of travel. There’s no chance to pause, rethink, or reverse direction; the threat of capsizing looms; and above all, it’s essential that everyone paddles together.

Layers of Change

The coronavirus outbreak marks a turning point in the 21st century. If the world that existed in the wake of the disastrous invasion of Iraq saw us at “a fork in the road” – in the words of Kofi Annan – then seventeen years later, we are on a razor-sharp knife-edge. 

In our report, we identify three layers of change that make up the greater COVID-19 emergency, each one unfolding at its own speed.

First, there’s the initial phase of the public health emergency, likely to last at least two years. We may have learned a lot about COVID-19, but many public health decisions are still surrounded by uncertainty, as much for those making them as for the public witnessing their effects.

The way in which the pandemic continues to unfold will be determined by many different factors, ranging from (poorly understood) fundamentals of epidemiology and governments’ effectiveness and legitimacy to patterns of inequality. We also don’t yet know how other shocks – heatwaves, conflicts, natural disasters – will be impacted by the pandemic.

The second layer is the economic crisis, which could last five years or more, and the impacts of which are still largely hidden to us. Bailout packages have been large and innovative, but it’s likely that governments will struggle to protect people as growth evaporates, supply chains erode, and systemic pressures build. 

For us, this raises two key questions. Can governments support their citizens in the short term while building a longer-term foundation for reset or recovery? And who will ultimately pay the greatest costs: younger workers or older investors?

Lastly, there is the social emergency, marked by polarisation and insecurity, that could last for a generation. Governments entered this crisis with already polarised societies and depleted levels of trust, and with many poorly led and coping with high levels of inequality, grievance, and populism, tensions are rising and fragility is spreading.

We do not yet know whether a democratic model for containing the virus will emerge, whether the wave of local mobilisation will be sustained, or if rifts between generations will widen or heal.

Playbook for collective action

Millions of lives, billions of people’s futures, and trillions of dollars depend on whether we opt for the ‘Larger Us’ approach to the crisis or polarise into ‘Them and Us’. It’s clear that collective action will be essential to effectively fighting the pandemic, but first, we need to lay the groundwork.

To promote collective action, there’s much to be done: enforce rules proportionately; confront the new inequalities that have emerged from the crisis; tell a story of hope rather than of tragedy; defend the facts; create consensus around solutions; build innovative partnerships and, perhaps most crucially, give everyone a role in the response – to once again employ the metaphor of shooting the rapids, the direction of the boat depends on the combined efforts of all those on board.

Plan for international co-operation

When a crisis is as complex as the COVID-19 pandemic, our strategies for fighting it need to be agile and flexible. Even so, we know that an action plan for international co-operation should have four main dimensions.

First, the international system needs to firefight better, getting the emergency response right to build hope that the most urgent problems can be overcome. 

Second, it needs to make societies and people feel more secure, not only to defuse risks of violence and conflict, but to create the psychological conditions needed to support collective action. 

Third, the critical global infrastructure must be protected, identifying the forms of global co-operation that we absolutely cannot afford to lose, and then defending them like our lives depend on it (they do). 

And finally, we need a new deal for a new generation, protecting the future of children and young people through education, jobs, and climate protection.

Whatever uncertainties we face as we navigate this crisis, one thing remains clear: it’s our capacity to act collectively that will determine our fate, and in the choice between adopting a ‘Larger Us’ approach or polarising into a ‘Them and Us’, the stakes are incredibly high.

One choice ushers in a breakdown, with sky-high infection and death rates, savage economic impacts, and people turning on each other just as the need is greatest to work together; the other, a breakthrough, where the toll of the pandemic is still heavy, but our capacity for collective action grows. These are the two futures we currently face – which one will come to pass is up to us.

To explore our findings in more depth, read the full report here – Shooting the Rapids: COVID-19 and the Long Crisis of Globalisation.

Wrapping Up Local Week

Wrapping Up Local Week

At the beginning of this month, in Building Trust, Confidence and Collective Action in the Age of COVID-19, we discussed the incredible potential of local communities as part of a wider plan to harness the “Larger Us”. 

That initial call for collective action has taken on new life during our Local Week series. Throughout the week, we’ve shared insights from leading thinkers on public health, policy, community empowerment, local politics, urban planning, and more, each exploring the effects of the unfolding coronavirus pandemic at a local level – you’ll find them all below.

The Next Wave: COVID-19’s Hunger Crisis

Much coverage of the ongoing global crisis has focused on what has already been done wrong, ineffectively, or too late. In The Next Wave: COVID-19’s Hunger Crisis, Rahul Chandran and David Steven make a plea for looking away from the rear-view mirror and instead making every effort to get ahead of the next wave before it, too, becomes a crisis.

Identifying the threat of widespread hunger as the next great impact of COVID-19, Rahul and David share actions for governments, big civil society, the food industry, and communities themselves to ensure that food continues to make it the last mile to where it’s needed.

Read the article

Typologies of Change

“As we begin to look forward to the world that emerges out of this crisis, there are three types of changes to consider. Each will need to be approached in a different way, using different tools and techniques.” So writes Elle Dodd in Typologies of Change, as she outlines the novel, evolving, and visionary changes we’re already witnessing as the pandemic unfolds, and what we can expect to see after the initial crisis has passed.

She asks: what is new that we want to keep hold of in the post-pandemic world? What has changed that we’re not yet happy with, the things that we once didn’t think possible but now understand to be malleable? And what are the things we now know we want to do differently, but aren’t yet able to?

Read the article

Learning from the Lockdown to Build Back Better

In Learning from the Lockdown to Build Back Better, Clare Wilks uses her hometown of Bristol, UK, as a case study for how our future towns and cities could better serve those who call them home.

Having witnessed both the positive effects of lockdown on her local area – a growing sense of community, the adaptiveness of local businesses, the reclaiming of street space by pedestrians – and the negatives – unequal access to green open spaces, overstretched food banks – Clare explores how the way we eat, move, and socialise now could provide a template for the future planning of less congested, more accessible, and more equal urban spaces.

Read the article

Respond and Renew: The Work of Local Trust

In the weeks since our article for World Politics Review, we’ve seen community groups all over the UK harnessing the power of collective action, organising, collaborating, and acting rapidly to ensure ongoing support for the most vulnerable at a local level.

In Respond and Renew: The Work of Local Trust, Jessica Wenban-Smith, Head of Communications for Local Trust, reports on the Trust’s Big Local areas and what we can learn from them, both those that have been able to step up and adapt and those that need more support to weather the COVID-19 crisis.

Read the article

Dying on the Home Front

In Dying on the Home Front, Professor David Bloom and David Steven discuss the hidden home deaths that have already begun to occur as the pandemic unfolds, and how these undercounted and often misreported fatalities could be skewing what we think we know about coronavirus.

As we face the ongoing challenge of fully understanding where COVID-19 kills and why, David and David explore the many reasons that people are dying outside hospitals – whether in their own homes or residential care facilities – and call for a serious attempt to better understand and prevent home deaths.

Read the article

After the Virus: Ensuring No Community and No-One is Left Behind

For Cambridge city councillors Alex Collis and Anna Smith, poverty alleviation is an ongoing challenge, frustrating to navigate in the most ordinary of times, but exacerbated further by the coronavirus outbreak.

In After the Virus: Ensuring No Community and No-One is Left Behind, they contrast the swiftness of community action in response to the outbreak with ineffectual national schemes aimed at tackling food poverty, highlight the need for structural change, and explore a new strategy for continuing to support those who have been in need, are currently in need, and will continue to be in need after the initial crisis has passed.

Read the article

Unnoticed, people are dying on the home front

Unnoticed, people are dying on the home front

This article is part of our Local Week series, a collection of articles focusing on the challenges facing communities as they confront the fallout of the COVID-19 pandemic. You can find the other articles in the series on our Local Week page.

People are infected with and dying from COVID-19 in three settings. In hospitals. In residential care facilities and other non-medical institutions such as prisons. And at home. With health systems under great strain, they are also more likely to die from other causes. To date, no serious attempt has been made to understand and prevent home deaths.

Reverse Pyramids

The World Health Organization advises that “all laboratory confirmed cases be isolated and cared for in a health care facility.” 

Given pressure on health systems, it accepts that not all patients can be admitted to hospitals, advising that patients with “mild illness and no risk factors” should be “isolated in non-traditional facilities, such as repurposed hotels, stadiums or gymnasiums.” If necessary, however, it recommends that patients should be isolated at home.

This guidance is based on four implicit assumptions drawn from experiences early in the pandemic:

  • Most infected people are in contact with the health system unless their disease is very mild or asymptomatic.
  • Most severely ill patients are in hospital.
  • When managing mild or moderate cases outside hospital, prevention is the primary objective – WHO says that “isolation to contain/mitigate virus transmission should be prioritized.”
  • Patients or family members can get help if they need it, by monitoring symptoms and “return[ing] to a designated COVID-19 hospital if they develop any worsening of illness.”

WHO illustrates these assumptions with pyramids for the severity of the disease and for resource requirements. 80% of people have mild or moderate symptoms. They need little medical support. 20% of people have a severe or critical illness and need intensive inpatient care.

Source: World Health Organization

Hidden Deaths at Home

These assumptions no longer match what is happening in the real world:

  • Most infected people have not been tested or do not know they are infected. A large, but unknown, proportion have not had any contact with the health system.
  • People at home may have severe symptoms and many are dying.
  • There is a substantial unmet need for healthcare in people’s homes.

The evidence to back up these assertions is fragmented but increasingly compelling. In Italy, for example, the government’s working assumption is that only 10% of infections have been detected. Certainly, many infections have not been reported, as the country’s crude case fatality rate is currently at an implausible 25%. In New York, early studies show that 15% of people have been infected, well above the number of confirmed cases.

Deaths are also being missed. The Economist sampled municipalities in Lombardy and found that excess mortality is more than double the confirmed number of deaths. In Spain and France, excess mortality was 60% higher. In the UK, mortality was 60% higher than for the corresponding period in 2019, with the number of excess deaths 76% higher than the number of officially registered COVID-19-related deaths.

In the United States, autopsies in a single county in California belatedly detected three home deaths – the first from February 6, three weeks before the first death was officially recorded. The first American to die of the disease was a 57-year-old who believed she had recovered from a bout of flu before dying suddenly. One New York hospital reported a sevenfold increase in strokes among patients below the age of 50. Two patients had delayed calling an ambulance. All tested positive for coronavirus.

Many people are dying in care homes and in other residential facilities. Analysis in five European countries suggests that “care home residents have so far accounted for between 42% and 57% of all deaths related to COVID-19.” In Madrid, 3,000 people died in care homes in March, double the normal rate. Prisons have a growing number of both reported and undetected deaths.

But a significant proportion of COVID-19’s hidden deaths are at home. In the UK, deaths at home have grown rapidly (see chart below) and few deaths have COVID-19 on the death certificate. In New York City, home deaths are being undercounted, but emergency calls because of cardiac arrests have quadrupled with fatalities increasing by a factor of more than six. In Massachusetts, the number of home deaths in March 2020 was 32% higher than the 20-year average for the month.

Source: Financial Times

Understanding Hidden Home Deaths

We know very little about deaths at home. 

In part, this is because “the virus acts like no microbe humanity has ever seen.” The picture of how COVID-19 kills is more complex and poorly understood than many realise. As well as the classic picture of a critically ill patient needing ventilation, there is growing evidence of impacts on the heart and cardiovascular system, on the liver and kidney, and on the brain and central nervous system. As a result, seriously ill people are slipping through. 

But we know even less about where COVID-19 kills and why. Clusters of infections are patiently being traced through communities, but we have found no equivalent collection of case histories of people who have died or become seriously ill from COVID-19 when at home. Instead, we must rely on scattered media reports to gain some sense of what is happening.

In Michigan, Gary Fowler, 56, had been sent home from the emergency room three times. He died on a recliner at home. Alessandro Bertuletti had been prescribed a painkiller and a course of antibiotics. His wife finally persuaded an ambulance to come. He died five minutes before it arrived. Jarrod Sockwell died in his bedroom in Brooklyn. 

A striking number of health and care workers have died at home. The British nurse, John Alagos, 23, died after a 12-hour night shift. Elsie Sazuze, a 44-year old care worker originally from Malawi, caught COVID-19 in a British care home and died two days after she was sent home from work. In Montreal, Victoria Salvan, an orderly, was sent home with a fever and found dead two-days later. 

These reports, of course, tend to include only those who had been diagnosed with COVID-19, so they only tell part of the story. But we surmise that people are dying outside hospitals for one of the following reasons. 

  • As they get sicker, people do not seek hospital care when they need it. One patient in his mid-50s describes being too weak and confused to know what to do. The virus itself seems to be causing neurological complications that may weaken decision making.
  • They are sicker than they realise or have atypical symptoms. One report suggests that some COVID-19 patients have critically low blood oxygen levels without showing obvious signs of distress.
  • They seek care but do not get it, either because health systems are overwhelmed or due to inequities in healthcare provision.
  • They do not want ventilation or other aggressive medical interventions that have a high risk of failure and often lead to lifelong disability. In countries where doctors are calling elderly patients to record their treatment preferences, this could lead to some believing they “will not be welcome [in an] intensive care unit.”
  • They are afraid to go to hospital or do not want to leave family members who will be unable to visit them.
  • They do not get the healthcare they need for other illnesses, which makes them more likely to die from non-COVID causes (18% of Italy’s excess mortality may be from non-COVID causes).
  • They are dehydrated and malnourished due to the severity of their symptoms (incessant coughing, for example, or diarrhoea) or because their sickness makes it impossible for them to buy food.
  • Illness, the lockdown, or economic factors leave them unable to access food or other care. Even in a rich country such as the United Kingdom, 1.5 million people report having gone a day without food in the first three weeks of lockdown.

Learning from the Past

Some may find it implausible that such large numbers of people can die unnoticed. It is not. More than 40,000 Italians were reported as infected before mayors of small towns rang the alarm about unreported deaths. In just one commune, more than 90 deaths had been missed – three times the official toll. 

Hidden deaths have been seen during other emergencies. In 2003, a heatwave hit France. In Paris, 15,000 people died, most of them old, of what Richard C. Keller has dubbed “fatal isolation.” According to Keller, old people were at risk not just because they lacked physical defences against the heat, but because they did not have the social networks they needed to survive.  

“Many of the heat wave’s elderly victims died alone from severe dehydration in tiny, boiling hot apartments,” he has argued. “Neighbors were alerted to their deaths only after a horrifying stench emerged from behind their locked doors.” 

Past pandemics also show the danger of concentrating only on prevention and allowing care to be squeezed out. In 2000, we called for a pivot to treatment for the millions of people who were by then living with AIDS. In a special issue of Science magazine for the 13th International AIDS conference, we quoted the pioneering Ugandan AIDS doctor, Peter Mugyenyi: “The medicines are where the problem is not, and the problem is where the medicines are not.” 

“Old people were at risk not just because they lacked physical defences […] but because they did not have the social networks they needed to survive.”

HIV/AIDS had spread globally but sophisticated medical care was the preserve of more educated and wealthy patients in rich countries. The world’s poor had only been given prevention. They were asked to practice safe sex but could not find treatment if they became sick. A global effort was needed to provide “care tailored for the poor and marginalized, where treatments are chosen to transcend, as far as possible, the limitations of delivery systems.” 

We now need the same shift for COVID-19. The pandemic has triggered a surge of collective learning by critical care doctors. Belatedly, efforts are now underway to raise standards in care homes and other residential settings. But there is no equivalent effort for people who are sick in their communities. It is all quiet on the home front. 

We are aware of no government that has an action plan for stopping people from dying at home. Innovations are piecemeal. For example, a pilot program in Cleveland, Ohio equips moderately sick people with a remote sensor that measures their oxygen levels. After they are sent home from the emergency room, doctors are alerted if they need urgent treatment and can call them back to hospital. The sensors can be bought for less than $50, and there may be a role for them as part of the home care response.  

Technological fixes of this kind are laudable but will be hard to scale up. More than 1.5 million people are now reported to have a mild or moderate illness and the true figure is likely to be at least an order of magnitude higher. The pandemic will continue to grow rapidly and to spread in countries where the weakness of health systems means that most patients can only be treated at home or in their communities. 

“More than 1.5 million people are now reported to have a mild or moderate illness and the true figure is likely to be at least an order of magnitude higher.”

We therefore need an urgent and ambitious effort to understand why people are dying at home and how these deaths can be prevented. As with HIV/AIDS, a hospital-centric approach must be supplemented by a community model that addresses all layers of WHO’s pyramid, not just those who are visibly sick in intensive care beds. 

This mission should be guided by medical science but must be undertaken by an alliance of health workers, social workers, teachers, voluntary groups, local government officials, faith groups, small businesses, and other grassroots networks. It must address health needs, but also the need for food, income, and the other necessities of life. 

Local leadership is essential, with funding, guidance, and support flowing from regional, national, and global levels. And the approach must empower people themselves, so that family members know what signals to watch for when a relative is sick, neighbours look out for neighbours, and systematic efforts are made to track and trace people who are in trouble and alone. 

A People’s Science

The urgency of a more people and community-centred approach will grow every day.  

As the pandemic spreads beyond high-income settings to the world’s poorer countries, a focus on care and prevention in communities and in homes will become ever more important. Most developing countries are either in the earliest stages of their epidemic or may have large numbers of hidden cases as most infected people shelter at home.  

As with HIV/AIDS, COVID-19 stigma is a growing problem, deterring people from seeking care. Hospitals and health centres in many low-income countries struggle to cope with their populations’ health needs during normal times. During a pandemic, it will be impossible for them to provide intensive care to more than a small proportion of those infected, and most of those in need of care will inevitably have to be treated at home or isolated in non-healthcare facilities in their communities. 

But poorer countries – especially those with recent experience of epidemics – have much to teach the world. The horror of the 2014 Ebola outbreak forced the rapid evolution of what Paul Richards calls a people’s science. “Communities had begun to think like epidemiologists,” he writes, “and epidemiologists (in providing timely and relevant advice to local agents) had begun to think like communities.” 

What would a people’s science for COVID-19 focus on?  

First, investigating how people get infected in their communities and what changes with different types of restriction on freedom of movement and association. Second, exploring what happens when people get sick or die, especially when this happens outside of hospitals. Third, understanding how people seek and get help, whether for their health needs or for food or essential needs. Fourth, mapping the ‘backbone’ of the response to COVID-19 in communities (including unusual suspects such as funeral directors). And finally, understanding what knowledge, resources, and technologies are needed to make community resilience stronger, and how to deliver these in ways that are likely to be accepted. 

Here’s an eight-point action plan for bringing hidden deaths out into the open and preventing as many of them as we possibly can: 

1. Instead of seeing people with COVID-19 predominantly as disease vectors to be isolated, recognise their right to healthcare in their homes and communities.

2. Revise and disseminate WHO’s guidelines on home care for COVID-19 patients, drawing on emerging models such as the guidance issued by the UK’s National Institute for Clinical Excellence (NICE) or the community management systems being tested in the US.

3. Ask UNAIDS to share its experience treating HIV/AIDS and empowering people living with the virus to the COVID-19 pandemic and apply it to home and community settings.

4. Make home and community care for COVID-19 patients a priority in the WHO R&D blueprint and invest in a rapid programme of epidemiological and ethnographic research in community settings.

5. Agree national action plans for caring for COVID-19 in the community, with models appropriate for high, middle, and low-income settings that balance isolation with effective treatment.

6. Ask mayors, local councillors, traditional leaders, and community activists to lead this effort and provide the resources, training, and protection for them to be effective.

7. Build a global platform to monitor excess mortality data, building on existing initiatives such as Euro Momo.

8. As soon as data are available, set a target for reducing mortality from COVID-19 at home and in communities.