Professor Baron Peter Piot

World expert in global health; Director of the London School of Hygiene and Tropical Medicine; Handa professor of global health

I met Peter at the National Academy of Medicine Healthy Longevity Global event that took place on 3-4 February, 2020, in Singapore. I had been asked to speak about the work we were doing with the APPG for Longevity, 10 days before we were due to launch The Health of the Nation Strategy, and I met Peter in one of the breaks.

COVID-19 was definitely "in the air," so to speak, and on people's minds—we had to use sanitizer before entering the conference suite and I remember feeling distinctly uneasy when someone started coughing in the row in front of me at one of the sessions.

Back from Singapore, I followed up with Peter to arrange a coffee in London, and a date was set for 23^rd March to meet at his office. This, of course, was a week after the first day of the official UK lockdown on 16^th March. Unsurprisingly, Peter was getting immersed in the UK Government's response to COVID-19, and his office asked to reschedule the meeting.

I followed up in April and was told that Peter was unwell, but I did not realize that at the time he was battling the COVID-19 infection himself, suffering terribly from "the revenge of the virus" as he described it when he had recovered.

He wrote about his experience very movingly in Science in an article headlined "Finally, a virus got me." He was compelled to publish the piece by a desire to communicate that COVID-19 is about people first and foremost, not just about the statistics that dominated the headlines. He also wanted to highlight that it is potentially far more serious than flu, with chronic morbidity and other long-term sequelae for some.

It turns out that Peter started suffering from the symptoms of COVID-19, including fever and a sharp headache, on 19^th March (he had started working from home on the 16^th). He tested positive in a private clinic on the 25^th March, as he had suspected. Peter initially thought the infection would pass in a straightforward manner, being fit and healthy, with his age (71) being the only risk factor. He continued his work for a while as a special adviser to the European Commission President, Ursula von der Leyen.

But the fever persisted, and complete exhaustion set in and was getting progressively worse. On the recommendation of a doctor friend, Peter went to get examined on 1st April, and discovered he had severe oxygen deficiency and severe pneumonia typical of COVID-19, as well as bacterial pneumonia.

He was hospitalized but tested negative for the virus at that time (this is also typical: the virus disappears, but its consequences linger for weeks).

Peter says this in his personal account: "I shared a room with a homeless person, a Colombian cleaner, and a man from Bangladesh—all three diabetics, incidentally, which is consistent with the known picture of the disease. The days and nights were lonely because no one had the energy to talk…but I always had that question going around in my head: how will I be when I get out of this?….after fighting viruses all over the world for more than 40 years, I have become an expert in infections…they got me, I sometimes thought. I have devoted my life to fighting viruses and finally, they get their revenge."

My interview with Peter was on the 29^th June. By then, he had been interviewed by many newspapers and broadcasters around the world, including the New York Times and the BBC, on his personal experience and what the pandemic is teaching the world. I was obviously very grateful to Peter that he kept our appointment!

Peter has an extraordinary background. His official biography is rich with the numerous prestigious posts he has held over his 40 years as an expert, but what stands out is his pursuit of access to health for all.

Peter co-discovered the Ebola virus in Zaire in 1976 while working at the Institute of Tropical Medicine in Antwerp. He was one of the leading critics of the UK, UN, and WHO's response to the Ebola outbreak in West Africa in 2014, which he thought was too slow. In 2014, he was named "TIME Person of the Year" ("The Ebola Fighters").

He also led research on HIV/AIDS, sexually transmitted diseases, and women's health, mostly in sub-Saharan Africa. He was the founding executive director of UNAIDS and Under-Secretary-General of the UN from 1995 to 2008, and an associate director of the Global Program on AIDS of WHO.

Under his leadership, UNAIDS became the chief advocate for worldwide action against AIDS, also spearheading UN reform by bringing together 10 UN system organizations.

Peter is the first chair of Her Majesty's Government's Strategic Coherence of ODA-funded Research (SCOR) board and is also a special advisor to the president of the European Commission on research and innovation for COVID-19. He is a member of the board for the Coalition for Epidemic Preparedness Innovations (CEPI).

Peter has published over 600 scientific articles and 17 books, including his memoir No Time to Lose in 2012 and AIDS Between Science and Politics in 2015.

Tina Woods: You've been in the field of virology for so many years. You've seen viruses grip communities and nations, and then suddenly you caught COVID-19 yourself; what surprised you about the experience? Did your experience as a patient match up to what you would have expected as a professional?

Peter Piot: Good question; I actually never expected I would get ill! I've never been ill in my whole life, or seriously sick, so I've been lucky at 71. I never thought about it. I didn't assume I was invincible or immune to COVID-19, but getting sick was just not on my radar screen. When I got it, I thought—as I believe the majority of people thought, as the consensus was then—that I'd be OK. I thought that with COVID-19, either you're asymptomatic or it's a bit like the flu, or sometimes a bad flu; 1% of those infected die, and they're older people anyway, and they have pre-existing conditions.

We were primed to think of it as if those deaths don't count. The more I thought about it afterward, I got really angry at some points. It's a very eugenic discourse and that's reflected in how in many countries—including the UK—care homes were treated seriously, or not. That's actually one of the reasons I came out of the shadows to talk about this.

I told the world that there is a lot in between. This disease is much more nuanced, and there's a lot of chronic sequelae—chronic conditions that could be with you forever that hang around as a result of this disease.

On the other hand, once I was admitted to the hospital, I became a patient 100%. I didn't try to be the doctor. I've said before that I'm not the type of person who tells a taxi driver which route to take.

Tina Woods: Yeah! You let them look after you, then?

Peter Piot: I let them do their job, yes.

I was also so exhausted, and actually quite confused, so I was not capable of thinking clearly. I think, retrospectively, it was a good experience. I mean, it was a terrifying experience, yes, but it was good to feel the virus inside, and not just look at it and try to defeat it, in some way or another, from the outside.

My mother tongue is Dutch, and we have this term "ervaringsdeskundige," which means "experience expert." It comes from the social side of government, from social policy-making. You wouldn't dream of developing policies for, let's say, the elderly, by only speaking to experts and not by involving people who are old. I come from the AIDS movement, and people living with HIV have been involved from really quite early on as part of our reaction to HIV/AIDS.

I think what getting infected has also done for me is make it clear that the official communication on COVID-19 has not been about people; it's been about flattening the curve. Certainly, the UK was probably an extreme example; you had ministers, even the Prime Minister, giving lectures about the reproductive rate (R₀) and flattening the curve. It was about saving the NHS, and so on; and then, as an afterthought, it was about saving lives.

That's why I think there was so much interest in my story. I gave the first interview to a Flemish weekly magazine, because I'm very well known in Belgium, and that was to help raise awareness. Then, when the interview was taken up by Science, it got millions of views. That was very interesting to me; it showed that there was a gap in the whole communication strategy and the storytelling.

Tina Woods: Where do you think, internationally, the public health messages were right? I know we certainly have got it wrong in the UK on a number of fronts, but what do you think the message should have been?

Peter Piot: Well, of course, the benefit of hindsight is always there. I'm probably a bit milder than many other people about all the mistakes we've collectively made, but the most important message is that the severity of this epidemic is unprecedented. I think that the communication of that message wasn't very well done.

I gave some talks about this with non-health experts in Singapore, but I don't think people internalize how contagious it is. Because of that, acting early is one of the most important things. That's one lesson that's particularly true for anything that's contagious; if you can nip it in the bud, you basically prevent not only the next generation of infections but the n^th generation. In essence, by preventing transmission in the beginning, you can prevent the whole chain that comes afterward.

COVID-19 also illustrates how important it is to prevent the development of obesity, diabetes, and cardiovascular disease through healthy lifestyles. I probably was lucky because I am not ill; I have no underlying conditions.

On the other hand, I got some messages from friends saying, "You'll be fine; you're a strong person."

In the hospital, I'm there thinking, "Well, there are certain things that your body does that are not under your control." You can't do anything at that moment of crisis, but you can make yourself more resilient as an individual or as a society.

The most important lesson for a government is to act early and at a scale that makes a difference, and an accompanying issue is maintaining enough trust in the government to do that. That's a big difference in what we've been seeing in Eastern Asia compared to Europe. There's one thing they had in Singapore, in Hong Kong, in Taiwan, and in South Korea: the SARS experience.

Tina Woods: Of course, they learned a lot from that.

Peter Piot: Yes, but we've also had lots of events to learn from. Afterward, we always say, "No, never ever again," and so on, and then we start again as if it were erased. Where SARS hit, those people learned from it, but more importantly, they set up a system to be ready when the next thing happened. It's not enough to learn and to say that we'll remember; you need to institutionalize that.

Internalizing the necessary changes, and making them part of the culture, is another essential element in making these changes stick. For example, in Japan, since the Spanish flu, people wear face masks even when they have a stupid cold to avoid infecting others. It's become part of the collective consciousness, and part of what's considered good behavior for the community.

Tina Woods: The masks are worn in a sense of collectivism, for the public good, then?

Peter Piot: Yes, the collective good. When in Japan, or in Singapore, people wear a face mask or a mouth mask, but it's not to protect themselves: it's to avoid infecting others. It took me a while to understand that; I've been going to Japan and East Asia for a long, long time, and at first, I thought, "These are people who are scared of others." I was completely wrong.

I've had a very hard time understanding the resistance to face masks and mouth masks. It's there in individuals as well as governments. I think in the UK, they still haven't said that it's compulsory [this advice has partially changed since this interview] and you can even hear resistance from scientists who say that the evidence is weak, and so on and so forth.

But they're cheap, there are no side effects, you can even make it yourself, and it can be sexy!

Tina Woods: I have seen some sexy face masks and some real creativity there! I think, if nothing else, it's a reminder of the fact that this is serious. That's what I found when I put the face mask on; initially, I found it very odd, but it's a very good reminder.

Peter Piot: I wear it as a reminder, too. I'm not contagious to anybody, and I assume I can't be infected because I have immunity.

Tina Woods: Is that true, though? Do we know for sure how long the immunity lasts?

Peter Piot: There's a lot we don't know, but frankly, if that's not the case, then a vaccine is impossible. In any case, I wear my mask whenever I go into a cubicle or an inside space in a shop because we go every morning to buy bread and vegetables, and what have you. I also always wear it on public transport, just as a way to let people know that hey, this change is coming.

Tina Woods: I think the key messages in what you've said are that governments and individuals need to act early, and that prevention, by remaining in good health, is important. Is there anything else you want to add to that?

Peter Piot: We need to be ready, meaning that we have a combination of systems in place: real-time intelligence on what is going on, cultural attitudes, and mental preparation. I think that these are the key issues. As a general reflection, you can assume that societies that are more cohesive are more resilient and are therefore better prepared for shocks like this.

Tina Woods: The sheer level of infections and deaths in care homes was a bit shocking, wasn't it? What do you think it told us about our values as a society?

Peter Piot: It was very shocking. As I've said, my work on HIV and epidemics has revealed how they exacerbate the fault lines in society, and make inequalities worse.

With COVID-19, the fault line that worsened the most in my opinion was how we treat our elderly; on the other hand, it revealed once again the higher vulnerability of ethnic minorities. Although we haven't totally understood why that's the case, in the US, a big part of that vulnerability is due to limited access to care. In the UK, that factor's a bit less important because we've got the NHS, but there are still maybe some genetic factors, as well as social discrimination and other social factors that are relevant. However, we've seen the higher vulnerability of ethnic minorities being exacerbated by different epidemics before.

The way the elderly have been affected by COVID-19, though, is something new. I mean that in the sense that I can't think of anything else that has revealed just how badly we are dealing with our elderly citizens. I've been in elderly care homes, though I'm not familiar with the British system. I know the Belgian system, because my parents were part of that before they died. My mother died in September, but she died with dignity, at a moment that she had chosen to die, which is something that's been possible in Belgium since '96. The economic situation and the housing situation mean that for most people, it's no longer possible to have, say, three generations in one home as used to be the case. So, what do we do when you're no longer productive, or when you become a bit of a nuisance for everybody? We park you in a pre-mortuary type of institution.

If you've got the money, then you can have even a butler and all that. There is an enormous class dimension in the quality of these institutions. But if you seriously think about it, this is how your old age is going to be; how comfortable you are in it depends on whether you have the money to affect it. Plus, of course, it depends whether you're abandoned by your family, and so on. Another revealer of this problem we have with how we treat our elderly citizens was the heatwaves in France in 2019. I read articles about old people who died during those heatwaves on their own, and it took two or three weeks to find out they were dead. It's so sad, this loneliness.

I think that it's interesting in the UK that the Department of Health changed its name to the Department of Health and Social Care in 2018. I never got a sense that social care was taken seriously budgetary-wise, and I'm a bit surprised when you look at it politically because older people are first in politics. They vote the most; they put pressure on their MPs; and they're well organized in many countries. Despite that, social care has been absent from the agenda of the politically active older generation. I never understood that. It may be completely unfair what I'm saying because it's a field I'm only viewing from the outside. I don't know for sure, but I've never seen a campaign in the media, or people testifying to how bad it is.

Tina Woods: All the data shows it's the most vulnerable who are hardest hit by COVID-19: those in deprived areas, the elderly, and the already unwell. Do you think there are any long-lasting changes that will come out of this pandemic?

Peter Piot: Well, I always have hope, I'm an optimist. Experience shows that it's not always the case. That's why it's important, I think, to understand that today we're in the midst of a crisis. It's not over. With this pandemic, we're only at the beginning; we're right in the midst of it. That means it's definitely worthwhile to take stock now and learn for the next wave. We need to put in place now, or start a discussion about, what we need not only for this next wave but also for the next epidemic, in 5 years' or 10 years' time. We need to start now, and not wait until it's all over, and when it no longer has any use.

Tina Woods: There's been a rise in nationalism and putting one's own country first during the pandemic, but there's a culture of openness that we need in terms of data sharing to help stop future pandemics. What do you think nations, and the global community of nations, need to do moving forward?

Peter Piot: First of all, we need to take a good and hard look at what happened. That's not about who's to blame—I don't think that's very useful—but about what the lessons are that we can learn.

We need to consider the immediate future, and the next outbreaks and waves. Next, we can start thinking in the longer term. For example, take Germany in Europe. I think Germany and Denmark probably had and have the best responses, and that's reflected in the lowest death rates and the lowest infection rates.

Part of that might be the backgrounds of the leaders—the German leader is a physicist. I'm not saying that people with a medical or scientific background make better politicians, but I do think there is an immediate understanding there of what needs doing; there is far more resolute leadership early on. There's been an interesting combination of strong national leadership and local implementation in the individual Länder, the federal areas of Germany. The central leadership gave a lot of resources and authority to local authorities.

In the UK—I knew this, but I hadn't understood how bad it is—it's a hyper-centralized country. No wonder Public Health England wanted to control everything to do with testing, and no wonder they were unable to do it, particularly since it was a home-based test. They weren't working with businesses, or with private firms, or with universities and labs. It's all about logistics, organization, and coordination when dealing with pandemics; it's all about communication. Government test stats show that these are not strengths of governments in general. Letting go is essential. By that, I mean that the UK Government needs to provide the resources, have the policies, take the decisions, and then let people do things. That's what's happened in other countries.

Tina Woods: That's something that we're also exploring in the All-Party Parliamentary Group that we're doing with the Health of the Nation: building up resilience for the next epidemic, with this concept we're calling decentralized health resilience. It's about health in our communities, starting individually with taking care of ourselves and building up from there and mobilizing local and regional networks to act quickly. There's a role for central leadership, but the implementation is very much driven from the ground up. Which countries are effective models that we could look to for inspiration, moving forward?

Peter Piot: National leadership is the easier one in a sense, because countries that have done well have seen strong leadership at the top. That's why when people say this is a public health crisis, I say no, this is a societal crisis, which requires the leadership of whoever is in charge in the country—prime minister, president, or whatever. We've seen it in Singapore, in Thailand, in South Korea, and in Vietnam.

There's another interesting lesson in the transition to the second part: Vietnam is a hyper-centralized society and politically controlled, yet the response has been very locally driven. Rather than to go for a nationwide lockdown, they did it sometimes as locally as by neighborhood, by company, by factory, or by schools. Rather than go for the bulldozer approach, which we've been using in Europe, they went for a more granular, more targeted or tailor-made approach. That's, I think, where we are now. This consensus is what we need to cope with the second wave and with particular local outbreaks. You used the term "localized resilience," is that correct?

Tina Woods: Decentralized health resilience. It's an approach where you're building from the bottom upward; it's this notion of decentralized networks.

Peter Piot: I like that a lot. I mean, it's nice to have the NHS, but it's also problematic to have the NHS as it is now with the hyper-centralized system. When you go to procurement and action, it's too slow and it's too heavy. And I never understood why one of the strengths of the NHS, primary care and GPs, who are much more connected to the community than hospitals, were excluded from the response.

Tina Woods: What key legacy points, moving forward, do you think we need to take on board as a country?

Peter Piot: I think we need to mobilize resources, not just money, to invest in new systems. In the UK, we can see that Public Health England is not fully equipped to the task. Frankly, its budget—the budget for public health and for the prevention of disease—has been cut. (Since this interview, the decision was taken in August 2020 to disband Public Health England; in its place will be the formation of National Institute for Health Protection (NIHP) that will absorb the pandemic response unit of PHE and combine it with the NHS Test and Trace service and the Joint Biosecurity Centre.) This is not recent. This has been going on, I think, from even when Labor was in power. I think it's been going down every year, because there's pressure to put money into the NHS into curative things, rather than prevention (since 2014, it is estimated that £850 million has been cut from public health budgets in England^[46]). That's also why care for the elderly and for others has been left out. Then, we spend all that money when someone from a care home has to be hospitalized, at enormous cost.

It doesn't make sense. Working out how to fix that, in political terms, is massively important.

Tina Woods: Is it fair to say that one of the key takeaways from the pandemic is that we need to focus more on prevention?

Peter Piot: Absolutely. But then, you see the rhetoric again; the UK Prime Minister, Boris Johnson, said, "We are going to build 100 new hospitals." I'm not sure that we need that, but that's very concrete. Compare that to saying, "We are going to cut obesity and diabetes and so on, by doing this and that." They're not very popular measures, but would contribute far more to the health of the nation than 100 hospitals. I am pleased to see that the PM and the Government are now going to tackle obesity.

Tina Woods: Do you think viruses sometimes get overlooked when we talk about planetary health and respecting the environment?

Peter Piot: Of course. I'm biased because I've spent much of my professional life dealing with viruses, but they do, it's true.

I remember when I was in my last year in medical school in Ghent in Belgium, and I did some of what today would be called career counseling; I don't think that term existed in '73! I said I wanted to study infectious diseases, and I wanted to specialize in that. All my professors said, "No, no, no! There's no future in infectious diseases. We've got antibiotics. We've got hygiene and vaccines." I still went for it, being a bit stubborn and thinking that you need to follow your passion.

There are cancers caused by viruses. When you think of liver cancer, you should think of hepatitis C; cervical cancer is caused by human papillomavirus. We have a cancer that's preventable through a vaccine, and really, isn't that wonderful? Looking at the take-up of the HPV vaccine in some countries, Britain is doing very well on that one.

I think we will see that more and more things are linked to viruses, and not only viruses but the whole microbiome (this is the aggregate of microbes—bacteria, fungi, and viruses—and potentially harmful ones, but mostly helpful ones). It's not just that an evil virus is attacking us—we need to understand it in the context of the wider microbiome. There is a kind of harmony of microbes in our guts—and there are more and more indications that something like that harmony exists with viruses as well.

Tina Woods: When it comes to the human impact on biodiversity, what do you think is the most important thing to understand from the general citizen's perspective?

Peter Piot: One extreme perspective is that these epidemics, these emerging infections, come from animals. In large part they come about because of risky interactions between animals and people, and sometimes extremely risky ones in poorer parts of the world. That's true in Central Africa, where everywhere people eat the proteins that are surrounding them, but also in China with the consumption of even threatened species. There's that, plus the whole modern food industry.

I'm not a vegetarian, but when you think about it, the way that food is produced and sold in the modern era is a very high-risk business. In the old days, when a small farmer had a few chickens dying from a microbe, that was bad for him and for the chickens. Today, you have literally a million chickens in one farm and they're sent all over the world. Industrial farming increases our risk of exposure, and the potential for novel viruses. That's one aspect.

On the other hand, we live in a completely obesogenic environment. That's certainly the case in Western countries, but also, increasingly, elsewhere. Think of the fact that even in Africa now—in South Africa—the percentage of women who are obese is as high as in the US.

All that together, plus the ever-looming threat of climate change, means that we really need to question, fundamentally, how we live and what we do and don't do. This is where planetary health is becoming very important as a concept. The question is how to translate that into action in the environment.

Tina Woods: So, if you had to pick one core message that you would want to say to the average punter about planetary health, what would you say?

Peter Piot: In order to have a better future for everybody, we need to not only work on our own health but also respect the health of the planet. That means thinking about biodiversity, how we consume food, how we produce it, and respecting the environment. I learned a lot about that from the Navajo and Hopi, and it had a big impact on me, particularly since they are so poor. I think that the core message is moving away from thinking we're the masters of the universe and everything around us. We need to stop thinking the universe is at our disposal and we can do whatever we want with it.

Tina Woods: Going back to health resilience: we've seen how huge a risk poor health is, on its own but also with the epidemic. Do you think we need a risk management framework for health like we have for climate change? Health is where the climate change agenda was 10 years ago—shouldn't we be guiding investment and innovation decisions by ESG mandates, like we do for climate change, and applying them to health?

Peter Piot: This seems essential. In terms of risk management for COVID-19, I think that there's some serious cognitive dissonance around it; there's this idea that we're going to end this epidemic, eliminate it, wipe it out with a vaccine, and so on. I don't think it's realistic. We need to see, as a society, that it's about harm reduction and about risk management. I think that's true for everything because I'm also realistic enough to know that we need jobs and employment. People need to move around. It's something I'd like to read more about.

Tina Woods: One final question: how have you changed your lifestyle since getting ill, and what is your secret for a healthy, long life now that you've gone through what you have?

Peter Piot: I think I'm looking for a better work-life balance—although I've not been very successful! Right now, frankly, I'm still in recovery. I'm rebuilding strength. There's no qualitative difference in my lifestyle yet, but I'm trying to do more exercise. I'm paying more attention to all kinds of things. I lost seven kilos with COVID, which is more than I ever succeeded in doing with exercise and diet, so I will try to keep it that way. I think that's a question to ask me again at the end of the year, to see whether I actually followed up on my intentions!