The director of the European region of the World Health Organisation has 900 million reasons to learn from the coronavirus pandemic. If being at the helm during the worst health crisis of the last 100 years has taught him anything, it is that no matter how hard we try, we cannot improve our response to pandemics without improving our approach to health as a whole.
The coronavirus pandemic will end. Though it has a taken a terrible toll, every pandemic from the Plague of Justinian in the 540s to the Spanish Flu of 1918 has taught us that there are perhaps only two certainties surrounding pandemics: they eventually end, and the latest will not be the last.
The problem now is that increasing globalisation and urbanisation mean the rate of new and different pandemics is likely to increase. Without serious change, we can expect to see many of the hallmarks of 2020 replayed. But where to concentrate our efforts? Mask wearing? Vaccine development? If we are to improve our response, we will have to do so by learning from the events of this particular epidemic. And to learn from the events of the coronavirus pandemic, we would do well to listen to the hard-earned wisdom of Dr Hans Kluge.
Dr Kluge is the World Health Organisation (WHO) Regional Director for Europe, having taken office only about a month before the coronavirus came crashing down across the 53 European and Asian nations – and the more than 900 million people – who fall under his charge. Instantly, his plans for his term of office were rent asunder, with priority given to a quick and clear response to the crisis at hand. Throughout the year, Dr Kluge and his team at the WHO/Europe have worked tirelessly to stem the tide of infection, to communicate the necessary measures to people across scores of different languages and cultures, and to fight the misinformation rampant in our connected age.
The pandemic has not yet run its course, but at this stage Dr Kluge is able to examine the role of the citizenry, WHO/Europe, and educational institutions such as KU Leuven in times of need. This is not a consideration of tactical matters such as whether to close playgrounds or what time to set a nightly curfew. To improve our response during the next pandemic, and to build a resilient society capable of withstanding the inevitable shock of future pandemics, we need an examination of our ability to respond effectively to whatever plague we must confront, be it bacterial or viral, airborne or droplet, novel or an old foe.
What is clear from listening to Dr Kluge is that health is far more than access to a hospital, a doctor or a vaccine; health is the totality of the way we live our lives. Health is the sum of the choices we make and the circumstances surrounding us that we may not be able to choose. It is dynamic and elusive, and needs to be pursued throughout the course of our lives, not only when we are ill. For Dr Kluge, we speak about the coronavirus in hindsight, but when it comes to real, resilient health, we talk with foresight and hope.
The one thing that the pandemic has taught us is that the poor and vulnerable get targeted disproportionately. This time it was the elderly people.
A university education has always meant more to Dr Kluge than simply earning a degree in a particular field. Born in Roeselare, Belgium, Dr Kluge first attended Kulak Kortrijk for his bachelor’s degree before making the move to KU Leuven for his doctoral training. From the outset, the attraction to KU Leuven was the emphasis on values. He chose KU Leuven deliberately for the Catholic values of the school, and specifically those of solidarity and equity. Despite this lofty starting point, university life was enjoyable for Dr Kluge. He enjoyed socialising and was in several student clubs, including the KVHV (Katholiek Vlaams Hoogstudentenverbond), and he found the camaraderie important, especially under the stressful circumstances faced by an aspiring doctor.
Today, Dr Kluge sees research universities as offering three pillars of value to society facing future pandemics: education, research, and social accountability. Education may seem an obvious pillar of a university, but what we study may not be. Interest in virology has exploded, but is this the best receptacle for the increase in public health consciousness?
For Dr Kluge, the answer to this question is simple. “Follow your heart. You have to follow your heart, because you’re not going to be able to sustain otherwise. Virology is an extremely important profession, but sometimes I see that the scientific advisors to the ministers are only virologists, and we need public health people who have a broad outlook.”
This idea that you cannot sustain your efforts if you do not follow your heart follows in lockstep with the most important tool Dr Kluge leaned in his own studies, something that has helped him get through the trials and tribulations of 2020: stamina. It was a lesson he learned from his own father, a former chief of surgery in Roeselare, and which was reinforced during his time at KU Leuven: “If you do medicine, you need to be able to sit on a chair for hours, to memorise, to structure, to analyse … so you really need stamina.”
Dr Kluge also implores everyone not to take this education for granted. An education at a world-renowned school such as KU Leuven is very cheap for the benefit it confers, a luxury that is not readily accessible to those living in developing nations. “I realised this afterwards. And that’s why, I always try – within my limitations – to give something back afterwards. Whenever I go to a county, I go to a university and I see how important it is for the students to tell them some stories, to fire them up, to show that the sky is the limit. I never thought I would get into this position, and now I have the opportunity to give something back to society. It’s very important.”
The research pillar may also seem obvious, given the emphasis during the coronavirus pandemic on developing new vaccines. This will certainly continue to be important going forward, but Dr Kluge notes that there are other medical benefits to university research, such as the development and improvement of diagnostic tests. More than simply expanding the medical toolkit, Dr Kluge sees promise in structural research models that promise large-scale benefits, specifically the utilisation of consortia in future research. “That’s something that we see more and more, [research] done not only at one university but conglomerates. If we want to continue to compete at the global and European level, this needs to be ongoing among universities.”
If there is one unexpected pillar in stemming future pandemics, it may be the third: social responsibility. Examples of this are the already extant programmes at KU Leuven that assist those in disadvantaged circumstances gain access to higher education. These may be training programmes carried out in other countries, or those that provide the necessary assistance to help students travel to and live in Belgium for their studies. One example of this latter kind is the scholarship funded by the Flemish Interuniversity Council and Belgian Ministry of Development Cooperation for students from developing nations to pursue the Master of Science in Water Resource Engineering at KU Leuven. No matter the method, further emphasis on these sorts of programmes will put the brightest minds in nations around the world in a position to manage future crises, wherever they may arise.
Yet social accountability can mean more than just delivering education. Dr Kluge recalls that students who had graduated and gone into international work could always count on KU Leuven for support in the field. In one instance, Dr Kluge was coordinating a tuberculosis programme in Somalia with Médecins Sans Frontières (MSF) when the UN pulled out in 1994. “I was completely isolated. Only MSF remained. It was completely dangerous, chaos, no rule of law or order. That’s typically when MSF goes in. And then, by hook or by crook, the university found a way to send me magazines, a medical journal and a news magazine, and this was very nice, a bit of normality. And then I had professors come to help me. I had a Professor De Kraemer, who used to be in charge of the Gasthuisberg campus of University Hospitals Leuven, help me to get front-line anti-tuberculosis medicines which I couldn’t get, they were too expensive.”
This, then, is the core of Dr Kluge’s message: a university is only as strong as its people. In this, Dr Kluge has his own advice for students, no matter what they study: read, read, read. As he says, “You stop reading, you stop writing, you stop thinking. Never stop learning, it keeps you sharp.”
Preventing health catastrophes
Flash back to late 2019. Dr Kluge is in the middle of his campaign for WHO Regional Director, traveling to all 53 member states and asking the health and foreign affairs ministers what they thought worked well in their experiences with the WHO regional office and what was faulty or needed to be abandoned. It gave Dr Kluge a deep well of information for later use, including the primary revelation that WHO/Europe has to have a country focus that achieves real results, not simply release theoretical proclamations or advice from an ivory tower at its headquarters in Copenhagen. Dr Kluge wins the election.
In February, Dr Kluge is appointed as Regional Director. He is more than ready to promote better overall health in all 53 nations under WHO/Europe by delivering real improvements on a country-by-country basis, an outcome dependant on a fundamental political question: What can citizens legitimately expect from their health authorities? WHO/Europe is a collection of wildly disparate nations, with wildly disparate cultures and governmental structures. The challenges seem overwhelming, but Dr Kluge is not dissuaded. In his career, Dr Kluge has been threatened with beheading by Charles Taylor in Liberia; he has worked in Russian prisons in Siberia; and he has lived under a military dictatorship in Myanmar. He has seen a lot. He is ready for the moment.
Dr Kluge rolls out the flagship programme for his term of office, the European Programme of Work 2020-2025: United Action for Better Health. The programme intends to deliver better health by focusing two goals. The first is to leave no one behind. This means achieving positive health gains for everyone, everywhere, no matter the level of development obtained in the country. The second goal is to empower national health leadership. This goal is intended to counter widespread public distrust in public health authorities, something Dr Kluge has encountered during his visits to nations across the region: “We see that the voice of the minister of health is still not heard in many governments.”
Achieving these goals requires action on three fronts. The first of these fronts is scaling up to universal health coverage. “This means that everyone has access to good quality health care, without being pushed into poverty due to ill health. Then, have two flagship programmes: digital health and mental health.” Digital health will put the tools of modern medicine in the hands of caregivers across the region, whilst attending to mental health will help end the stigma that degrades physical health.
The second front is to prepare people and regional authorities to better respond to emergencies. Unbeknownst to Dr Kluge, this front is about to be tested to an almost unimaginable extent. An examination of the programme as it was affected by COVID-19 was undertaken in September of 2020, and the stress test provided by the coronavirus revealed weaknesses in health delivery unanticipated only a year before. These were tragedies, but they are now also opportunities to fortify WHO/Europe’s approach.
The third front is to improve whole health and well-being. “It means making a paradigm shift from a curative system to a preventative system. If we want to live longer, we have the four big risk factors: alcohol, tobacco, inactivity and obesity. So, prevention, because I always say most of our ministers are ministers of disease, not health. They focus on the hospital system, when it’s already too late, so we need to move the health focus to the population.” These behavioural risk factors are called Non-Communicable Diseases, or NCDs, and they are perhaps the one aspect of health most within our control.
All of these fronts are meant to operate in a mesh of mutually reinforcing practices, ensuring that individuals – and the systems designed to take care of those individuals – are healthy and robust against shock. They are meant to address the risk of epidemics, but also the more quotidian threat of NCDs that take a devastating but quiet toll on European health. In short, they are meant to address a wide range of issues at multiple levels of governmental involvement.
Then the coronavirus hit, and Dr Kluge’s plans were almost entirely eclipsed in the public mind. But they were never permanently laid aside, and the desire to enact the programme remains. As vaccines start to come to market, Dr Kluge is incorporating the lessons of the past year into his vision of broader health for Europe. “I created a new health initiative: Behaviour and Insights. WHO is a bit too populated by doctors and nurses. We need behavioural scientists, anthropologists. What’s the biggest problem of COVID now? It is what I call “pandemic fatigue”, people are tired of restrictive measures. So you have to understand what’s in people’s minds, and what can motivate them to protect themselves, their parents and their grandparents. That’s the key issue.”
If motivating people to fight a pandemic is difficult, motivating them to consider their long-term health and well-being will be no easier. Yet that is a fight that we must win if we are to be better prepared when the next short-term crisis hits.
A more balanced response
Even with more robust general health, it is inevitable that a new pandemic will hit at some point. In the last 20 years, we have seen the rise of SARS, MERS, Bird Flu, Swine Flu, and so on down the line. When the next crisis hits, what should our response look like, in both the medical field and in society as a whole?
To begin with, our response needs to be more balanced. “I was speaking to the World Health Assembly, a gathering of the world’s 193 ministers of health, and I was speaking to them of the dual-track health system. The hospitals are swamped by COVID-19, and we’re not paying attention to the collateral damage. In some countries, breast cancer mortality will increase by 10%, colon cancer by 15%, but screenings have stopped for breast cancer, for colon cancers. So these are people who never would normally have died, our sisters, our mothers, our grandmothers, just because everything went to COVID and the hospitals, the primary healthcare stopped doing those things, and that’s what we advocate for at WHO. The same for routine immunisation. Everyone is nuts about this COVID-19 vaccine, but in 40% of our countries, the basic routine immunisations for polio, tetanus, the forgotten diseases, have been halted.”
We can also certainly do better in preventing the spread of the next pandemic. “We are working with the Institute of Health Evaluation and Metrics in Seattle, Washington, and we calculate that with systematic mask wearing and strict controls on social gatherings, we could save up to 261,000 lives by 1 February 2021. Compare Singapore, where mask use is 95%, to Europe, where it’s 65%. By elevating to Singapore levels, we could save so many lives.” This is also one area where developed nations could better partner with developing nations, where many of our textiles, including facemasks, are made.
Physical health is not the only consideration for Dr Kluge. One area of special concern is the need to stand up for European social values of solidarity and equity, values that can fall by the wayside when times are difficult. However much we prepare for the next pandemic, it is important to realise that any mass health crisis will affect different segments of the population differently and we must adjust our efforts accordingly. “The one thing that the pandemic has taught us is that the poor and vulnerable get targeted disproportionately. This time it was the elderly people. This was a human catastrophe in Belgium, and not just in Belgium, in the first wave. We left too many people behind in the first wave.”
Another vulnerable group are the youth, who suffer more than may be expected during lockdowns. “We heavily advocate within WHO/Europe to keep the schools open during lockdowns as much as possible. Pupils with special needs didn’t have anything to help them in digital learning. We always say we don’t want to have a COVID-19 Lost Generation.” Whilst mortality rates for the young who contract COVID-19 are generally very low, what may not be appreciated is the degree to which youth are suffering from mental health issues during lockdowns. “We see that more than 50% of youth have mental health issues like anxiety, depression, questions about the future.”
A third group identified by Dr Kluge that suffers during lockdowns are those who suffer from gender-based violence. “One out of four women and one out of three children suffer some form of domestic abuse, and during a lockdown this increases. I mean, imagine you are locked up with your aggressor because the social support services do not function during a lockdown.”
As bad as the coronavirus pandemic has been, things could have been worse. The virus could have been more virulent, or more easily communicable. Still, so much went wrong. We know now that a better response to a pandemic means taking better care of each other. But it shouldn’t take a pandemic to understand that.
The personnel and the personal
In late 2020, Dr Kluge was at a lunch for ambassadors in Copenhagen, being bombarded with the same questions that he always received (When will the pandemic stop?), when the Israeli ambassador asked him, “You talk about the health workforce, but how do you motivate your own people in the WHO workforce? They must be exhausted, working now 24/7 for all that time.”
The ambassador was right. He’s right about the WHO/Europe workforce, and he’s right about healthcare workers across Europe. As Dr Kluge puts it, “In the first wave, people were clapping for health care workers, and that has pretty much stopped, although the virus hasn’t stopped […] but the impact on society isn’t equal, and the pressure on healthcare workers is huge, and they never had the time to rest [between waves].” The unequal impact extends beyond WHO/Europe, and beyond the hospitals to workers in long-term care homes: “Workers there haven’t always received the most sophisticated training on pandemic control measures, nor were they necessarily given the right protective equipment. The priority simply wasn’t placed on them, and they were left to fend for themselves. Preparation can help with some of this neglect of healthcare workers, but it cannot stave off the indifference of a society should it turn a blind eye.”
The holistic themes of health and wellness that Dr Kluge has espoused are perhaps the only way to combat the extreme wear and tear felt by healthcare workers during a pandemic, a medicine for the tired soul to which Dr Kluge can personally attest. WHO/Europe is a multicultural agency, and there are lots of staff in Copenhagen who are far from home, separated from their families. Many realised that 2020 would be the first time they would not see their families at Christmas. It is for this reason that – despite the long hours and hectic schedule – Dr Kluge has reminded himself often that he is very fortunate, as he has his family with him in Denmark, even if they haven’t seen him as often as they would like. “It’s very important to have this family base because you need to stay sane. For all those people in this field, you don’t want to come home and talk about COVID, but this family support is very important and we should not take it for granted.”
Dr Kluge is looking to the future to try to prevent the next pandemic, but he is also looking to the future for renewal, and the same resumption of life that we all desperately await. After all, his own daughters are in their teens, looking around and considering where they want to attend university. Questions about the future, then, abound in his household. Will his daughters, too, go to KU Leuven? Will they go the virology route? Or will they perhaps pursue public health in a broader sense?
Whether they attend KU Leuven is yet to be determined, but in this case, it appears that Dr Kluge’s advice to follow the heart makes a career in medicine unlikely. After such a trying year, it is good to hear him laugh when he says, “The eldest would like to be a lawyer.”