Men at some time are masters of their fates;
The fault, dear Brutus, is not in our stars,
But in ourselves, that we are underlings.
(Julius Caesar, Act I, Scene III, L. 140-141)
The COVID-19 pandemic, generating cases and deaths daily, has impacted all parts of the world. Australia, along with the USA, proposed an independent inquiry into the origins and responses to the COVID-19 pandemic. This has generated backlash from China which placed economic sanctions on Australia. Recently, the World Health Assembly passed a resolution calling all stakeholders to respond to and find the source of the pandemic. An inquiry was included in the resolution, but it would mainly focus on WHO’s response to the COVID-19 pandemic at the expense of the responses of individual countries, including China, as outlined in the excerpt below (emphasis mine):
…Initiate, at the earliest appropriate moment, and in consultation with Member States, a stepwise process of impartial, independent and comprehensive evaluation, including using existing mechanisms, as appropriate, to review experience gained and lessons learned from the WHO-coordinated international health response to COVID-19, including (i) the effectiveness of the mechanisms at WHO’s disposal; (ii) the functioning of the IHR and the status of implementation of the relevant recommendations of the previous IHR Review Committees; (iii) WHO’s contribution to United Nations-wide efforts; and (iv) the actions of WHO and their timelines pertaining to the COVID-19 pandemic, and make recommendations to improve global pandemic prevention, preparedness, and response capacity, including through strengthening, as appropriate, WHO’s Health Emergencies Programme…
Focusing mainly at WHO’s response to the pandemic overlooks the important roles that countries have played in perpetuating the COVID-19 pandemic. A lot of blame is placed on China for not reporting the seriousness of the pandemic in a timely manner, but other countries must also share the blame for not preparing for the pandemic. In this blog post, I will explain the International Health Regulations (IHRs), a legal document that enforces countries to be prepared and responsive to disease outbreaks and pandemics. I will then explain how China and other countries such as the USA have violated the principles and rules of the IHRs to cause a pandemic that could not be contained.
The International Health Regulations (IHRs)
The World Health Organisation (WHO) is a UN organisation that focuses on the health of people globally with the aim of everyone to achieve …the highest possible level of health… In particular, it works to eradicate disease, particularly infectious diseases, and respond to disease outbreaks. WHO is the custodian of the legal document the International Health Regulations (IHRs). The IHRs provide a set of rules that all countries must follow to …prevent, protect against, control and provide a public health response to the international spread of disease… that are commensurate with… public health risks… [without] unnecessary interference with international traffic and trade.
Did you know? The IHRs don’t just cover infectious diseases. They also cover all public health risks that can cause disease such as radiological sources (e.g., a nuclear meltdown), food (e.g., mad cow disease) and chemicals (e.g., emission of toxic fumes).
The IHRs aim for countries to contain disease outbreaks in their own borders and prevent them from spreading to other countries. Under the IHRs, countries have a responsibility to:
- Report to WHO diseases that can harm humans, may spread internationally and would require a coordinated international response (these are called Public Health Emergency of International Concern (PHEIC));
- Develop capabilities to detect and respond to disease outbreaks, including the development of a pandemic plan; and
- To respect and protect the rights of people and travellers while implementing public health measures.
The IHRs also describe the processes for WHO to alert countries of disease outbreaks and issue recommendations of how countries should respond to them. However, it is up to each country to implement measures that minimise the spread of disease nationally and internationally.
All countries are legally bound to follow the principles and rules set in the IHRs. However, during the COVID-19 pandemic, all countries have violated the IHRs in one form or another. China failed to promptly report and update WHO and other countries of the threat of COVID-19. Other countries that have responded to COVID-19, including the USA, must also be blamed for not sufficiently preparing themselves for a potential pandemic, suffering severe consequences as a result.
China: covering up the true extent of the COVID-19 outbreak
Under the IHRs, each country uses an algorithm to decide whether a disease outbreak is serious enough to affect the health of people nationally and/or internationally. If it does, the country needs to report to WHO within 24 hours. After notifying WHO of the outbreak, the country is also responsible for forwarding new information of the outbreak to WHO, including where the disease came from and how it spreads. The first COVID-19 case was admitted on 1st December 2019 and the WHO China Country Office was notified of a cluster of COVID-19 cases (under pneumonia cases of unknown aetiology/cause) on 31st December 2019. WHO was informed of the cluster one day later on 1st January 2020 which requested further information from China. Hence, China followed the timelines set by the IHRs when reporting COVID-19 to WHO.
However, China failed to promptly update WHO on the full extent of the COVID-19 pandemic despite having information to report. This potentially misinformed WHO and other countries on the seriousness of the pandemic and delayed responses to contain it. There have been many examples of how China failed to keep everyone informed:
- China censored Wuhan whistleblowers in late December as they tried to warn other clinicians of the COVID-19 outbreak. These whistleblowers were reprimanded by the police and hospital authorities for spreading rumours of the disease that claimed to cause panic in the general population.
- China may have also not promptly informed the public and WHO of human-to-human transmission of COVID-19 despite internal memos stating the possibility. WHO have leaned on information from China to report in their risk assessment and in the tweet that there is no clear evidence of human-to-human transmission, putting them under immense pressure for not running independent investigations.
- China covertly imported PPE from many countries earlier in the year to protect their doctors and nurses against the virus. This deprived other countries of essential PPE that was needed to protect their health workers during the pandemic.
There is a lot we do not know on how China have handled the early stages of the COVID-19 outbreak and whether they sufficiently informed and updated WHO on the situation. A potential inquiry would look at the information built up in China and WHO and investigate whether China could have notified and updated WHO sooner given the information they had at the time.
Other countries: being unprepared for the upcoming pandemic
The WHO Director-General is responsible for deciding whether a disease outbreak constitutes a PHEIC (Public Health Emergency of International Concern), in consultation with an emergency committee of experts and after considering country reports, scientific evidence and risk assessment. Once a PHEIC is declared, WHO continually updates all countries about the disease outbreak and the Director-General issues temporary recommendations on how countries should respond to the PHEIC without unnecessarily disrupting international traffic.
Under the IHRs, when the WHO Director-General declares a PHEIC, countries must prepare to respond by:
- Determining and implementing control measures to prevent the spread of disease nationally and internationally;
- Setting up structures and support to detect, isolate and treat cases of the disease; and
- Following recommendations issued by WHO and adapting them to their own context.
A PHEIC declaration also tries to generate a global coordinated effort to support countries that need help in preparing and responding to the PHEIC.
However, despite repeated warnings from WHO of the threat of COVID-19, many countries ignored the PHEIC declaration and continually downplayed the threat of COVID-19. This left them unprepared for COVID-19 to spread in their country, leaving them surprised when there are a lot of cases and deaths. For example, Donald Trump in the USA ignored warnings from health experts that COVID-19 could rapidly spread nationally, downplayed the threat of COVID-19 and did not mobilise resources to prepare for the pandemic. As a result, the USA has the highest number of cases and deaths of all countries. As many countries did not act on the PHEIC declaration to prepare for COVID-19, the WHO Director-General had to declare COVID-19 a pandemic on 11/3/20. Even though there is no legal definition of a pandemic from WHO, it prompted a strategy shift for countries to enforce social distancing and mitigation measures such as closing schools and shops.
Countries also ignored recommendations from the Director-General and the Emergency Committee. Countries are not legally bound to follow these recommendations and are able to implement their own measures depending on the local context. For instance, despite the Emergency Committee not recommending travel bans as there is limited evidence that they can prevent or delay pandemics, a lot of countries still implemented them. Countries that implement additional recommendations exceeding the Director-General’s temporary recommendations have to report them to WHO and provide a public health rationale and relevant scientific information. Despite this, on 7th February 2020, only 32% (23/72) countries that implemented travel restrictions sent official reports to WHO. Some countries also implemented public health measures that violated human rights such as unjustified detainment of groups of people and state-wide lockdowns and not acted cooperatively in the interests of global health such as banning exports of critical medical supplies. These examples indicate that countries implemented reactive measures to the COVID-19 pandemic as they were unprepared despite repeated warnings from WHO to prepare for the upcoming pandemic.
Conclusion
Multiple factors have contributed to the emergence of the COVID-19 pandemic. Whilst China covered up the seriousness of COVID-19 in its early stages, other countries did not sufficiently prepare for the pandemic which has devastated their people and economy. Unfortunately, despite the IHRs being legally binding, there are no legal or monetary sanctions to punish countries that do not notify and update WHO of disease outbreaks on time or fail to prepare themselves to detect and respond to disease outbreaks. This is due to countries wanting to preserve their national sovereignty, wanting to implement their own public health measures without any interference from WHO. This need of national sovereignty has undermined efforts to reform the IHRs and to learn from past disease outbreaks.
The COVID-19 pandemic provides a sobering reminder that infectious diseases do not discriminate in infecting people and can devastate any country by transmitting between people. The pandemic highlights the need for WHO and all countries to fully cooperate in an independent inquiry where everything, from notification to response, is under the microscope. Given that most infections of pandemic threat come from animals and disease outbreaks occur globally, it is urgent that WHO and countries act on the recommendations generated from the inquiry to benefit themselves and the world.