Ep63: the WHO’s biggest test

Ep63: the WHO’s biggest test
Date:
6 October 2020
Category:

Fellows of the RACP can claim CPD credits via MyCPD for listening to this episode and reading the resources below.

During the COVID-19 crisis there has been some criticism of the World Health Organisation as to whether it declared a pandemic soon enough or covered up for China’s failings. But few commentators have explained the role and responsibilities it shares with its member states in dealing with a pandemic. A prototype of the International Health Regulations were conceived during the cholera epidemics of the mid 1800s, and but the most current version of the IHR was formalised in 2005 in response to SARS. Associate Professor Adam Kamradt-Scott has documented the political and social factors that have accompanied the implementation of the IHR. In this podcast we consider how the unprecedented scale of the current pandemic and the mixed response from member states has challenged the viability of the WHO.

Credits

Guests
Associate Professor Adam Kamradt-Scott (University of Sydney, United States Studies Centre)

Production
Written and produced by Mic Cavazzini. Music courtesy of Free Music Archive includes ‘Amsterdam’ by LASERS , ‘Capgras’ by Ben Carey and ‘Let Us Overcome’ by Tayler Watts. Image licenced from Getty Images.

Editorial feedback for this episode was kindly provided by physicians of the RACP’s Podcast Editorial Group;  Rosalynn Pszczola, Li-Zsa Tan, Michael Herd, Sern Wei Yeoh, Oliver Dillon, Priya Garg, Ilana Ginges, Duncan Austin, Saion Chaterjee, Leah Krishchock and Lisa Mounsey

References

COVID-19 — a timeline of the coronavirus outbreak [Devex]
Timeline of WHO’s response to COVID-19 [WHO]
Disease Diplomacy: International Norms and Global Health Security [Johns Hopkins University Press]
International Health Regulations 2005
[WHO]
Frequently asked questions about the International Health Regulations

Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China [The Lancet]
A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster [the Lancet]
Did China downplay the coronavirus outbreak early on? [Vox]
Coronavirus Disease (COVID-19) Press Conference 28 February 2020 [WHO]
Global coordination on cross-border travel and trade measures crucial to COVID-19 response [Kamradt-Scott, Lancet]
Global Health Security Index [Johns Hopkins University]
Diseases have no borders – report on the inquiry into health issues across international borders [Department of Health]
On The Value of Viewing Antimicrobial Resistance as a threat to International Security [Kamradt-Scott, AMR]
Coronavirus pandemic shows it’s time for an Australian Centre for Disease Control – in Darwin [Kamradt-Scott, the Conversation]
Explainer: what Donald Trump’s funding cuts to WHO mean for the world
[Kamradt-Scott, the Conversation]

Transcript

MIC CAVAZZINI: Welcome to Pomegranate Health, a podcast about the culture of medicine. I’m Mic Cavazzini for the Royal Australasian College of Physicians.

Over the next three episodes we’ll use COVID-19 as a launching pad to examine some little-known politics behind global public health. Today, we’ll ask how COVID-19 has tested the World Health Organisation and specifically, its convention on pandemic preparedness and response known as the International Health Regulations. As well as all the guidelines and diplomacy, we’ll get to some of the less tangible social factors that influence health security.

The prologue to this story goes back to the third great cholera pandemic of the mid-1800s which over fourteen years devastated every inhabited continent. This is the same pandemic that put London physician John Snow and his water pump into epidemiology textbooks forever more. In 1851, twelve imperial states came together for the first International Sanitary Conference in Paris, each represented by a physician and a diplomat. The main question they wrangled over was when maritime quarantines could be legally enforced so as not to conflict too much with trade. Over sporadic reunions plague, yellow fever, smallpox and typhus were also added to the list of actionable diseases.

After World War 2, this loose confederation was reborn with 61 member states as the World Health Organisation. The earlier treaties morphed into the 1951 International Sanitary Regulations and the following decades did see wins against smallpox and typhus.But in 1991, cholera and Ebola reared their heads again and the spiralling HIV pandemic made it clear that infectious disease was not just a concern for the developing world. The prevalence of co-infections by multi-drug resistant TB further put to rest the hubris of the antibiotic era.

So in 1995 the WHO started updating its convention with the expectation that all states would now be obliged to report outbreaks as soon as possible. But the members bristled at giving up too much sovereignty, and negotiations had virtually stalled until 2003 when a new name was added to the most-wanted list; Severe Acute Respiratory Syndrome. The SARS coronavirus was carried from a wedding in Guandong China, to a hotel in Hong Kong, and then within a few days to Singapore, Vietnam and Canada. This was the first time in history that an infectious disease had globalized over a matter of days, and it then reached 29 countries over the next 5 months.

In the book “Disease Diplomacy,” Associate Professor Adam Kamradt-Scott writes how this rekindled the impetus for a coordinated effort to anticipate the next pandemic, not just respond to it. The Revised International Health Regulations, finally passed in 2005, had a framework of core capacities that every member was expected to comply with.

ADAM KAMRADT-SCOTT:             So my name’s Adam Kamradt-Scott. I’m an Associate Professor at the University of Sydney in the Centre for International Security Studies.

The big change with the 2005 IHR was that it reversed the onus of responsibility on governments with the aim or objective that governments would not only be able to rapidly identify disease outbreaks in their territory but they would contain it before it then started to spread. And so there were issues such as disease surveillance systems, versus laboratory analysis, through to capabilities to respond to chemical and biological, and radiological events,.

But there were a series of other changes such as governments were required to appoint a national IHR focal point – a direct point of liaison with Geneva. And so the World Health Organisation would be able to contact them and have them respond to requests for information or verification within a 24 to 48 time period.

MIC CAVAZZINI:               In drawing up the IHR, the WHO recognised that countries had in the past delayed in fessing up to outbreaks of infectious disease because they feared reputational damage or travel and trade embargoes against them. SARS, for example, wasn’t reported by Chinese authorities for three months after the index case was recorded in Guangdong province in November 2002. So how did the IHR propose to incentivise more timely reporting from member states?

ADAM KAMRADT-SCOTT:             So the IHR have always been designed or built around this delicate balance. So we want countries to be open and transparent and notify the WHO of disease outbreaks as soon as they detect them. And the bargain then is that if countries do that the WHO will use its normative weight as the global health authority to discourage other countries putting in place trade and travel measures. But ultimately the objective is to prevent the international spread of disease. That’s fundamentally – it’s all about saving human lives. And in that context it’s recognised that sometimes there are trade and travel measures that need to be legitimately put in place to help try and save lives. ***

MIC CAVAZZINI: The first outbreak to meet the formal criteria for a ‘public health emergency of international concern’ was the H1N1 influenza outbreak of 2009, aka the swine flu. As soon as human cases came to light in rural Mexico the information was rapidly shared with the WHO, so it was a good debut of IHR principles in practice. But it wasn’t such great news for the pigs. The Egyptian government ordered the mass culling of 400,000 animals even though there hadn’t been any outbreaks locally. Several countries also banned imports of live pigs and pork products and compensation was sought through the World Trade Organisation.

The WHO has since recognised that names like swine flu or Middle East Respiratory Virus can lead to stigma, which is why the current contagion was named simply COVID-19 for corona-virus-disease. This is now the sixth ever Public Health Emergency of International Concern, but it’s an entirely different narrative to the polio, Ebola and Zika outbreaks that came before it. Those events were much more easily contained, and the countries affected welcomed the intervention of the WHO. As Adam Kamradt-Scott and his coauthors explain in their 2015 book, the International Health Regulations were being systematically implemented by member states year by year. To find out how these norms have held up during COVID-19, I’ve followed the style of the book and mapped out a timeline of early spread of the disease, focusing in on key decision points.

Do you remember where you were last New Years Eve? Well on the 31st Dec 2019, a media statement was released on the website of the Wuhan Municipal Health Commission describing some cases of ‘viral pneumonia.’ And that’s where it would have remained were it not for a web crawler operated by the WHO called Epidemic Intelligence from Open Sources, which isn’t exactly what I imagined by the concept of disease surveillance.

ADAM KAMRADT-SCOTT:             EIOS as it’s known within WHO is a tool that scrapes the internet 24/7, 365 days a year, and as time has progressed, they’ve increased the number of languages that it does searches in. So it’s becoming much, much more comprehensive. And each day there is a series of reports that are generated, and I believe on average it’s at least about 300 every day. There’s a team of people in WHO that then go through those reports and then those reports which are identified a particular concern are brought to a management meeting each morning to review the reports and make a determination as to whether or not further information is required or requested.

MIC CAVAZZINI:               Interesting. On the 1st of January the WHO engages an Incident Management Support Team and for a couple of days requests more information from Chinese health authorities. On the 3rd of January China reports to the WHO 44 suspected cases of ‘viral pneumonia of unknown cause’. We’ll talk about some of the transparency issues later, but sticking with surveillance; as recently as July the director of the WHO Health Emergencies program, Dr Michael Ryan puts this all in perspective with the following comment. He said, “Picking up 41 unusual pneumonias in a population of 23 million people in the middle of an influenza season was like picking the needle out of the haystack. It's quite amazing that the signal was picked up.” So he’s actually saying it could have been a lot worse if the surveillance wasn’t up to scratch. Is –?

ADAM KAMRADT-SCOTT:             Is that a reasonable conclusion? Yes it is because also obviously at that time it’s winter and it just goes to show how refined the system has become over the last decade or more since it was introduced. So it should give everyone a little bit more confidence in the future that we are actually picking these things up when we need to. But again this is the advantage that we’ve seen develop as a result of the WHO’s ability to access non-government official information. Prior to that the WHO had only been able to take action if a government reported a disease outbreak officially. And so governments were getting quite sneaky with how they would try and circumvent using the word ‘cholera’. So they would turn around and say, “We’ve got an outbreak of acute watery diarrhoea disease” – rather than use the word ‘cholera’ because then other countries would put in place trade and travel sanctions.

MIC CAVAZZINI:               On the 7th January China announces that a coronavirus is responsible for the infection – in fact a sister of the SARS coronavirus. On the 11th the genetic sequence of the novel coronavirus is shared by Chinese scientists and within days the WHO publishes a protocol for a diagnostic assay. On the surface this looks like model compliance and suggests that China has learnt from the blowback for its handling of SARS. But it later turns out that a government lab has been sitting on this information for over a week due to a fierce publish or perish mentality between competing Chinese labs.

ADAM KAMRADT-SCOTT:             You know, and certainly in January when we heard news of this outbreak, I myself was out publicly commenting and saying what a great job the Chinese government had done because they’d been so forthright and transparent. The Chinese government was very embarrassed by the SARS outbreak in 2003 and the timeframe in which the Chinese authorities notified WHO had reduced from the SARS period by about six weeks – so that halved. They’d gotten a bit better, but not tremendously.

MIC CAVAZZINI:               So on the 13th January the first confirmed case outside of China was reported in Thailand – a Wuhanese woman who said that she hadn’t visited the Huanan market. The next day the WHO puts out this Tweet: “Preliminary investigations conducted by the Chinese authorities have found no clear evidence of human-to-human transmission of the novel coronavirus.” Behind the scenes, though, the WHO were begging for more information. On the 20th WHO investigators in Wuhan recognised that healthcare workers were getting sick. This is what would be known as a Phase 3 in the Pandemic Influenza framework. A few days later on January 24th, the Lancet published a case series by Chinese medics showing that the first case of atypical pneumonia had presented symptoms on December the 1st – not the 12th as Chinese authorities had stated.

That person, and indeed a third of the cases known at the time had not been to the Huanan seafood market at all. Another study in the same issue showed that transmission between family members was already suspected on the 10th of January, ten days before official warnings by Chinese health authorities. So would ten days – that ten-day window – have made a critical difference?

ADAM KAMRADT-SCOTT:             As with any disease event time is everything. This is why governments have 48-hours in which to verify whether or not a disease event is occurring. Because in that time, and particularly with something like COVID which is spread through droplet form, in that context obviously ten days could see something get away – and that’s pretty much what happened. It was later revealed President Xi Jinping had known about it for quite some time.

MIC CAVAZZINI:               There’s a good analysis of these research findings in Vox and it’s not obvious whether errors were due to deliberate misinformation, or bureaucratic rigidity or, less cynically, “the fog of war'” as they call it, at the clinical frontline across different hospitals and clinics. But by the 21st of January South Korea and the USA confirmed their first cases of COVID-19. The WHO Emergency Committee of the IHR was convened but Director General Dr Tedros Ghebreyesus and announced that the outbreak shouldn’t at this state be declared a public health emergency of international concern. Within China they were restricting movement within the cities of Wuhan and Huanggang and travel through Hubei province, and Beijing cancelled its Lunar New Year festivities. Would Chinese authorities have been following a formula, now that they knew there was increasing person-to-person transmission?

ADAM KAMRADT-SCOTT:             So the Committee structure system is a process whereby decisions are made about the types of measures internationally, but it’s always still very much up to the individual member state as to what they do domestically. That is considered sovereign territory and so I wasn’t privy to the IHR Emergency Committee discussions. We understand from the reporting that that first Committee meeting was – that opinions were divided which is why they didn’t then recommend declaring a public health emergency. And from what I understand that there was also some diplomatic manoeuvring from the Chinese government to say, “Look, we are putting in place these measures – just hold off.” Now again, that’s on hearsay and second-hand reporting so we don’t really know exactly the level of diplomatic pressure that may have been applied.

MIC CAVAZZINI:               On the 25th of January, so four days later, four travellers returning to Australia from China tested positive for COVID-19. Over the next five days cases were detected in Singapore, Vietnam, France, Nepal, Malaysia, Canada, Cambodia, Germany, Sri Lanka and the UAE. By the 30th of January there were over 7,800 cases worldwide and 170 deaths, still within China. The IHR Emergency Committee was reconvened and the COVID-19 outbreak was now declared a public health emergency of international concern. So what resources and actions kick in at this stage that weren’t available before?

ADAM KAMRADT-SCOTT:             So by this stage the WHO Health Emergency Program was already on full alert. The recommendation to declare a public health emergency obviously brings – the only real benefit that that brings per se is that it really raises the profile of the event. So it’s the highest alert level that the WHO can issue. As a consequence of that, we sometimes see then that once WHO does declare a public health emergency then we see other governments then willing to put in resources and funding. But largely it is a political tool to say, “We’ve got a problem here folks, and you need to pay serious attention to this, and put measures in place.”

MIC CAVAZZINI:               In the two days after the declaration of public health emergency of international concern, cases of COVID-19 were reported among travellers returning to the UK, Russia, Sweden, Spain and Belgium. Then the Philippines and Hong Kong announced the first deaths outside China. Australia implemented a “do not travel” advisory for China and started quarantining non-citizens arriving from there.

On the 2nd February the US closed its borders to all foreign nationals earning a rebuke from China not to overreact and cause panic. On the 11th the death toll reached 1000, surpassing the 774 killed by SARS and the 858 death toll from MERS in 2012. The first case of COVID-19 in the Middle East was confirmed in Egypt on the 14th February. Over the following days Iran, Lebanon and Israel also raised their hands and the death toll quietly toll crept past 2000.

The WHO was publishing countless strategic documents and guidelines, apps and alerts yet little of this seemed to be sinking in. In the last few days of February the virus hit 25 more countries in Europe, the Middle east, and in Africa. New Zealand detected its first case of COVID-19, and Mexico and Brazil became the first casualties in Latin America. The WHO raised the alert to phase 5, which means there is sustained community transmission and a very high risk of global spread. But not yet a pandemic.

At a press briefing on the 28th, Dr Michael Ryan of the WHO Emergencies program gave the following warning; “We can say, and I’ve said in previous press conferences if this was influenza we would probably have called this as a pandemic by now. But what we've seen with this virus is that with containment measures, with robust public health response the course of this epidemic, or these multiple epidemics, can be significantly altered… If we say there's a pandemic of coronavirus we're essentially accepting that every human on the planet will be exposed to that virus. The data does not support that as yet and China have clearly shown that that's not necessarily the natural outcome of this event if we take action, if we move quickly, if we do the things we need to do that does not need to be the history of this event. But if we don't take action, if we don't move, if we don't prepare, if we don't get ready that may be a future that we have to experience and we have to endure. So, much of the future of this epidemic is not in the hands of the virus. A lot of the future of this epidemic is in the hands of ourselves … and health systems around the world — and I mean North and South — are just not ready.”

A day later, the WHO published advice on the limited circumstances when travel restrictions might be permissible. But it still maintained that travel bans have a “significant economic and social impact," and indeed there have been profound consequences on the movement of health personnel and resources to places of greatest need. A polio outbreak in Niger has gone unstemmed since April and the Stop TB Partnership says that lockdowns around the developing world could cost five years of progress against tuberculosis. They estimate an additional 1.4 million deaths by 2025. Adam Kamradt-Scott has written about the mixed evidence for effectiveness of travel restriction strategies in a commentary for the Lancet.

ADAM KAMRADT-SCOTT:             I’m actually involved in a research project and its multinational team looking at this very issue as to the measures that countries have put in place. And what we found is that the range of measures have far exceeded what were every envisaged under IHR. We still don’t know the public health benefit of these border measures and now the big lot of work to go ahead really is trying to evaluate the effectiveness of these measures. And it is obviously a viable option for island-based countries to implement. Obviously, flight cancellations to Pacific Islands has worked because a lot of the Pacific Islands have recorded either no cases or very small cases. The challenge is really around the other countries that have common land borders where people can move between them.

And again, keeping in mind that IHR was designed around a repeat of SARS. At the time WHO issues a series of temporary recommendations directly to travellers saying, “Please don’t travel to SARS affected areas.” And what we saw as a practice since then is that WHO has really refrained from ever making those sorts of statements ever again, because they do have economic consequences. And the Secretariat learned pretty quickly governments don’t like it when they delve into that sort of area.

MIC CAVAZZINI:               But are they – are they sort of existing policy tools that have been set up for this purpose because that’s in the IHR core capacities or are they emergency measures that have come out of the blue?

ADAM KAMRADT-SCOTT:             Well in the Australian context obviously we’ve got the Quarantine Act of 1908 which was then incorporated into the Biosecurity Act of 2015. So that gives the Federal Government this authority to respond to a pandemic. And because we also don’t then have a bill of rights it means that we don’t have the protections that some other countries do. So in Canada during SARS for instance there were members of the public that had been forcibly quarantined that then took the Federal Government to their equivalent of the High Court claiming that was an infringement of their civil liberties. We don’t have that. And the IHR does specify that the quarantine is a reasonable public health measure where it’s justified. But again, you’re not meant to do it arbitrarily – you’re meant to have a very strong scientific rationale for implementing those measures.

MIC CAVAZZINI:               Australia’s first death to COVID-19 occurred on the 1st of March. Over the next week the virus was reported in another 38 countries including the Dominican Republic and the Maldives. On the 7th and 8th the landmarks of 100,000 cases and 100 countries affected were surpassed. On the 9th of March the WHO was still equivocating around using the “P” word while over a couple of days the virus reached another 16 countries, largely around the Caribbean and west Africa. Finally, on the 11th of March, the WHO made the assessment that COVID-19 could be characterized as a bona fide pandemic. What does this declaration change in terms of global or local coordination, in the context of the fact that they’ve been criticised for not doing it so much since?

ADAM KAMRADT-SCOTT:             Yeah, so some people have made the argument that the WHO’s decision to declare a pandemic, or not declare it, or delay declaring it, was meaningless and it has no impact on a public policy or practical level. And they are right to some degree. Having said that a number of governments around the world also have developed their own pandemic preparedness plans and have pegged those plans to WHO’s framework, because they were encouraged to do so. So the declaration actually does have meaning to a number of countries, because it means that their pandemic plans also automatically kick in. So there are – it wasn’t a nothing event. Nor was it though something that was then going to radically change the global response at that point. And I think that’s where WHO’s frustration again started to come through because they’re like, “We’ve been telling you – you need to get ready, you need to put systems in place, and you need to have done it like weeks ago.” So they’re like, “Whether or not we declare this a pandemic or not is irrelevant. You need to prepare for this thing and put those systems in place.”

MIC CAVAZZINI:               I think that was Michael Ryan’s comment, that public health emergency was already the highest level of alert – “you should’ve been listening”.

ADAM KAMRADT-SCOTT:             Yes.

MIC CAVAZZINI:               Must be feeling like Cassandra of Troy.

ADAM KAMRADT-SCOTT:             Yes. And the concern associated, and I think it was Mike Ryan that also made the comment, that one of the reasons why they were hesitant to use the word pandemic was that they were worried that some governments would then just simply throw their hands up in the air and go, “Oh it’s all too hard – and let the virus sweep through then.” And we see that sort of fatalism when we think about another public policy issue with climate change. You know, there’s a similar sort of reaction – it’s like: “We need to do something, we need to do something – oh, it’s all gone to hell in a hand basket.” So again, probably understanding human behaviour you can appreciate why they were reluctant in some respects to use that term.***

MIC CAVAZZINI:               The fatalism that Adam Kamradt-Scott mentions highlights another variable in effective public health coordination. Human behaviour. All the policies and declarations and science can go out the window with a few ‘animal spirits’ to borrow a term from economics.

We’ve talked about the IHR core capacities. I found one scorecard for assessing laboratory systems all the way from the coal face to the top levels: “Does the relevant Ministry have a dedicated unit [and budget for] …  health laboratory coordination?” “Do representatives from reference laboratories routinely participate in outbreak … preparedness and management meetings?” There are 240 items and to be honest it’s hard to imagine anyone having the patience to go through it.

There’s another metric out of out of Johns Hopkins University called the Global Health Security Index which scores in even more detail areas like “Early Detection and reporting”, “Rapid Response and Mitigation”, “Sufficient and robust health system.” Ranked 1 and 2 over all, and with high distinctions in most categories, are the United States and the United Kingdom. At time of publication, however, these two countries rank 1st and 5th for the total deaths to COVID-19. As a proportion of population their death rate is 10th and 11th highest, compared Vietnam down in 188th place. That’s a country with an economy less than 10% the size of the UK’s, and which ranks only 50th in terms of preparedness.

I wonder if the IHR capacities or the GHS index miss out something even more important than all those granular metrics. You probably heard about the song released by the Vietnamese health department to encourage hand washing- the catchy electropop tune prompted a host of fan dance videos that went viral. And people didn’t resent the requirement to wear face masks in public- in fact these have been commonplace in busy Asian metropolises since the SARS outbreak. I’ve always thought this represented a greater civic duty, and indeed the Vietnamese Prime Minister’s has stated; "Each citizen is a soldier, each house, hamlet, residential area is a fortress in the fight against the pandemic."

Compare this to the people in protesting in our streets with some perverse idea that facemasks and lockdowns are an affront to their individual rights. I’m afraid to say I’m just one of the 19 million Australians who didn’t bother to download the COVIDsafe app. Fancy technology aside, communitarian behaviour needs to be modeled by respected leaders before its taken up by the rest of us. Sociologists call this process norm socialization, and its applicable to the behaviour of countries too. In his book Adam Kamradt-Scott uses this lense to gauge the slow but steady adoption of IHR values and capacities since 2005.

ADAM KAMRADT-SCOTT:             So this was a framework developed by two academics by the name of Martha Finnemore and Kathryn Sikkink back in the 1990s, where they were trying to unpack exactly how is it that we see the emergence of new standards for instance around human rights or arms controls – so the landmine agreement. And what we’ve done with that book “Disease Diplomacy” is apply that model to new developments that were being proposed with the revision of the IHR. And what we saw was that some governments were really quite willing to accept these new developments while other governments were very resistant towards it. So in this framework the governments that are out the front – we call them the norm entrepreneurs and the norm leaders – versus then the norm followers, the people that are sort of dragged along a little bit later. Because by that stage there comes a tipping point where they realise politically we kind of have to go along with this.

MIC CAVAZZINI:               It’s embarrassing not to be a part of the club.

ADAM KAMRADT-SCOTT:             Exactly. Now there’s been also some work around that framework further by some other academics that talk about norm antipreneurs now, and we are certainly seeing evidence of that. Again, particularly in this space whereby some governments objecting to what they see as a western driven agenda are trying to offer a different pathway and are consistently sort of playing a spoiler role in international negotiations.

MIC CAVAZZINI:               The book was published in 2015 and up to that point there were many countries that hadn’t met the minimum IHR requirements for pandemic preparedness, and 36 of them said they had no intention of doing so. But you maintain that this was almost always about economic means to do so rather than lack of political will.

ADAM KAMRADT-SCOTT:             That’s right. And I was fortunate enough – I was doing my PhD over the UK at the time – and I was fortunate to be able to participate in the IHR negotiations. And I recall very distinctly that there was a timeframe for developing these core capacities that were built into the IHR. And low income countries at that time at that meeting said, “We will agree to this timeframe but you need to help us.” And wealthy countries listened to the first half of that statement and ignored the second. And it wasn’t really until around 2012 to 2014 – finally in 2014 we see the Obama administration put in place the Global Health Security Agenda. And its focus was explicitly on trying to help countries build these core capacities – those countries that hadn’t yet got them in place. And I think COVID really – I would certainly hope that on the other side of pandemic there is going to be a lot more focus and commitment to actually helping all countries put in place these core capacities.

MIC CAVAZZINI:               Donald Trump obviously – Donald Trump has been heavily criticised for the horror show in America’s response to COVID, and in mid-July he makes good on a threat to withdraw the US from the World Health Organisation, saying that “they missed the call" and covered up China’s failures. The US contributes $116 million and more to the WHO every year – several times as much as China which is the next biggest donor. So yeah, the US alone makes up a quarter of the organisation’s entire budget. What will the loss of the US’s support for the WHO mean for its – let alone capability to operate on the ground – what will it mean for its standing amongst other member states?

ADAM KAMRADT-SCOTT:             That’s a very good question. So the United States was the only country to lodge a reservation when they joined the WHO that they reserve the right to withdraw. There is no provision in the constitution for member states to withdraw from the organisation once they have joined. So if Donald Trump gets re-elected and if he follows through on his threat, it really is quite alarming on many levels from a global public health perspective the impact that it would have on funding of WHO programs will be significant. Some initiatives will shut down likely, as a result. It’s going to be really challenging. And the US has been a very big supporter and driver of WHO, and there’s a lot of exchange between – at the technical expertise level – between the United States and WHO.

MIC CAVAZZINI:               To carry that theme further, even in September 2019 Trump had addressed the UN General Assembly with the message that "the future does not belong to globalists but to patriots". And days later our own Prime Minister used a foreign policy speech to warn that Australia would not be dragged into “negative globalism" or to be stymied by "unaccountable internationalist bureaucracy.” And he was specifically batting off criticism of Australia’s approach to carbon commitments and refugee conventions. But as global conventions it can’t help the legitimacy of the WHO and the International Health Regulations when member states pick and choose which agreements they’ll honour and which ones they’ll ignore?

ADAM KAMRADT-SCOTT:             Yeah, I mean this is – thankfully – let me say this: thankfully the Australian government has made it quite clear that they’re not going to follow Donald Trump in withdrawing from the World Health Organisation. And that is not the way to go. So –

MIC CAVAZZINI:               No. No, but even just the symbolism of saying, “Well we’re not going to follow the Paris targets.” Would that give another country an excuse to say, “Well we’re not going to follow the IHR”?

ADAM KAMRADT-SCOTT:             Yes. And if the United States does ultimately withdraw the other element to it is that after – for all the hubris about how claiming that it was too much in China’s pockets, Donald Trump has now gifted the WHO conceivably to China and Russia who will use that political opportunity to exert more influence and try and shape the organisation to what they want to see it do. So Trump is actually creating the very circumstances which he’s criticising them for.

MIC CAVAZZINI:               Again, the book was published in 2015. You describe that the uptake of the IHR in sort of fits and starts, and one of the sticking points was that WHO would have access to informal advice, bypassing government health departments. And you wrote that this kind of understanding, this agreement had – and I quote – “shifted the balance between sovereignty and health security.” Would you still make that claim today with all that we’ve talked about and vaccine nationalism, and so on?

ADAM KAMRADT-SCOTT:             When it comes to detection of disease outbreaks, yes. I mean the system is still in place, and even if the United States withdraws from it it’s not going to be – that system is not going to be adversely affected. What we are seeing is at the same time obviously the development of the vaccine has been a race, and it’s a ‘me first’ race. So there are still big limits to this idea of globalist approaches because governments go off and do their own thing.

The thing that probably keeps me up at night at the moment though is that the window of opportunity to try and bring everyone together is already rapidly closing. And my concern is that on the other side of the pandemic governments will very quickly shift from responding to the crisis to: now we’re going to focus on economic recovery – without then wanting to spend money on building public health capacity to prevent the next COVID. And so when we are thinking about what comes next in terms of the framework and multilateral agreements that we want on the other side of this, we have to think carefully as to what sorts of new requirements we’re going to insist on, what penalties and enforcement mechanisms are going to back them up.

Because that’s the big problem with the IHR at the moment, there’s no penalty for governments doing the wrong thing. There’s nothing that the WHO can do to a member state that flagrantly breaches the IHR except to effectively try and name and shame them. And we’ve seen that the WHO’s been very reluctant to do that. When I’ve asked former members of the WHO legal counsel why that is the case they pointed out the fact that, “Well, WHO doesn’t have an adversarial culture with its member states.” Because you can imagine that if they do then members states also – so they’re both the people that WHO serves but they’re also its boss. So they can react and respond by putting in place new measures, cut the budget – do all sorts of things to limit the WHO’s powers further.

MIC CAVAZZINI:               And there was a Professor for globalisation and security risks, or something, at Oxford University – Ian Goldin, I think his name is – who said, “There’s no use blaming Director Tedros or Michael Ryan – they’re just staffers. The WHO is its member states.” And it’s the members that have allowed the authority and the financial viability to wither.

ADAM KAMRADT-SCOTT:             Yes. And the reason why the IHR are toothless is because member states designed it that way. And this was the thing, so with the 2003 SARS outbreak – anyone can go back and have a look at this – you look at the transcripts of the World Health Assembly that year in May 2003. Government after government after government is praising the WHO for its strong management of the SARS crisis, and for calling out China, because it had done the wrong thing in trying to hide news of the outbreak. In the intervening years governments get together, and they’re like, “Yeah, it was good back then, but what happens if it was you next time?”

And for that reason we saw the introduction of new measures designed to try and curtail the WHO Secretariat from acting so autonomously. And the Emergency Committee is the classic example – that’s probably one of the clearest examples – is like: “No, actually we don’t want you just making these judgement calls yourselves. You are bureaucrats, you don’t have the authority to make those calls, so we’re going to insist that there’s an expert committee that you have to consult with that we have an opportunity to feed into. And it will be on the basis of that, that you get to then call a public health emergency or not.” ***

MIC CAVAZZINI:               Many thanks to Associate Professor Adam Kamradt-Scott for contributing to this episode of Pomegranate Health. I’ve put links to his articles and book at our website racp.edu.au/podcast. There are heaps of additional references embedded in the transcript of the story too. I want to give special credit to the journalists at Devex, for much of the excellent COVID timeline I borrowed.

At the website you’ll also find music credits and individual thanks to all the editors of the podcast editorial group who help to tighten this story up. Thanks especially to Associate Professor Peter Hill, who conceived of this theme for RACP Congress. You’ll hear from him in our next episode about the intellectual property rules that govern medications and vaccines- and whether COVID-19 might reshape this 25 year old system. In the third podcast of this series we’ll talk about Australia’s role in pandemic preparedness for the region- and whether health security comes at the expense of more important development goals.

If it’s your first time listening to the Pomegranate Health, you can browse every episode using a podcast aggregator app on your smart phone. There’s also a subscription list at our website that will alert you by email every time a new episode is published. I hope you like what you hear. The views expressed in this podcast do not necessarily represent those of the Royal Australasian College of Physicians. I’m Mic Cavazzini. 

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20 Oct 2020
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