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Opinion: 

We Preach Prevention, WHO Practices Response

January 26, 2019

by Anthony Falzarano

with Taylor Winkleman, Stephen Taylor, Kate Kerr and Jessica Smrekar

Diseases do not respect borders. For years, the global health community has used this phrase as both a tagline and a call to action. And for years, experts have warned of the dire impacts a pandemic disease may have and the need for transparency and collaboration -- a coordinated international response -- to mitigate the toll of such events in our increasingly-connected world. To the initiated, the spectre of pandemic disease is a case of when, not if; always looming just one zoonotic spillover or genetic reassortment away.

This has yet again manifested - now taking the form of a novel coronavirus outbreak (2019-nCoV) epicentered in Wuhan, Hubei Province, China. 2019-nCoV’s meteoric rise to the forefront of the global consciousness is striking: in a matter of weeks the disease, causing severe pneumonia, fever, and other upper-respiratory symptoms, has spread to 14 countries. In recent days, we watched as case numbers soared from less than 100 to well past 2000, claiming at least 50 lives.

If there was ever a time for the World Health Organization to demonstrate poise and guidance in this crisis, it came and went last week.

The rapidly escalating situation has since prompted the Chinese government to implement draconian quarantine measures, locking down more than 50 million people as President Xi Jinping desperately tries to get a handle on what he calls a “grave situation.” Meanwhile, the US announced plans to evacuate roughly 1000 Americans still in Wuhan.

If there was ever a time for the World Health Organization to demonstrate poise and guidance in this crisis, it came and went last week. When we thought we’d surely see the WHO take the reins and declare a Public Health Emergency of International Concern -- a clarion call to mobilize funding and political will in order to preempt disease spread and ultimately prevent loss of life -- WHO Director General Dr. Tedros Adhanom Ghebreyesus and his Emergency Committee chose to hold off, instead opting to await new information or developments, saying the disease was “...not yet a global health emergency.”

Public trust is the cornerstone of public health, and trust is not earned through inaction. 

The International Health Regulations were developed as a proactive tool for prevention, with the PHEIC as a means to garner support in the fight against unusual events which: pose serious public health impacts, have a significant risk of international spread, and carry risks of international trade or travel restrictions. Unfortunately, the PHEIC has once again 

been shackled in practice to resemble a tool of response, only utilized once the embers of disease have grown into a wildfire. This is antithetical to the foundations of public health preparedness and an abdication  of global health governance. Public trust is the cornerstone of public health, and trust is not earned through inaction.

The lack of action by the World Health Organization in this situation is baffling, although somewhat unsurprising if one peers into history. Concerns around economic impact, travel disruption, and international stigma that follow the declaration of a PHEIC cannot be overstated. These were important delaying factors in the belabored decision to declare the ongoing Ebola outbreak ravaging the Democratic Republic of Congo a PHEIC -- a delay which drew almost unanimous criticism from experts in global health.   

Perhaps these concerns were at least valid at face value: the last thing the fragile, emerging economies of both the DRC and the proximal countries of Uganda, Rwanda, and Kenya need is the spread of pervasive fear and targeted travel restrictions based on a disease that has yet to sustainably stretch eastward into much of the African Great Lakes region. Indeed, these measures could have (and historically did) decreased the flow of money from the global economy into Africa. Yet still, the event was eventually declared a PHEIC - a correct decision which helped call the world to action, providing at least some semblance of relief to the good guys in a fight which is sure to rage on for the foreseeable future.

It appears the WHO has chosen the DRC-Ebola playbook for their approach to the 2019-nCoV outbreak. But this is not the DRC, and this virus is not Ebola. Wuhan, with its 11 million people, high-speed rail system to Guangzhou, and international airport transiting over 30 million passengers a year, is a different city. China is a different country.

Visualization of outbound direct and indirect flight destinations from Wuhan, Hubei Province, China. Source: flightconnections.com, tweeted by @infectiousdz

The rapid emergence of 2019-nCoV in countries across the world is a testament to the reach of the Chinese global engine and underscores the difficulty in stopping an upper-respiratory virus during the heart of flu season. The WHO showing an aversion to a PHEIC declaration for fear of political and economic impacts appears almost comical as the Chinese government continues to proceed -- with the whole world watching -- in a manner that is unanimously condemned as an ineffective method of infection control, to say nothing of the human rights violations for the millions sealed inside those quarantined cities.

The global health governance enterprise, which has blossomed to life through the likes of the IHR and the Global Health Security Agenda, seems non-existent now when it is needed most. Any hope that existed for strong global health leadership to quell the potential for travel, economic, and political consequences accompanying the inevitable public panic has seemingly perished. News outlets and social media timelines are overflowing with concerned and angry commenters asking questions about a crisis they do not understand and sharing videos depicting difficult scenes in hospitals a world away.

It would be absurd to pretend that the decisions we make do not have cascading consequences well outside of the sphere of health, yet at the time of writing this you would be hard-pressed to find a single expert in this field unwilling to face those consequences and any associated challenges in the spirit of protecting human health and societal order. We are aware of those second and third-order impacts and are prepared to face them and help mitigate them through smart and calculated decisions. 

But we have grown jaded by living and re-living what are perceived as failures in health preparedness. The groundwork for success has been established, and we must be bold enough to leverage it.

Arguments have surfaced about what -- if anything -- changes when a PHEIC declaration is made. Watching and waiting is a valid and rational approach in many situations. This is not one of them. Leveraging our tools for preparedness should be an active, collaborative, and preemptive process, as global health experts have preached around the world from Vienna to Kampala, Bali to Sydney, and everywhere in between. Unfortunately, the WHO is failing to walk that walk for the second time in less than a year.

Watching and waiting is a valid and rational approach in many situations. 

This is not one of them. 

As this disease continues to radiate outward from China and around the globe, some of the most vulnerable regions on Earth await on the far side of the planet in the Middle East and across Africa. Are the countries that lack the infrastructure and resources to fight this battle without our assistance not worth our call to action? We refuse to accept that a lack of sustained human-to-human transmission of this virus in countries with competent public health systems is the one box that still must be checked in order for the WHO to leverage its power and get serious about preparing the planet to mitigate further spread and calamity of this disease.

We must begin a coordinated, international response to 2019-nCoV that is evidence-driven and appropriate to the scale of the threat. Dr. Tedros must reconvene the EC at once and demonstrate the awesome power of the health community. A PHEIC declaration would show the world that the WHO is in the driver’s seat, is garnering the appropriate resources and support, and is prepared to leverage these resources to prevent further spread of this disease. A PHEIC will not induce panic; rather, it will reassure the world that the best minds in global health are standing by and ready to come to their aid if and when they are called.

While the shifting sands of political expediency, emotion, and economy threaten to undermine our efforts, science and evidence-based approaches have always been the unmoving rock we rely on to justify our decisions as we work to improve health and save lives. If our tools of global health governance are not applicable now, when will they ever be? And more importantly, if we can’t stand up and face political, economic, and social consequences which may be necessary in our quest to protect human health, what are we really working for?

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