 Good morning. Welcome to Global Report. I'm your host, Lily, hosting live from Singapore. We have with us today Dr. Ben Roff, who is the CEO of the communicable, I'm sorry, communicable disease stress initiative. He's based in Singapore, is currently in Austria. Welcome to the show, Dr. Ben Roff. Hi. Dr. Roff, I would say right off the bat, that's not a lot of people for whom I will wake at 3am to do an interview. But I know with your vast experience in supporting health initiatives across 30 countries over the past 20 years, our viewers will benefit tremendously from listening to you. So press a good start by having you give us a little background on your remarkable career journey to get us better acquainted with you please. Sure. Well, I've been quite fortunate. I've been kind of on the road for the last 20 years. I've lived in seven different countries and worked in well over 30. And it's given me a pretty good breadth of experience of working in Sub-Saharan Africa, right across Asia, into Australia, also for the UK government. So I've worked with a lot of governments, a lot of countries. And that's given me a bit of breadth. I've also worked for the Australian Department of Foreign Affairs and trade as a senior health specialist there and also at the Asian Development Bank. So I've had a good exposure to the financing side of some of these challenges. Also the diplomacy side and a little bit on the technical side as well. So I've been quite lucky to have quite a broad exposure. That's truly impressive. Now, where you are now in Austria, I understand that along with Germany, along with Italy, they have started to talk about lifting the lockdown. Can you tell us what is like on the ground? Is it a calibrated step-by-step process? It is, yeah. I mean, we're really fortunate that both Germany and Austria moved very quickly. They had a great focus on testing, very good communications coming from leadership. And I think they've brought the population along with them in that. That's meant the lockdown has been very effective because people have been brought along with it. And so people have genuinely been off the streets. It's extremely quiet here. And now as we've seen cases declining, there's a very gradual unlocking of the city. So public transport is running again. People are allowed to use it. You see a few people on the streets still shopping for essentials and small things. Public gatherings and other things are still banned. But yeah, it's a gradual return to some economic activity. So as they start, you know, lifting aspects of the lockdown, what are some of the things they are looking at? Do they look at the RO? Do they look at the number of free vats in a hospital? It's all of that. Yeah, of course, we're trying to assess the reproductive rate. But without very widespread testing, you can't be completely sure of that. And of course, you have to remember that the people you're testing are people that are symptomatic, which means that they actually got sick quite a few days ago. And we're probably transmitting the virus even a couple of days before that. So your tests today give you a snapshot into the past. They tell you where you were maybe 10 days ago. That's why we have to wait quite a long time to see the impact of the interventions. But now we are seeing cases go down. We're seeing some pressure being taken off intensive care facilities. And so that's allowed some relaxation of the measures for now. But of course, this is a very long game. Most of the populations still don't have any immunity. And this will continue for some time. Now, as you mentioned, indeed, Germany has been larger for its efforts for its management of the virus. Its mortality rate seems to be lower than its European counterparts. Italy, on the other hand, had once been the epicenter of the pandemic. Its first confirmed case actually had zero contact with China. What is that signal to you when your first confirmed case has no contact with China? Well, I think the first thing you have to understand is our visibility into where cases are coming from and how many cases we have are extremely limited. So you know, we we don't have serological testing. We don't know how many in the population have been impacted. We're looking at this problem through a very narrow window, only seeing the people who have presented with a sickness who have been tested. And so there are many people that may have been missed. And when exactly the first case and where it came from is not so relevant, because of course, we don't necessarily know if we've seen all cases. What is certainly true is that Germany moved very quickly. They put in social distancing measures quickly, they rolled out testing very quickly. So they had very good visibility of their own epidemic. Italy, and to be fair to Italy, of course, they were one of the first countries in Europe to be affected, didn't move as quickly, and unfortunately suffered the consequences. And I would like to point out to that Italy does have certain unique demographic differences too. They do have a more elderly population, is that correct? Yeah, that's correct. They have a more elderly population and also more comorbidities, more obese people, people who may be suffering from diabetes and other things that suppress their immune system. But I think it's also important to underline how little we understand of this virus. You know, we've been looking at what happened in Wuhan and extrapolating from that to try and understand, but we are really learning by doing. So we can't really pretend to have a full understanding of why this epidemic is playing out so differently in different contexts, compare New York with other parts of the US, for example. Now, what about leadership wise? I know that when Italy first started introducing the social distancing measures, on one hand they're saying, okay, these are the measures, on the other hand, they're also encouraging the people to keep the habits, you know, just hold on to your habits. And even the mayor of Milan was coming out saying that he was doing a campaign. I think it was titled, Milan doesn't stop or something like that. So there was different messaging coming out from the Italian government. Meanwhile, on Germany's side, it's pretty consistent. You have Chancellor Angela Merkel came out and she was very clear on what needs to be done. Do you see a vast difference between the leadership too, between the two countries? Absolutely. Well, there's a vast leadership divide across the world and we saw Boris Johnson in the UK boasting about shaking hands with COVID patients. We've seen Donald Trump in the US surrounded by advisors with very little social distancing right from the beginning of this. You know, the populist leaders have taken maybe one tack with this and others like Angela Merkel, who is of course a scientist, has taken a much more measured and maybe slightly more constructive approach. And I think that has also played out in government's response to the crisis, undoubtedly. Yeah. Well, talking about the US, which is now the epicenter of the pandemic, I think even as the American president continues to toot his own horn on how he's been handling the crisis, the management, it has been nothing short of a disaster. What do you think was the biggest recipe for his disaster? Well, I mean, again, you only have to look at the cases to see that the US have a major crisis on their hands. This is not a partisan approach. You can really just see the data that the US are really struggling. And if you look at the leadership style, I would say that, you know, if you compare, for example, Singapore, where I've been based for the last three and a half years, the leadership style has been very measured and very consistent. And they've brought the population along with them. And that is something that really has not happened in the US. You know, during a crisis like that, a crisis like this, people really need consistency from their leaders. They need a factual basis for information. There needs to be a degree of trust built up in the leadership. And Singapore were very careful to have a single message. This was repeated through all organs of government, not just the Prime Minister. But the Prime Minister did come out with an empathetic, sincere approach to communication, evidence-based, factual, calm. And it brought the population along with them. We've also seen the same in New Zealand, the same from Germany. I think it's fair to say that is not what we've seen from the US leadership. When you mentioned trust, this is something that's not built overnight. But the crisis is here. It's here in United States. How can they go forward? Well, I think there's a lot of basic communications practice that they can learn from. You know, crisis communications. How do you build trust? How do you make sure your messaging is consistent? Also pushing experts out front. You know, people will trust people that have expertise. We know that our leaders, be they populist or otherwise, are not epidemiologists. They're not public health specialists. It is better for them to push out leaders who can speak authoritatively and from a subject matter expertise. But also, I would really like to see more diversity in the voices that we're seeing. More people of color, more female scientists, more female leaders. You know, we're really seeing, unfortunately, and being a white middle-class man myself, you know, we're seeing too many of faces like mine in the media. You know, we really need to see more diversity and also have a better understanding of the diversity of experience. You know, this is a disease that does not affect everybody equally. Older people, poor people, people of color, are all experiencing the brunt of this crisis. And I think we need to see more voices from the communities that are affected. That just kind of cast a glum over United States because we know President Trump tends to just listen to his inner circle. He has this inner trust circle that he listens to. The only people that he listens to. So is there no hope for United States? Well, there's certainly hope. You know, I'm very hopeful that we will get on top of this crisis with enough testing, keeping on with our social distancing measures and making sure that we're consistent and we take an evidence-based approach. Then we will get out of it. You know, it'll be a long haul, but we have to base our response on evidence. It is not okay for leaders to make unilateral declarations around reducing the lockdown if it is not based on evidence and the public need to be holding their leaders accountable to make sure that they will not accept dangerous decisions. Decisions need to be based on evidence and that means a slow and careful relaxation of lockdown measures based on good data, good testing. Now, currently in the United States, there's a lot of protests. There's actually people protesting against the lockdown. How do you deal with those group of people? Well, again, this has its origins in the degree of trust that you have between the nation-state and the population. And again, coming back to Singapore, this is something that Singapore have really focused on for many years. You know, the Prime Minister speaks all of the major national languages of the country and addresses them directly in their own language on social media and national media. He's empathetic. He's evidence-based. You know, he has brought the whole population along with them. And you know, Singapore now has a crisis on its hands from 30, 40 cases a day for the last few weeks. We're now seeing today one and a half thousand cases. You know, their cases have doubled in just the last three or four days. So they are really in crisis, but they have laid the foundations. They've built public trust. And there are no demonstrations on the street in Singapore. The population are at home. And you know, I think the U.S. can learn a lot. I believe you are talking about the outbreak in a foreign workers dormitory. That has been a ticking bomb. And to that, I will say that it wasn't oversight, I think, on the Singapore government. But like you said, they have the infrastructure in place to tackle it no matter what. Now, we cannot talk about United States without talking about China. We know the two superpowers have been trading in soils. China has, U.S. has been accusing China of not disclosing information in the early days. And even the WHO has not been spared. They have been accusing Dr. Tadros, who is the director general at the WHO, of sort of conspiring with China on this. What are your thoughts about that? Well, it's interesting. I mean, we have to remember that President Trump was praising the Chinese premiere in the early days and lauding his comprehensive response. So there's certainly been a change of tune from the leadership in the U.S. And I think this game of past the crisis, which any government can play, is just profoundly unconstructive. You know, we need to focus on the facts. You know, we had an outbreak in China. It spread around the world. Public health professionals like myself and others have been warning the world for many, many years that this was going to happen. It was only a matter of time. Where it emerged is now a historical artifact. China moved incredibly quickly. They mobilized 40,000 health workers in days. They built 50,000 beds in days. It was an extraordinary response in China. And if other countries had moved that quickly, we frankly wouldn't be in the mess we are now. So it's right to scrutinize the response from China and others that all leaders and countries should be held accountable. But we do need a constructive approach. You know, what are countries doing now? What are their figures telling us? Do those figures indicate success or failure? You know, I'd be looking at the data right now. Yeah. I don't think I know of any other country that can build a hospital in a matter of two weeks. Now, Dr. Roth, tell us what do you know about Dr. Tedros? Well, you know, the World Health Organization has a critical role in this. And, you know, Tedros was elected just over a year ago. Popular vote, you know, member states have a vote and have a say in who they elect. Now, of course, there's a lot of backroom bargaining between nation states to decide who gets this role. It's a high status leadership role in in the public health world. You know, Tedros has been a minister in multiple departments of government in Ethiopia who's extremely experienced. And he immediately said about reforming the World Health Organization, which has frankly been underfunded and neglected for many years by all member states. You know, they're working on a very, very small budget, tiny compared with the U.S. Center for Disease Control, for example. And he said about very significant reforms. So, you know, I think he's been an impressive leader, probably the strongest leader we've seen in WHO for 20 years. Do you think that the fact that he is the first African has been elected in the post, do you think that sort of bring on some bias against him too? I think there's actually a deeper, deeper reasons behind this. You know, when there's an election at any multilateral institution, be it the World Bank, the IMF, WHO, nation states are always vying to get their person in the top job. It's completely normal. They put money into these institutions and they hope that their man or woman gets to lead it. That is the way of the world in multilateralism. Tedros was not the U.S.'s guy. He wasn't the guy that they were lobbying for. And so I have no doubt that there are some people in the U.S. administration who saw that they didn't get their guy. I'm not sure it's on racial lines. I think it's much more about multilateral politics actually. Now, Dr. Tedros himself is, it's not a man without a controversial past, either. As you mentioned, he was the former Minister of Health and also the former Minister of Foreign Affairs. I understand that when he was former Minister of Health, he was involved in this alleged cover-up of three collateral outbreaks. Are you acquainted with that? Are you aware of that? I'm not familiar with it. I mean, I would say that it's undoubtedly, it's inevitable that when people get into these leadership positions, when they're contested and certainly in a crisis, it doesn't surprise me at all. That there would be people digging up potential things from the past to try and undermine leadership. It doesn't seem to me constructive in a crisis. If you look at his track record at WHO, he's put some of the most skilled people back out to the front lines. He's created a new chief scientist position to build links with academia. He studied reforms to the HR and hiring structure, rapidly hiring stronger people. He actually set up a department of emergency preparedness in May last year, way ahead of this crisis. So, you know, my focus is really on the near term and what has he done in terms of his leadership leading up to this crisis and in a crisis? I have to say it has been impressive. Now, I know that Mr. Trump may very well be deflected blame for his own miscarriage. But as you mentioned, the WHO does have its own structural problems after it relies on information that's given to it by its members. So it works with whatever it has. So to that extent, it's sort of limited, isn't it? Yeah, of course. I mean, member states will always be very cautious about sharing data. This is true of all member states and it's been a major battle with the World Health Organization to encourage companies to countries to share data. But the good thing is that we have the international health regulations which were 10 years in the making. Countries do not like giving up sovereignty to outside actors. And so it was a victory to get this agreement which defines what is the role of WHO and member states when we have a crisis like this. And so we are seeing data sharing. We are getting reasonable visibility. But to be honest, I don't believe the constraint is in sharing data with WHO. The big constraint we have is countries not testing sufficient numbers of their own populations. That is the major challenge. I think it's an act of deflection on the part of member states to focus on WHO. This is about countries testing. And you know, Germany has been doing an extraordinary job. UK and the US, certainly less so. What about adequacy of test kits? Could it be that the countries, their hands are just tight because they couldn't get their hands on sufficient test kits? Well, does WHO play a part in getting the test kits to where they need to be? Yeah, WHO has an important role. Certainly for lower income countries, they have a role in distributing test kits. They also have a very important role in defining standards for tests. But I think the real challenge we've had with tests beyond the supply chain constraints is that when we knew this was coming in late January, the world did not mobilize. And the US particularly chose not to use a WHO test and to do their own test, which of course we know was beset by problems. And the US was very late coming into the game in terms of testing. But again, the main challenge now is countries doing sufficient testing. The sad fact is that there was a lost six weeks where countries failed to mobilize despite every headline being about what was happening in Wuhan. That was the point that countries should have been manufacturing test kits, getting them out into the front line and it didn't happen. Now, as you mentioned, the WHO has to do a lot with very little. And it depends on funding on its members. So I think too that it will think twice before it picks a bone with its member state, especially the big donors. And United States know this. They know they are the biggest donor and they know they have leverage for this and they are putting this to full use right now. So they have cut funding to WHO. Where are they now? Is it possible to get them back on the table? Well, my understanding is there's still some debate around whether President Trump has the authority to cut that funding. But I think the critical point is that the US have a very strong interest in a strong world health organization because although the US have the capacity to manage their own crisis internally, US CDC and an extraordinary academic strength, this is a global problem. And unless the globe tackles this simultaneously, we will have more cases coming back in and infecting the US again and again. And many low income countries are wholly dependent on the world health organization for guidance and technical expertise. You know, if Bangladesh doesn't get support from the US, from the WHO, the US is at risk. So, you know, it's short-sighted to defund an organization that the whole world is depending on. No one will benefit. And in fact, everyone will suffer. This is quite different from other diseases you've dealt with. I know you are a malaria expert. That seems to be confined to the, you know, primarily to the African continent. So do you think this is a sort of a civil lining and then this COVID-19 is that it's no longer just a problem of a certain region, but it's actually a global problem. It's actually an opportunity for us to come together in global solidarity. I think that's a really important point. You know, we have countries that spend like Afghanistan $18 per capita per year on health. India maybe $45 per capita. You know, you cannot buy a healthy population for that money. And you cannot buy a healthy world for that money. You know, it is inevitable that where you have large populations in poverty, crowded conditions, no access to adequate health services, you will get not only a humanitarian disaster, not only suboptimal economic growth, you will also get outbreaks of disease that affect the whole world. And I think this has started to shine a light on that issue. I think the tragedy is that as this crisis unfolds and we see this disease moving through countries like India, Bangladesh, Nigeria, we're going to see a real humanitarian crisis potentially. And again, that is because we have as a world under-invested under-invested in health services and the well-being of those populations to all of our risking all of our well-being, in fact. Now as the virus it has made its way to Africa but as it, you know, come on full blast in Africa, are we doing anything there to sort of softening the blow softening the impact upon the populations there? Just yesterday I was watching a report the people were not thinking about the virus just you're thinking about food security. We have people in queues within just centimeters from one another trying to get a hold of the food donations. So how can we better help those people out there? I agree. This is a real problem and it's not just the epidemiology of course. We have, you know, a disease that we don't know what the transmission dynamics are in sub-Saharan Africa there's not enough tests to give us visibility. So firstly we have this horrible situation that we don't actually know the scale of the problem. But then we have a huge amount of economic vulnerability as you say and many of these countries are reliant on primary commodity exports that are now not being exported demand that has evaporated. And so, you know, we risk seeing a very a multifaceted crisis that is both economic and public health. And a very limited global capacity to respond certainly from the global north there are very few experts traveling around providing support to government. Many governments are struggling with debt repayments liquidity crisis. So we have a really multifaceted crisis impacting low and middle income countries in both Africa and Asia at the moment unfortunately. Now since the first time you went into Africa fast forward to today have you seen much improvement pertaining to all these barriers to healthcare? Really extraordinary improvement actually. Yeah, I mean I first worked in Tanzania in 2002 and I've worked all over sub-Saharan Africa certainly East Africa and a lot of time in Nigeria. We've seen maternal mortality reduce dramatically. We've seen a halving of child deaths from malaria. You know, we've really seen some extraordinary progress and I think it's proven that when we do invest relatively modest funds on a kind of global scale we see extraordinary gains but it's not enough. You know, and ultimately we need to be looking at the investment per capita and it's still peanuts frankly in many sub-Saharan African countries way less than $100 per capita per year. You cannot buy good health for $100 a year per person. You just can't. That's such a tragedy. No, Dr. Raap before we go I'd like to pick your brain on herd immunity. What are your thoughts on that? Well, I think the responsible answer is we really don't know. Firstly, the idea that herd immunity can be used as a strategy is completely false at the moment. You know, the idea that even the UK government announced that they were going to take this on the chin and let this run through the population made no sense. We didn't have a sufficient understanding of the disease and we still don't to understand the immunity that infected people gain. So firstly, herd immunity as a strategy makes no sense. The extent to which we will ultimately become immune to this and transmission will be interrupted is impossible to know. We know that with other coronaviruses there is some immunity. We know there's some cross immunity conferred by coronaviruses. In many cases it seems short lived but the truth is we just don't yet understand the immunity dynamics sufficiently to make a judgment call. That means we need to be sheltering in place reducing the transmission rate until we can get a better understanding of the dynamics both of transmission and immunity and get further forward on a vaccine. Now you are then Europe and I know that Sweden is deploying this strategy. How is it working out for them? You know, I think it's too early to tell. Sweden is a very unusual European country and it's really impossible and actually unwise to start inferring what's happening in Sweden and making judgments around strategy. You know Sweden has a very large number of people living alone for example. They are naturally potentially in terms of the dynamics. It is reasonable to assume there may be a lower natural transmission rate for various social reasons in Sweden than elsewhere. So I don't think we can infer too much unfortunately from the Swedish approach at this point. Awesome. All right Dr Ruff on a cautiously optimistic note I believe there is a way forward and what do you think is the way out of this virus not just for one country or one region but for the whole world what is needed to bring all of us out of this crisis? Well firstly I think your point around solidarity is critical. You know we are all in this together and we will not get out of it until every country has a funded response and so whilst all eyes have been on successes and failures in Europe and North America we need to start looking at the developing world the four billion people that don't have access to healthcare you know until they are taking care of the world is not out of this crisis that would be the first thing. The second thing is that we need to invest in research we do not understand enough about the transmission dynamics at the moment we're using all of the weapons in our arsenal shutting businesses staying at home all of this social distancing we don't know what's the contribution of different aspects of these measures to reducing transmission which means we're doing everything perhaps unnecessarily so we need to rapidly ramp up research on social distancing measures transmission dynamics and then invest in finding a vaccine and get more testing you know if we don't know where the battle is we can't fight it effectively so testing is critical. I hear you loud and clear now I guess the next step is how do we get that message into every country and get them to come on board it seems like that's a sort of like a leadership how can we get everybody to come on board on that one platform? Well I think you know one really positive that we've seen from this is the role of social media you know academics are sharing their work online it's being peer-reviewed live on Twitter you know the potential for activism at a community level even if people are sheltering in place is extraordinary it wouldn't have been possible 15-20 years ago people can get behind leaders that are showing leadership get behind the World Health Organization and you know show leadership on people's individual Twitter accounts you know demand accountability from leaders that we believe are failing and get behind those people that are showing leadership and showing a path out of this crisis so you know people are uniquely equipped I think to engage in this crisis in a way that no one has been previously. Well thank you so much for that positive note with that I really want to thank you for staying up to do the interview and thank you for sharing your wisdom and your experience with our viewers thank you so much Dr Raab thank you Thanks Lily It's a pleasure Thank you