In my first post on the coronavirus outbreak, I reviewed the nature of the disease. Here, I want to ask and answer the first of four questions I posed about whether a global public health emergency should have been declared earlier. In the next post, I’ll tackle the appropriateness of China’s quarantine measures, the adequacy of its overall response, and what should be done going forward.

The response to the COVID-19 coronavirus has been draconian. With the lunar year vacation looming at the end of January, China shut down travel out of the city of Wuhan on January 23rd (and severely restricted entry as well), soon extending to the wider province of Hubei, with a population of 58 million people.

Commerce and public outings in much of the rest of the China have also dropped markedly with cities like Shanghai looking like ghost towns after the government extending the lunar holiday and people stayed away from malls and other public places.

Meanwhile, the World Health Organization finally declared the COVID-19 outbreak to be a Public Health Emergency of International Concern (PHEIC) on January 30, 2020 after having deferred making such a declaration the week before.

In making the declaration, WHO Director-General Tedros Adhanom Ghebreyesus praised the Chinese response and argued against travel and trade restrictions with China, raising concerns he was being overly deferential to the Chinese government.

In many ways, #China is actually setting a new standard for outbreak response. Our greatest concern is the potential for the virus to spread to countries with weaker health systems, and which are ill-prepared to deal with it. #2019nCoVhttps://t.co/GdUQZGvzkd

— Tedros Adhanom Ghebreyesus (@DrTedros) January 30, 2020

In response, the United States elevated its travel advisory warning citizens not to travel there and said it would deny entry to foreign nationals who recently visited China. On January 31, three American air carriers — American, Delta, and United suspended all flights to China temporarily, with some airlines cancelling all flights to China and Hong Kong through the end of April.

Should a PHEIC been declared earlier? Has it had an impact?

Should a Public Health Emergency of International Concern (PHEIC) been issued earlier?

The World Health Organization was given the power to declare a PHEIC as part of the 2005 International Health Regulations, revised in the wake of the 2002-2003 SARS outbreak that also affected China.

In the SARS outbreak, China’s dilatory response and opaqueness led the WHO to use its discretion and issue a travel warning for people not to go to parts of China affected by the outbreak as well as Toronto, Canada.

The PHEIC declaration is intended to respond to events that are determined to:

– constitute a public health risk to other States through the international spread of disease; and
– “to potentially require a coordinated international response”. This definition implies a situation that: is serious, unusual or unexpected; carries implications for public health beyond the affected State’s national border; and may require immediate international action.

WHO

If you recall, the WHO delayed declaring the Ebola outbreak in the Democratic Republic of Congo (DRC) as an international emergency for months, waiting until July of 2019 to make such a declaration.

It may be helpful to take a step back and ask what is the purpose of the declaration. It’s intended to galvanize the international community to pay more attention to a health emergency that threatens to pose a risk to other states. For some problems, that might mean money. For others, that might mean more concerted and coordinated international responses.

The IHR regulations are also supposed to ensure that affected countries do their duty to both prepare for health emergencies and be willing to share information and data in the midst of a crisis. A PHEIC declaration may put a government on the spot for not being as forthcoming.

The declaration is also intended to balance the need for protection with desire to maintain the free flow of commerce and travel. The public health space has long been preoccupied with ensuring that disease outbreaks are handled with care and do not trigger disproportionate responses like travel bans or quarantines that may undermine commerce and exchanges between countries.

There have been six PHEIC declarations since 2009: the 2009 H1N1 (or swine flu) pandemic, the 2014 polio declaration, the 2014 outbreak of Ebola in Western Africa, the 2015–16 Zika virus epidemic, the 2018–20 Kivu Ebola epidemic, and the 2019–20 novel coronavirus outbreak. There wasn’t one called for the Middle Eastern Respiratory Syndrome (MERS).

During the Ebola outbreak in the DRC, Dr. Tedros and WHO insisted that money wasn’t an issue so a declaration was unlikely to be all that helpful in galvanizing leader support for action. He feared it might backfire and lead to DRC commerce and travel being adversely affected. Yet, as the DRC looked increasingly unable to contain the virus inside its borders, WHO finally declared a PHEIC in July 2019, though without clear impact on funding and attention.

PHEIC are supposed to be temporary and reviewed every three months. The WHO recently extended the declaration for Ebola in the DRC.

What does a PHEIC for the coronavirus mean?

In China’s case, it’s not clear that China needs outside money to address the problem. It has plenty of domestic resources, though it could benefit from external help from the World Health Organization and the U.S. Centers for Disease Control. In both cases, it appears that coordination prior to the declaration (and even after) has been lackluster.

According to a February 7 New York Times article, China rebuffed the offer from the CDC to assist China with the coronavirus for more than a month. China was thought to want to appear not to need help.

Current and former public health officials and diplomats, speaking anonymously for fear of upsetting diplomatic relations, said they believe the reluctance comes from China’s top leaders, who do not want the world to think they need outside help.

ONALD MCNEIL, JR. AND ZOLAN KANNO-YOUNGS, NEW YORK TIMES

The Times article said the WHO made a similar offer two weeks ago with no response. On February 9th, WHO veteran Bruce Aylward was reported to finally be en route with an advance team to China. It is unclear what took so long but perhaps the declaration set in motion the ability for the WHO to send a team.

I’ve just been at the airport seeing off members of an advance team for the @WHO-led #2019nCoV international expert mission to #China, led by Dr Bruce Aylward, veteran of past public health emergencies.

— Tedros Adhanom Ghebreyesus (@DrTedros) February 9, 2020

It’s unclear if a declaration was necessary to facilitate the trip, though it is arguable that had the declaration been made a week earlier, that a WHO field visit could have been set in motion much earlier. If a declaration had been made around January 22nd, could efforts have helped staunch the dramatic rise in new cases?

China apparently needs help in molecular virology and epidemiology, so to the extent the declaration were made earlier, that might have helped the country address two core issues:

The first involves sequencing the virus’s genome and manipulating it to refine diagnostic tests, treatments and vaccine candidates.
The second involves figuring out basic questions like who gets infected and who does not, how long the incubation period is, why some victims die, how many other people each victim infects and how commonly hospital outbreaks are occurring.

DONALD MCNEIL, JR. AND ZOLAN KANNO-YOUNGS, New YORK TIMES

Did the PHEIC work as intended?

I reiterate my call on all countries to share what they know about #2019nCoV in real time with @WHO.

I reiterate my call for calm.

I reiterate my call for solidarity – human, financial and scientific solidarity. Any breach in solidarity is a victory for the virus.

— Tedros Adhanom Ghebreyesus (@DrTedros) February 9, 2020

The PHEIC declaration may have also facilitated or provided cover for countries including but not limited to the United States to respond to the outbreak by shutting their borders to travelers from China and preventing travel to China, the opposite of what such declarations are intended to do.

As Adam Kamradt-Scott notes, a number of countries are in breach of their obligations under the International Health Regulations, notably Article 43 which states: “Such measures shall not be more restrictive of international traffic and not more invasive or intrusive to persons than reasonably available alternatives that would achieve the appropriate level of health protection.”

Given multiple countries’ behaviour in breaching WHO recommendations (IHR Art 43) re #coronavirus (not to mention dissatisfaction with #PHEIC), is it time for #EB146 to call on #WHA73 to update the IHR (2005) to develop a new framework? Or are govts just going to discard norms?

— Adam Kamradt-Scott (@adamkams) February 3, 2020

In response to the travel bans and restrictions, 16 international law scholars wrote in the Lancet to register their disapproval: “Many of the travel restrictions being implemented during the COVID-19 outbreak are not supported by science or WHO.”

Tom Bollyky in a conference call for the Council on Foreign Relations suggests that delay in issuing a declaration may have made it harder for WHO to undercut the impetus for travel restrictions:

Arguably, by being slow to issue a PHEIC—a Public Health Emergency of International Concern—the WHO has fallen down a little bit in terms of getting ahead of those travel and trade restrictions because they have come in the last few days while everybody was waiting for that declaration to be made.

Thomas Bollyky, Council on Foreign Relations

Should rules for declaring global health emergencies change?

Even before the coronavirus outbreak, there have been a variety of proposals to update them since the WHO seemed so reluctant to declare one in 2019. Some have suggested a tiered system of levels rather than a simple yes/no, though others question whether or not this would help in the current crisis or any other.

There is a broader problem of these declarations. As Lawrence Gostin noted:

Unfortunately, the declaration of a PHEIC does not have major legal significance. The IHR does not give WHO additional powers or resources when the Director-General declares a PHEIC. This is a problem with the IHR that should urgently be remedied. Declaring an emergency should unleash new powers and a surge of funding from a well-financed Contingency Fund for Emergencies.

Lawrence Gostin, Health Affairs

I’m ultimately not certain that the declaration process matters all that much for powerful states, if they are asked to do something they or their leaders are unwilling to do. In the case of 2015 Ebola outbreak in West Africa, the declaration served a useful purpose for the Obama administration to make a major commitment of resources.

In the current context, I’m not sure the declaration would have any bearing on travel restrictions to and from China or China’s policies within the country. I’m a bit ambivalent about whether they were justified in the first place, and I will have more to say about that in my next post.

When the world gets on the other side of the coronavirus outbreak, there may be time to reconsider whether the process is working as intended and what refinements might offer an improvement over the status quo.

In the meantime, we need a clearer sense of how international cooperation can be deepened to avoid calamity, at a time when the United States and China increasingly are de-coupling. That’s the more urgent task in the short run.