Coronavirus Outbreak
One of the fastest moving global news stories of early 2020 has been the spread of the coronavirus. Sourced back to Wuhan, China, the virus has reached over 7,000 confirmed cases worldwide according to the latest data from the World Health Organization. The World Health Organization is deciding again whether to declare a Public Health Emergency of International Concern (PHEIC), a major move that would intensify the global response.
The World Health Organization’s (WHO) Role
What is the World Health Organization’s role in a situation like this? Ambassador John E. Lange, previously a U.S. Special Representative for avian flu and pandemic flu preparedness and currently a senior fellow for global health diplomacy at the United Nations Foundation comments on the current coronavirus outbreak in a podcast interview of Global Dispatches. “When SARS first came about [in 2003] it really sent shockwaves around the world because there was so much fear and confusion.” He goes on to say that SARS spurred changes in International Health Regulations. Each state that signed onto the agreement, now over 194 countries, are legally bound to follow the updated international health requirement “to build their own capacities to detect, prevent, and respond to emerging health threats.” It established norms and guidelines to share information and respond quickly to growing health threats with the World Health Organization. The World Health Organization coordinates the reporting and responsiveness of global health threats on an international level.
Public Health Emergency of International Concern (PHEIC)
Dr. Tedros, the Director-General of the World Health Organization, met with Xi Jinping, the president of China in Beijing to discuss the coronavirus outbreak. Dr. Tedros himself said afterward, “stopping the spread of this virus both in China and globally is WHO’s highest priority”. Ambassador John Lange continues to say, “so it’s very clear that they’re fully geared up on this and working with the government of China and other countries that are affected to try to provide the information that they need. How to diagnose the virus, how to manage cases, how to connect surveillance efforts from different countries, etc., all with the goal of reducing transmission and eventually stamping out what seems to be a growing epidemic and maybe a pandemic.”
Invoking a Public Health Emergency of International Concern (PHEIC) is essentially the most dramatic step that the World Health Organization (WHO) can take. According to Lange, to declare a PHEIC, three criteria must be met. It must be an extraordinary event with a risk that constitutes public health risk to other countries and requires a coordinated international response.
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Mark Goldberg: (00:32)
At the time of recording the coronavirus outbreak that originated in China has infected over 4,500 people though that number is sure to dramatically increase in the coming days. The vast majority of the people affected by this outbreak are in China. Though infections have been confirmed in at least 14 other countries. And again, the number of countries impacted will certainly increase in the coming days. There is still a lot we do not know about this virus and the outbreak, but we do know that this coronavirus outbreak is poised to become a major global health crisis. So for this episode, I wanted to give you a sense of the kind of global health infrastructure that exists for exactly moments like this on the line with me to discuss. The international response to this outbreak so far, including actions taken by the world health organization is ambassador John E. Lange He is a retired ambassador from the United States who currently serves as a senior fellow for Global Health Diplomacy with the United Nations Foundation.
Mark Goldberg: (01:47)
Ambassador Lange also served from 2006 to 2009 as the U.S. special representative for avian flu and pandemic flu preparedness. This gives him some unique insight into how both the U.S. Government and entities like the World Health Organization respond to these kinds of fast-moving outbreaks. We kick off discussing the WHO’s role in managing the global response, including the relevance of something called the 2005 International Health Regulations. We also discussed potential scenarios for this outbreak to turn into a pandemic that could deeply impact poor countries with weak health systems. Now at the time that I spoke with ambassador Lange, the World Health Organization had not yet declared that this outbreak constituted a Public Health Emergency of International Concern. However, by the time that you are listening to this, they almost certainly will have done so. And we do discuss in this episode at length what a public health emergency international concern means and why it’s so significant.
Mark Goldberg: (03:03)
So this episode, obviously, is dealing with a fast moving global news story. And whenever I approach those kinds of stories on the podcast, my intention is always to give you context. You need to understand events as they unfold. So that was my intention with this episode. I think you will appreciate it. Also, I think one thing this episode does hammer home is the need for more global health professionals. And if you’re thinking about pursuing a career in global development or global health, I do strongly encourage you to check out Northwestern University’s online master’s program in global health. You can learn how to make a meaningful difference in places where it is needed. The most go to sps.northwestern.edu/global or click on the add on globaldispatchespodcast.com to learn more. And if you have any questions about that graduate program, please reach out to me directly. And I’m happy to put you in touch with the good folks at Northwestern. All right. And now here is my conversation with ambassador John E. Lange of the United Nations Foundation.
John E. Lange: (04:18)
today January 28th, Dr. Tedros met with the Chinese president, um, as Xi Jinping in Beijing and with him or of the WHO Regional Director for that region plus the head of the who emergencies program, Dr. Mike Ryan. So you, you’re dealing with the highest-level people in WHO, who will focus on this particular issue. And Tedros himself said afterward, stopping the spread of this virus both in China and globally is WHO’s highest priority. So it’s very clear that they’re fully geared up on this and working with the government of China and other countries that are affected to try to provide the information that they need. how to diagnose the virus, how to manage cases how to connect surveillance efforts from different countries, et cetera, all with the goal of reducing transmission and eventually stamping out what seems to be a growing epidemic and maybe a pandemic.
Mark Goldberg: (05:24)
So what is the world health organization’s role in a situation like this? Like what can the WHO do and what can the WHO not do in these kinds of situations?
John E. Lange: (05:35)
The specific role for WHO in this case stems from the international health regulations. That’s something it may not sound very exciting when you say it stems from regulations, but it’s really one of the few areas of international law dealing with global health that the regulations themselves STEM from efforts way back in 1851 when there was the international sanitary conference and the efforts then to revise the International Health Regulations over the years occurred to the point where they had to be expanded from their original focus, which was just cholera plague and yellow fever. And in the early two thousand the severe acute respiratory syndrome, SARS came about and that really spurred the effort to finalize the new regulations that were finally adopted by the World Health Assembly. That’s all the member states of WHO, now 194 countries. In the year 2005.
Mark Goldberg: (06:43)
So you’re seeing, it was really like the, um, the problematic global response to the SARS outbreak, which also was a coronavirus that originated in China, um, in 2003 that led to a revamping of these new International Health Regulations in 2005. What went wrong in 2003? And how does that 2005 International Health Regulations sort of offer a remedy to what went wrong?
John E. Lange: (07:12)
Yes. When SARS first came about in February 2003 and ended up killing a 774 people and infecting 8,098 people it really sent shockwaves around the world because there was so much fear and confusion. What was the cause of this what was the source? The modes of spread the appropriate interventions, et cetera. And SARS had a 9.6% case fatality rate, which is about triple to what the current novel Coronavirus has. And there was a question of what seemed to be a lack of transparency on the part of the government of China. so the, this, while there had been contemplation of updating these International Health Regulations prior to SARS, SARS really spurred this and they were quickly produced by 2005 and so that it would bring about a, a fundamental requirement on the part of every government that signed up for this.
John E. Lange: (08:18)
And every member of who did sign up for it that they would accept the legally binding requirement to build their own capacities to detect, prevent and respond to emerging health threats. And it establishes important norms and guidelines to share information and, and report quickly possible health emergencies of international concern to the world health organization. so that this can be coordinated at the global level by who. So who is really the repository of the secretary at for the International Health Regulations? And it really has set the norm for how countries should respond and be transparent in their response. And it really has made a major difference in global health.
Mark Goldberg: (09:11)
So how, how are you seeing the International Health Regulations being applied today in response to this coronavirus, for example?
John E. Lange: (09:21)
Well, for one thing there’s a the importance of transparency. Now. Dr. Tedros has said that he appreciates the seriousness with which China is taking the outbreak and its commitment from the top leadership and the transparency. It’s demonstrated including sharing data and genetic sequence of the virus. There have been some who’ve complained that China should be more transparent than it has been in terms of sharing not just the information, but also the data. But on the whole, I think this is a, and I’m not the expert on this, but I think its much better emphasis on the transparency than, than was witnessed back in 2003. So that’s a clear example of how the IHR have made a big impact. But I think the biggest area in this is the public that whether or not who will declare a Public Health Emergency of International Concern.
Mark Goldberg: (10:30)
What’s your preferred nomenclature?
John E. Lange: (10:32)
I like PHEIC.
Mark Goldberg: (10:34)
Well, we’ll go with PHEIC, but if that’s based off stands for the Public Health Emergency of International Concern. And this is essentially the most dramatic step that the World Health Organization can take by to invoke this emergency, which I suppose probably triggers other aspects of the international health regulation. Can you just sort of describe the process that leads to that declaration? Because as we’re speaking now, that declaration has not been evoked. There was one meeting of outside experts that are advising the executive director, the director of general of the World Health Organization on this. But in that meeting they declined as of yet to declare that emergency. Um, could you describe the process behind the PHEIC and then if the PHEIC is declared what that means in terms of those international health regulations, what additional obligations are required by a member states, the world health organization upon that declaration?
John E. Lange: (11:36)
Yes. The, um, the, the way the PHEIC is defined, it’s, there are basically three essential criteria. it needs to be an extraordinary event with a risk that the constitutes of public health risk to other countries through international and potentially requires a coordinated international response. Now the director general does not just make this decision on his own or on her own. His, Dr. Tredos, his predecessor was Dr. Margaret Chan. instead, there is an emergency review committee that meets, and these are true experts in public health. and they meet that they did last week to discuss whether or not they will recommend to the director general to declare a PHEIC. and that then it is up to the director general to make the decision. When the committee met last week, it was split down the middle and in terms of whether or not to recommend to the director general to declare one, and he decided not to declare it at that time.
John E. Lange: (12:49)
I myself was surprised by that. I thought it met the definition of a Public Health Emergency of International Concern. But I have to say, I’ve since heard from some people who believe otherwise, that there just wasn’t enough data. They weren’t sure whether it was any worse than seasonal influenza. The severity at that time wasn’t yet clear. And there was also concern about the economic and trade implications because once a peak is declared, then that can trigger actions in terms of tests for people entering countries to determine whether or not they’re ill. and other things that can have economic and trade implications. So the decision, and I, I would put, from what I can gather, it was a close one was that it was not this international emergency of international concern.
John E. Lange: (13:50)
But I have to say, if you just look back and look at how this has progressed on January 20th eight days ago from today, there were over 200 infections reported. today we now have a total of over 4,500 infections reported. and while there were three deaths back that were known on January 20th, it’s now up to 106. So this has really become much bigger just in days. and it includes 73 cases outside of China. So it has, the international spread has become clearer. I was just on a conference call earlier today with, um WHO staff saying that once the director general returns from China to Geneva, they expect that he soon thereafter we’ll reconvene that emergency review committee to determine whether or not now is the time to declare this PHEIC.
Mark Goldberg: (14:48)
And so assuming a PHEIC is declared, um, what happens then? Like what, what is incumbent upon both the WHO and also WHO member states? Like, I guess my understanding is that in part it’s a bureaucratic designation that for one allows, for example, the expedited, you know, visa approval of WHO experts and other international health officials to visit affected sites. Um, are, are there like other aspects of the International Health Regulations that are relevant? Um, to this situation if, if that emergency declaration is, is declared.
John E. Lange: (15:24)
What happens is it, first of all, it’s, it clearly puts all countries in the world on notice that this is a global concern and that’s then likely to trigger actions. And those actions are, are clearly needed. And already being anticipated. the Bill and Melinda Gates Foundation, for example, yesterday announced that they were giving $10 million, $5 million to entities in China and also $5 million to the African centers for disease control and prevention so that they can help improve the preparedness on the part of African governments. And that’s along the lines of what one can expect globally once a PHEIC is declared, because it does trigger those international actions now WHO normally doesn’t recommend travel restrictions, but those, um but, but it has developed guidance for travelers and for airports and other points of entry. And that’s the kind of thing that will kick in once a PHEIC is declared and so it basically, it puts the entire world on a higher state of vigilance.
Mark Goldberg: (16:40)
So from 2006 to 2009, you served in the State Department as the Special Representative on Avian and Pandemic Influenza. Presumably you, um, game planned and went through various scenarios for situations like this. Can you just sort of discuss what, how that experience is informing how you’re understanding this developing situation and what sort of preparations the U S government for example, would be making in a situation like this?
John E. Lange: (17:12)
Yes. While I’m no longer in the State Department that whole experience is informing me, but I have to say there are people who were very much involved in the planning for a possible pandemic influenza stemming from the H5N1 virus back in that period, 2006 to 2009 when I was working on this, who are still in the U.S. Government including at CDC at very high levels. And all of that kind of preparedness that was done in the past helps to develop, the responses to the current situation. And even though this novel coronavirus is not influenza, many of the things that one does and needs to do are similar. For example, there were a lot of, studies and modeling done during the presidency of George W. Bush on the idea of whether the U.S. Government should close its borders to keep out the pandemic.
John E. Lang: (18:20)
and all the conclusions were that it would give only maybe a week’s worth of gain if you tried to close the border because there’s just no way to completely seal off the United States. And you can’t just do that kind of thing without having major disruptions to not just people crossing borders, but the trade could really cause much more harm to the U.S economy than any good by gaining a strong short amount of time, by closing the border. So that’s something that I would assume will apply now also, and particularly since we already have some cases in the United States and people being checked, right as we speak on as to whether or not they have the novel coronavirus. it’s just the kind of thing where it sounds easier, it sounds so obvious. Well, let’s just close the border and we’ll keep it out. And all the studies and modeling indicate that that won’t work. So that’s one of one example of some of the studies that were done to prepare for pandemic influenza that would apply now
Mark Goldberg: (19:35)
In the coming weeks and even days. Are there any indicators that you’re going to be looking to that will suggest to you one way or another, how this situation is, is unfolding?
John E. Lange: (19:49)
Yeah, we’re talking about days and maybe a few weeks be is to see how this unfolds. one of the keys is human to human transmission. if that is self-sustaining that is a major concern. and that was the concern back when we were worried about H5N1 which was known as bird flu. you had just a few cases within families of human to human transmission, but mostly it came from very close contact with poultry that were infected by H5N1 in the case that we’re dealing with now with the novel coronavirus initially it seemed that the only people who got it were at these wet markets in Wan in China and those live markets with the animals. And some speculate that this came from bats.
John E. Lange: (20:43)
They were the ones who were getting it since then there been human to human transmission and it’s already present in most if not all major cities in China. so that’s probably the single most important factor in my mind as to what the future of this holds. Another factor is what an expert would call the ‘are not’ factor. It’s the reproductive level. And, and if it reproduces at a level of less than one, in other words, every individual insect less or fewer than one other person, then you then eventually this dies out. If it’s more than one, then it will spread. And right now the estimates are it’s about 1.5 to 3.5, so that and while it’s very early to get some of these estimates, if that were to continue, that would mean this will spread and not be quickly eliminated. And once it is spread, then one of the key things is to limit the population mobility and what they call ‘social distancing’. And what they’ve already been doing in China, especially at the time of the Lunar New Year Celebration there is to cancel mass gatherings and closed schools and you can urge people to work from home, um, and other things so that by limiting that population mobility, you can try to keep many people from being coming infected.
Mark Goldberg: (22:13)
Um, okay. Well this, is there anything else you think is worth emphasizing or discussing or pointing out about the global response or, you know, just in general the situation?
John E. Lange: (22:25)
Yeah, I think one of the important things that’s come about in the years since SARS is not only the international health regulations, but certain norms for sharing of data. For example, the Global Initiative on Sharing Avian Influenza Data, called GISAID, is a platform for open and timely sharing of influenza data and for building trust. and the theory is that transparency brings about confidence, which, which brings about rapid sharing of critical data. And China has released genome sequencing and China, Japan, Thailand, Taiwan in the U S have been sharing genetic sequence and metadata in this situation. And that’s so it’s, it’s not just a matter of one entity out there who, and it’s International Health Regulations that are dealing with this globally, but others also that, that are working to help scientists analyze the pharmaceutical industry will be working on vaccines once the viruses themselves are available for that.
John E. Lange: (23:45)
And that will possibly then become a longer term solution even though it takes many months to put it together. Um, and there’s one other thing I think is very important to, to mention that that has occurred since in this period since SARS. And that is the Global Health Security agenda. It was launched in February 2014. it has about 60 or 70 governments that are involved in it and many other institutions, including the United Nations Foundation where I work. and that has been an effort to try to promote and help countries to build the capacities that they need under the international health regulations. Because even if you say that these International Health Regulations are out there and accepted by all countries, that doesn’t mean all countries in especially low and middle income countries have had the capability to build up their capacities, laboratories, train staff, et cetera, that you need to monitor infectious disease outbreaks such as this one and the GHSA has been a major effort to build up those capacities as well as other capacities to improve health security.
Mark Goldberg: (25:04)
Well, it’s just interesting you’ve cited a number of, well, it’s just interesting that you’ve cited a number of sort of innovations and like global governance and multilateral cooperation that have occurred over the last decade that seemed to have like this, you know, kind of seemed to be custom built for this very situation. And it seems in a way, this is both a demonstration, one of the value of things like the International Health Regulations and the global health security initiative that you just described, but also sort of a test of them as well.
John E. Lange: (25:37)
Yes, but I think it is a test, but I my concern is that despite all the efforts that have been done over the last several years to focus on these needs to build capacity on under the international health regulations, especially in lower middle income countries, so much more needs to be done. It’s a matter of providing the financing and the part of donor governments and other institutions to help countries so they can make it a priority to build up those capacities. And to tell you the truth, one of my concerns in a global context is in Africa, I already mentioned how the Gates Foundation has given $5 million to the African CDC, but you also have a lot of Chinese who are working in Africa based there who presumably many of them went to China for the Lunar New Year when they come back to their homes in Africa. you may find that this starts spreading there and spent much of my career in Africa at different embassies. I must say it’s very worrisome, just w when, when these kinds of things an infectious disease outbreak such as this one hits a very poor country it could be very bad.
Mark Goldberg: (27:03)
At least like China has like some capacity to respond, but the capacity is far limited, say in places, you know, like where you’re in a master like Tanzania.
John E. Lange: (27:13)
Yeah. Or, or Botswana or Togo. They’re the three countries where I was based in, and so I have to say it’s a, we have all these efforts out here, but there an anybody who’s been dealing with the IHR or the Global Health Security Agenda or these other efforts, who would say, who would say that they’re well-funded?
Mark Goldberg: (27:35)
Can I ask one final question? you brought up Taiwan. Um, how has the sort of relationship between Taiwan and China complicated the global response to this new coronavirus right now? Or has it?
John E. Lang: (27:52)
I’m not aware of a complication that has occurred, but it does get to be a little tricky within the context of a U.N. agency when you have Taiwan and China and how they relate to each other. and who is no exception in that regard. But it’s a moment I, I’m not aware of any concerns or complications that have arisen during this current outbreak.
Mark Goldberg: (28:21)
Um, all right. well, thank you so much for your time, ambassador. This was very helpful.
John E. Lange: (28:27)
Okay. All right. Very good to talk to you, Mark.
Speaker 4: (28:32)
All right. Thank you all for listening. Thank you to ambassador Lange. That was very helpful, and as I said at the outset, you know, I do think it does provide some helpful context for understanding events as they unfold. So let me know. Let me know what you think about this episode. Let me know what’s on your mind. You can always reach out to me using the contact button on globaldispatchespodcast.com. All right sees you next time. Bye.
Shownotes and Transcript by Launchpod