- The World Health Organization (WHO) needs a more proactive and transparent Emergency Committee to raise the alarm in health crises
- Potentially catastrophic disease outbreaks must trigger a fire alarm, because humans resist action unless a piercing alarm is sounding
- New international structures for rapid high-level propagation of the alarm are needed to ensure hasty responses
- It will be necessary to have false alarms to ensure all true threats are detected
- WHO pandemic advice should be tailored to contexts (eg island nations), rather than one-size-fits-all
WHO? The Emergency Committee
The international health regulations (IHR) provide for the Emergency Committee of the World Health Organization (WHO) to declare a Public Health Emergency of International Concern (PHEIC) in appropriate circumstances.
PHEIC is meant to be a signal to all countries that significant actions, aid and cooperation may all be needed. Critics have lambasted the late timing of PHEIC declaration for COVID-19 and also the opaque nature of the acronym.
The WHO Emergency Committee declared a PHEIC on 30 Jan 2020, not at its first, but at its second meeting, two months after searches for ‘SARS’ had been spiking on WeChat and one month after laboratory confirmation of a ‘SARS coronavirus’ in the context of dozens of cases of pneumonia of unknown origin.
SARS is specifically named in the IHR as a virus of significant concern. The world saw in 2003 how SARS coronaviruses can behave. Surely there was a strong argument for convening the Emergency Committee as early as 1 January 2020 and declaring a PHEIC immediately. We argue this point in our research letter published 23 February 2021.
Unfortunately, key information appears to have been suppressed in Wuhan during December 2019 leading to continued widespread travel in and out of the region throughout January.
With a more flexible decision-making process, able to countenance disparate and informal information sources (WeChat, Google, ProMed, Twitter), and with a mandate to investigate to verify concerning information, things might have been different for the Emergency Committee, and the world.
We need a fire alarm
Entities like the WHO Emergency Committee are fearful of unnecessarily alarming the world, so they remain silent for too long. Their function is analogous to a fire alarm, they are supposed to warn us loud and clear of imminent emergency. But fire alarms don’t actually tell us when there is a fire, as Eliezer Yudkowsky has explained. More times than not when a fire alarm sounds there is no fire, and this is how it must be. The threshold for alarm must be set below the threshold for risk so that the alarm sounds for all actual fires. Missing even one fire ends in ruin. The WHO Emergency Committee clearly missed a fire all through January 2020.
The mere sight of smoke (think snippets of information appearing on ProMed, or WeChat, or sidebar news stories) is not enough to compel people to act. This is especially true in a crowded world because of psychological barriers such as the bystander effect (surely someone else will act! I don’t want to look silly…).
Fire alarms give permission to act. If the alarm sounds, it’s OK to leave the building. It’s OK to get the extinguisher. It’s OK to close borders to arrivals from a disease epicentre. It’s OK to put masks on in public. You’re not going to look silly, because the alarm is sounding.
Well-functioning alarms activate at a low threshold and early enough that the fire can still be extinguished. The alarm must be piercing enough that normal activity cannot continue until the alarm is off. Alarms can be switched off right away if there is no evidence of a fire, but the fire brigade has to have time to check the building first.
A case in point was Auckland in February 2021. The city was put into a three-day lockdown in response to three community cases of COVID-19. Some critics said, with hindsight, that it was a ‘false alarm’ and complained that the government was too hasty. But the sight of people suddenly wearing masks, social distancing, and getting COVID tests because of the lockdown ‘alarm’ shows that fire alarms have a purpose. The brigade checked the building, and the alarm was quickly switched off.
PHEIC and prejudice
The issues surrounding the failures of the PHEIC alarm system are discussed in more depth in a podcast published by Nature. In sum there probably should be:
- More transparency around the activities of the WHO’s Emergency Committee, in particular have the IHR criteria for declaring a PHEIC been met? (we know that Emergency Committees have been inconsistent in this aspect)
- More powers to investigate/respond to non-official data on outbreaks
- A ‘traffic light’ system so that PHEIC isn’t simply ‘yes’ or ‘no’, giving the Emergency Committee more powers to raise alert levels early on.
- An international Pandemic Treaty
- Reduction in Incentives to NOT report outbreaks (due to fear of economic harm if hotspots are then avoided – perhaps a compensation system could be workable?)
- Incentives for countries to WANT to set up long-term systems and care about monitoring
- Incentives for countries to agree to do these things
An industrial inferno: Global catastrophic biological risks
COVID-19 is a serious smouldering house fire, needing constant vigilance to put out hotspots. The next pandemic could be an industrial inferno.
There is a significant difference between a virus that causes fewer than 1% of those infected to die and one that causes 10%, 20%, 50% or more to die. Higher case fatality risk than COVID-19, or even higher than SARS (2003), poses the risk of a global biological catastrophe that overwhelms human systems and devastates society.
In our research letter, we argue that not only should PHEIC be declared much earlier, but that it should be declared ‘with-‘ or ‘without-‘ catastrophic risk. This might be the impetus for even stronger initial measures (such as Wuhan-style lockdowns, or border closure for island nations) right at the outset, with a realistic chance of eliminating the outbreak before it becomes a pandemic.
As successive instances of community transmission and the alert level system in several countries have shown, an initial overreaction can always be swiftly downgraded as information comes to light, but the reverse is not possible.
Pandemic advice: one size does not fit all
Initial and ongoing advice by the WHO following the PHEIC declaration was not context specific. For example, though possibly in line with evidence at the time for some contexts, advising against travel restrictions was completely inappropriate for small island nations. Perhaps even larger island nations such as the UK should have closed borders and pursued an elimination strategy for COVID-19. The UK faces obvious additional hurdles to the success of such a strategy, including dense connections to continental Europe, close proximity to other landmass making non-commercial sea and air access easy, as well as a huge logistical challenge and high probability of quarantine failures. That said, it may not be impossible and the debate was presented in The Guardian.
International cooperation is needed
Former New Zealand prime minister Helen Clark is leading an independent investigation into the global response to COVID-19. Speaking at the University of Otago, Wellington, on 1 Feb 2021, she indicated that a number of her recommendations, forthcoming in May, will centre around strengthening global institutions and connecting top-level decision makers. These connections will facilitate the functions that the world expects of these institutions.
A summary of her talk was published in The Conversation. Clark emphasised that nations must stop trying to go it alone. There is a strong case for multilateralism and the world needs to remove obstacles to a precautionary approach that were evident in China in December 2019, and within the WHO in January 2020.
At the Davos 2021 meeting, Ursula von der Leyen (President of the European Commission) delivered a speech noting that Europe is proposing a biodefense preparedness programme to sit within the new European Health Emergency Response Authority (HERA). The programme will scan for pathogens and prepare vaccines, with long-term predictable funding and public-private partnership. Earlier detection and faster scaling of response is needed. These are positive steps.
However, the solution, according to Helen Clark, must be global, and may need to include a high-level pandemic council consisting of the UN Secretary General, the WHO Director General, and the heads of the IMF and World Bank. This council can immediately agree on a course of action then use their influence to directly contact heads of state, finance ministers, and health ministers to coordinate a response. New Zealand could advocate for such a Council so that it is no longer a cork bobbing in the ocean of audacious whims of individualist global leaders, awaiting the sound of an alarm that will legitimise the necessary drastic action.