The World Health Organisation (WHO) has suddenly found itself caught in the crossfire between the US and China, or perhaps Donald Trump and China or even perhaps Donald Trump and his re-election aspirations. It is difficult to pinpoint the actual reason for the controversy but there has been a sudden furore about the manner in which the WHO has managed this pandemic and the president of the US has threatened to stop funding the international health organisation. There are many memes doing the rounds on social media implying that China has been given considerable latitude in reporting the nature of the illness and its management. It has been imputed by some and dismissed by others, that the virus in question is a product of human manipulation and part of a conspiracy which is being covered up with the support of the WHO.
We do not need to be either a historian or virologist to know that the relationship between disease and disturbance in eco-systems is a long one. Malaria, one of the earliest pandemics, has been associated with agriculture, deforestation, development and urbanisation. In Roman Europe, malaria is said to have spread when farmers abandoned their low-lying fields which became swamps and breeding grounds for mosquitos. In America, when labour-intensive agriculture was introduced with slave-labour from Africa, mosquitoes spread and so did malaria. The famous Centre for Diseases Control (CDC) in Atlanta, started its life as a malaria control centre in South Eastern US.
Deforestation and tea plantations led to malaria in Assam during colonial times in India. Dams and canals led to the resurgence of malaria in the 1970s just when the world thought malaria was on its way out. Similarly, the rise in temperature in Central Asia is said to be responsible for rats moving out into human populations, bringing the plague with them. Among more recent pandemics, HIV is associated with chimpanzees, influenza with birds and pigs, and COVID-19 is being associated with bats. As we humans keep intervening in the environment in different ways, the chances of a disease agent jumping from its animal host to us humans will remain. And we will also keep coming across newer and newer agents.
COVID-19 is caused by a novel virus and hence we are still learning how the virus spreads and how infective and virulent it is. One of the allegations against the WHO was it initially provided the wrong guidance about whether the virus was spread through the human to human contamination route. There is a flurry of evidence on dates of what happened when and whether information was suppressed and to what extent advisories accurate and so on.
The point is we are facing a disease agent which we have not faced earlier and so there is inadequate information available. This is not a unique situation. Up until the mid-19th century, managing pandemics such as plague, cholera or smallpox were all based on the reasonable certainty that they spread from person to person, so isolation was important. However, there was a lot of confusion about what the causative agent could be.
Scientific knowledge and government actions
In 1854, John Snow demonstrated in London that cholera was spread through contaminated water by identifying that those who used water from the ‘Broad Steet pump’ suffered the disease and that it was controlled once the pump was replaced. In 1861, Louis Pasteur in Paris published the germ theory. In 1882, Robert Koch, a German, announced the discovery of the tubercle bacillus in Berlin and then identified the cholera bacteria in 1884 in India. The proof that vaccines could prevent the rapid spread of infections had earlier been provided by Edward Jenner in 1798, in England, when he discovered the smallpox vaccine. However, it was only in the late 19th century in Europe that governments were convinced enough to pass laws for compulsory vaccination. There was a level of confidence that scientific knowledge and technology was now letting humans control germs and disease.
When in 1918, the influenza pandemic struck in the US and spread from cantonment to cantonment, there was confusion. The disease agent eluded identification. In England, where public health standards were higher, there was less caution and only masks were considered necessary. Physical isolation was not enforced. The disease spread rapidly, killing hundreds of thousands of young people, killing over 50 million in all. Initially, it was thought to be caused by bacteria, and it took years before the influenza virus was identified in 1933. Flu vaccines have also been around for years, but the flu virus keeps changing mutating and so the effectiveness of the regular vaccine is compromised. Even with AIDS, while the Human Immunodeficiency Virus (HIV) was identified soon after the disease was described in the early 1980s, the search for a vaccine is ongoing even 40 years later.
Clearly, even with the most sophisticated technologies and our extremely advanced knowledge systems, they will never be ‘perfect’ cures and there will still be ‘unknown’ areas. We need to be prepared to manage these uncertainties and states of imperfect knowledge.
International collaboration and spread of disease
The idea that international collaboration is essential for preventing the spread of diseases has been around for centuries. The term quarantine itself is derived from the 40 days that ships were prevented from unloading their goods in Venice during the Black Death in Europe. The history of international deliberations began in July 1851, when France convened the International Sanitary Conference in Paris, trying to arrive at agreements on quarantine regulations for cholera. In 1892, the first International Sanitary Convention addressing cholera was adopted. In 1897, quarantine for the plague was discussed. Discussions on disease-specific regulations continued through right up to 1938, when the fourteenth and last International Sanitary Conference took place in Paris with 50 countries represented.
After World War II, the responsibility of international collaboration was taken up through the WHO. Disease-specific international collaboration continued through the WHO until 2005, when the International Health Regulations (IHR) were adopted by 196 state parties at the World Health Assembly.
The IHR is the only legal agreement between countries for the prevention and control of the international spread of disease. The most important difference from the earlier approach is that it does not depend upon a specified list of diseases for surveillance and reporting but adopts a more open-ended approach based on cooperation and good faith. WHO coordinates the implementation of the IHR. This is done primarily through a globally networked system of surveillance, risk assessment and alerting member states of the risks.
In this particular case, Trump alleges that the risk alert from WHO came late, and the organisation argues that they had issued their alert around travel in early January itself, and critics of the US president point out that he was visiting India much later, in mid-February. Clearly the WHO advisories had no impact on his travel itineraries.
The WHO is tasked with risk assessment and when the situation seems particularly grave, the director general (DG) convenes an Emergency Committee which advises them around issuing a Public Health Emergency of International Concern (PHEIC). For COVID-19, the PHEIC was announced on January 30, 2020. There have been five earlier situations when the PHEIC was declared and these were with respect to H1N1 influenza, Polio, Ebola (twice) and Zika. In the earlier cases, the situation had not proceeded as it has with COVID-19, and there may have been a delay in announcing it.
But the WHO has little jurisdiction over the actions of individual countries and is limited to developing national implementation plans and build capacity in countries to do so. Key elements of the international obligation are related to international travel and to minimise risks at ports, airports and other points of crossing. Individual countries are left free to develop their response in line with their assessment of risk. Considering the little we know about the disease, we see countries adopting vastly different approaches in managing the situation. Even the interpretation of social distancing and lockdown differs in countries.
The US’s threats of withdrawing funding
The US has used the threat of withdrawing funding from international agencies for a long time. Under Trump, it withdrew funding from the United Nations Population Fund (UNFPA) in 2017 for its work on abortion. Earlier, Ronald Reagan, George H.W. Bush and George W. Bush had also withdrawn funding from UNFPA for the same reasons. The withdrawal of funding from UN Agencies would appear to be standard operating procedure for US presidents who find their own agenda not aligned with international multi-country endorsed agenda. These hurt the international agencies but have not crippled them.
But with Trump, it is also known that he has been systematically reducing internal funding within the US for epidemic control through the CDC. So it is difficult to believe that Trump’s only agenda is to teach WHO a lesson.
There is little to be achieved at this point by debating who let the novel coronavirus out. There are probably many interconnected reasons for the wide and rapid spread of this pandemic. The more important issue for consideration is what do we do now, because countries are autonomous to develop their own response.
What should be done in India now that the virus is out there and the people have been locked-in in extremely vulnerable situations for over a month? Will this be enough? Are we considering the unique social, cultural, demographic, the economic situation and the wide diversities that we have in our country to fashion our Indian response? We cannot wait and watch, we cannot debate on and on. We need to act on what we know about our people about our country. Are we doing that rigorously? I wonder.
Dr Abhijit Das is managing trustee, Centre for Health and Social Justice, India and clinical associate professor, Department of Global Health, University of Washington, Seattle, the US.