“A strange virus is circulating in Wuhan, China,” said my grad school intern, Grace Ren, just back from a visit to her mother in Shanghai. Somewhere in between end-year holidays and WHO’s last-in-person meeting in early February 2020 - a pandemic swept through New York City and Milan, Geneva and the world. One year later, new variants of that virus are on a new onward march. Are we better armed today?
Grace’s warning to me in the first week of January - when most people in Europe are still concentrating on their holidays, coincided with WHO’s first formal alert on 5 January about a mysterious pneumonia-like disease circulating in Wuhan, China. “Where is Wuhan?” I asked, feeling ignorant already. I soon learnt that it is a city of 10 million people, home to China’s steel industry and a major international base for auto manufacturing.
Somewhere in between the brief respite of New Year’s and a hurried fondue alongside frigid Lake Leman after a session of the WHO’s last in-person meeting of the executive board in the first week of February - a pandemic crept into Milan, and New York City, Geneva - and then onto Tehran, Rio, Cape Town, and Delhi.
We wouldn’t know until later. But this was to be the first time rich countries would be hit first and hardest by such a virus in over 100 years. Beginning with Italy, but soon followed by France, Spain, the United Kingdom, and the United States - health systems in one rich country after another struggled to care for a surge of desperately ill people.
One year later. Exactly one year after WHO declared a Public Health Emergency of International Concern on 30 January, many of those same countries are struggling yet again with dangerously high mortality rates and overloaded health systems - as new and potentially more infectious virus variants emerge in places as far flung as the UK, South Africa, Brazil and Japan. And that is despite the remarkable progress made in new vaccines and therapeutic tools for the disease that WHO named Covid-19.
Some 100 million people have become ill and over 2 million have died. Many of the world’s poorest countries have escaped with comparatively fewer Covid cases and lower mortality. But these countries may still suffer more “collateral damage” in terms of health as well as economies, over the long term, according to recent studies. And as those countries wait for access to vaccines, they face tough, every day choices about how to keep case rates low with curfews and lockdowns, while ensuring peoples’ everyday survival.
Against that landscape, here is a rundown of some of the key issues WHO and the global community faced in the pandemic’s early days; ironically some of the same issues loom again as variants proliferate now.
Person-to-person transmission - yes or no? In February last year, journalists - myself included - regularly crowded into the WHO’s strategic health operations centre, or “SHOC” room as it’s better known, used for briefings on the most important WHO statements and decision-making moments. The room is a small airless space measuring only about three to five metres. WHO had just declared the coronavirus “public health emergency of international concern”, and as we gathered there during the WHO’s executive board meeting, I wondered: was WHO headquarters virus-immune?
Initially, Chinese and WHO officials downplayed the risks of person-to-person transmission of the virus. The unspoken hope was this new coronavirus might behave like a foodborne virus - tied largely to workers at the Wuhan Seafood market where wild animals from around the country were housed in crowded conditions, prior to their on-site slaughter and sale - for use in traditional medicines and food platters.
Or, perhaps this new coronavirus would behave like its SARS circa 2003 predecessor - transmissible at close range, but less deadly.
It was an underestimation of the initial signals about virus spread, thanks partly to an “alert system that seems to have come from an earlier analogue era”, that led to WHO delays in its international health emergency declaration for a full month after the first reports of the virus were made, stated an independent panel co-led by New Zealand’s ex-prime minister Helen Clark, and Liberia’s former president, Ellen Johnson Sirleaf, in an interim report to WHO published last week.
However, there were worrisome signs from the start. Among the very first cluster of early infections reported in Wuhan were household members of people working at the city’s seafood market - who had not shopped there themselves. This already suggested the virus was transmissible among people living in close proximity. Then, on 13 January, the first case outside of Wuhan was reported by Thailand’s Ministry of Health, in a person who had been in Wuhan, but not the market, followed by other similar cases in Thailand and Japan. These were widely reported in the press, as evidence that human transmission was occurring.
Even so, it was only on 19 January that the WHO finally acknowledged that there was “limited” evidence of human-to-human transmission of the virus, just three days before an official Chinese announcement. Was the WHO’s caution and delay due to an excessive WHO subservience to official Chinese views - or a lack of means to quickly gather all the expert evidence?
Preliminary investigations conducted by the Chinese authorities have found no clear evidence of human-to-human transmission of the novel #coronavirus (2019-nCoV) identified in #Wuhan, #China🇨🇳. pic.twitter.com/Fnl5P877VG— World Health Organization (WHO) (@WHO) January 14, 2020
Zhang Yongzhen, the Chinese virologist who first released the full sequence of the novel coronavirus in early January, 2020, is one expert who said that his early January warnings about human-to-human transmission went unheeded, in a recent New York Times interview:
“At that time, I made four findings about the virus. One, it was like SARS. Two, it was a new coronavirus. Most important, the virus was transmitted through the respiratory tract. I also thought it was more infectious than the flu virus… Even then, I thought it must be able to spread from humans to humans,” he said, wishing that “more experts had shared my opinion from the beginning… Whether in the United States or in China, we need to cultivate a group of critics — real scientists in the field. ... Who will be the next to dare to speak the truth? You must have enough courage.”
To travel or not? Early on countries began to slap travel restrictions on China, then on other countries, first in Asia and later even on close neighbours as the infection spread. Canada closed its borders to the US; European Union countries, pledged to open traffic in the Schengen agreement, took the same steps. WHO staunchly opposed any travel restrictions, however, and repeated pronouncements by WHO’s director general Dr Tedros Adhanom Ghebreyesus and health emergencies executive director Mike Ryan - were widely cited by politicians and media well into the summer of 2020.
WHO’s argument has been that the widespread use of travel restrictions will further inhibit countries from reporting on future pathogen outbreaks. A WHO insider admitted in a private conversation recently to me: “We also were playing from the book of Ebola - when they didn’t really help anyway, and developing countries were injured by travel restrictions.”
In fact, travel restrictions failed entirely in many cases. The United States was among the first countries to limit international travel - restricting the entry of most foreign nationals who had visited China within the past 14 days, after declaring its own international health emergency on 31 January. The US restrictions, poorly framed and executed, ultimately left the virus to infiltrate via US nationals returning from China as well as travellers arriving from other countries around the world where the virus rapidly spread.
On the other end of the spectrum, New Zealand initially banned flights altogether, later opening its airspace subject to strict, and consistent Covid testing and quarantine restrictions on incoming arrivals. And it’s infection rates have remained among the lowest in the world. But its success was never championed by WHO as something to imitate.
“It’s part of the religion of global health: Travel and trade restrictions are bad… I’m one of the congregants,” said Lawrence O. Gostin, a professor of global health law at Georgetown University, in a recent New York Times investigation into how open skies policies helped fuel the rapid, early spread of the virus with globe-trotting skiers bringing infections from Asia to Europe and Europe to the United States.
Paradoxically, it has been low- and middle-income countries, including China and many countries in Africa, that have gradually implemented a more nuanced approach - including strict Covid-19 test requirements as a prerequisite for travel - and precisely as a low-cost measure to control the introduction of cases from abroad.
A trip from Geneva to the Democratic Republic of Congo, for instance, requires a Covid test 72 hours in advance of travel, followed by quarantine and another covid test several days after arrival. Greece has been one of the European countries that has succeeded in keeping Covid cases exceptionally low during the present virus wave, possibly as a result of its Covid-testing rules.
To mask or not? Early on, China and other Asian countries also adopted mass masking measures to combat virus transmission. This was something that WHO would resist for months - while insiders say a fierce internal debate over the issue raged - until finally making a 180 degree turn - after some 239 experts criticised the WHO stance in an open letter in a scientific journal - about the hottest form of scientific protest that you can imagine.
At the core of the early - but unstated - WHO concerns was that masks were in short supply. In light of that, they should be allocated to health care professionals who needed them most urgently. As with travel, senior WHO officials were operating from the only playbooks that they knew, those designed for earlier WHO responses to the 2003 SARS pandemic, more recently, two successive Ebola epidemics in West and Central Africa in 2014 and 2018.
When asked why so many Chinese were wearing masks and yet WHO was not recommending the practice - at one press briefing in February 2020, WHO’s executive director Mike Ryan called masking a “cultural practice” in Asia - essentially something that other countries didn’t need to fuss about.
Dovetailing with that was a WHO message that the virus was only transmissible at very short range by humid droplets of coughs or sneezes - but not from the smaller particles also emitted in routine speech and breathing. Over and over, the public was assured by the WHO that staying a metre away from other people and hand-washing would be sufficient to stem the tide of the rising virus story.
In one social media video broadcast in mid-March, a WHO expert talked about how to use public transport safely in the Covid area. Asked if masking on a bus might be a good idea if the bus was full - she responded with an alternative - just skip the crowded bus until the next one arrives.
Yet the WHO advice to the public also seemed disingenuous - not to mention impractical. How many people dependent on public transport would have the luxury of skipping a bus to catch the next one - unless they happened to be riding the New York City subway?
And on the New York subway, as well as in many other parts of the world, masking was rapidly taking hold. Israel mandated it universally in March. In cities from Prague to Lagos, homemade cloth masks also became popular- sparking an entire cottage industry of mask making - including ones with design sense - quietly supported by WHO’s Africa region, which said social distancing rules were impractical in many crowded African cities.
For nearly three months after WHO declared Covid-19 a pandemic on 11 March, the WHO continued to resist suggestions that public masking should be recommended - even in virus hotspots or for workers like border control police or bus drivers. In early June, WHO began issuing guidance to the public on how to wear non-medical masks of fabric.
The final WHO volte-face came only in July, after scientists in 32 countries called on the agency to revise its guidance to acknowledge that SARS-CoV2 virus transmission was indeed happening via tiny aerosol particles, and not just larger droplets. Soon after, the WHO embarked on a media campaign to promote masking.
Covas and other WHO successes. So far this article has focused on shortcomings - because the shortcomings suggest areas where improvements might be urgently considered as the world faces the variant threat. But this is not to detract from the successes either. These include leading the development of the ambitious Covax and ACT Accelerator initiatives to provide broad access to drugs, diagnostics and vaccines; as well as Solidarity trials that identified dexamethasone as a valuable Covid therapy, while ruling out hydroxychloroquine and remdesivir; clinical guidance and training; leadership in the massive rollout of personal protective equipment (PPE) and Covid tests in low- and middle-income countries; constant media and social media outreach to confront fake news and provide clear pandemic messages; and alongside, or above all, the appeals by WHO director general Dr Tedros Adhanom Ghebreyesus about the need for global solidarity.
Admittedly, the fortunes of the WHO co-sponsored Act Accelerator have been uneven - with funding still far short of the $28bn WHO says is needed and a “C-Tap” global patent pool failing to get off the ground. However, the Covax global vaccine procurement facility - which aims to rollout vaccine doses more equitably, received a boost last week (22 January) when Pfizer joined the initiative, offering 40 million vaccine doses on a no-profit basis. Adding to pre-existing commitments from AstraZeneca and other pharma firms, the facility should now be able to distribute some 2.3 billion vaccine doses in 2021, said Seth Berkley, CEO of Gavi, another Covax co-sponsor. That, he adds, should be enough to vaccinate at least 27 per cent of people in the world’s 92 poorest countries that will be dependent on donor-financed vaccine contributions.
Repeating the same mistakes? Yet there are signs that WHO’s cautious response to the emergence of the new Covid-19 virus variants, may lead the agency to repeat some of the same mistakes made in the early days of the pandemic. For example, the WHO has so far downplayed the mortality risks from the virus variant, even as research accumulates that they are indeed more dangerous. It remains to be seen if WHO will change it’s tune in the wake of expert findings from the United Kingdom, the United States and elsewhere that variants are not only more infectious, but also potentially more deadly.
Related to that, countries such as Germany and Austria in Europe, as well as experts in the United States, are now recommending the public replace their cloth masks with more infection-proof “high-filtration” FFP or N95 alternatives, at least in crowded indoor spaces. But it remains to be seen if WHO, which was slow to take up masks in the first place, will rapidly update its own advice.
On international travel, the global health body has yet to recommend COVID-19 tests as one of a suite of strategies for controlling international travel-related transmission. This is despite tests now being faster and cheaper - and travel being the main vector for the spread of new variants of the disease. This reticence remains - fuelled by fears that testing for travel would divert resources from testing other, much larger, suspect groups, WHO insiders have said. Although this is numerically correct, it ignores the proportionally greater risks of new variants spread. Further in the horizon looms the thorny issue of vaccine passports for people who have been immunized - although a WHO expert committee recently said this would be premature, in light of the small numbers of people who have been immunized
Cautious hopes - despite all. Despite the setbacks seen over the past year - and the worrisome signs of variants on the rampage over the past month, a number of factors still give rise for cautious hope now. Here are three reasons for hope to propose:
United States move to rejoin the WHO. This cannot be understated - in light of the new challenges being faced by virus variants - which will eventually force WHO to adapt its advice yet again on all of the sensitive points raised - transmission risks, mortality estimates, masking, and travel. What’s important is that the United States Centers for Disease Control (USCDC) advice has batteries of research teams - backed by a budget that is far larger than WHO’s. The two entities have traditionally worked synergistically - alongside other global health colleagues the world over - in developing balanced guidance.
Quickening response to variants. The emergence of variants is no surprise - what may be a surprise is that until now few threatened the root efficacy of existing tests, treatments and vaccines in the pipeline. But in laboratories from the most highly-infected and thus concerned countries - from South Africa to the UK, Brazil, Israel and the USA, sleuthing for variants is now in full swing. That will allow governments to identify them and respond more rapidly, including “booster doses” of vaccines as was suggested by Moderna this week.The variant story is also an important wake-up call to politicians and the public that vaccines are not a panacea - and that countries in fact need to continue using other means - e.g. masking and social distancing - if they want to bring mortality rates down. Along with that, WHO is moving to create a Swiss-based “biohub” to share genetic information about pathogens and variants in a faster and more efficient channels than current WHO Pandemic Influenza Preparedness (PIP) networks.
Member state determination to reform WHO and pandemic alert systems. The WHO has recently spoken about a pandemic “treaty” that would strengthen the legal requirements attached to the “International Health Regulations” that currently regulate emergency response. This initiative, however, is primarily led by G-20 states and could lead to a standoff in May with China, Russia and its allies - which see stronger enforcement of global rules on pathogen risk reporting as a threat to their internal control of information flow - regime stability, and sovereignty. At the same time, with African, Latin American and South-East Asia crippled by the pandemic, many member states that often swing in the direction of China, may be reflecting on whether a stronger and faster alert system may also serve their interests.
A wake-up call for climate change and biodiversity loss. For climate advocates, another faint silver lining in the pandemic cloud may be that the world is also waking up to the risks of climate change - which is also deeply intertwined with the risks of biodiversity loss, driven by a global passion for meat-rich diets and in parts of Asia and Africa, wild meat from primates, reptiles, rodents (e.g. bats), or other endangered species like mammals like the pangolin, which is widely consumed for their meat in Asia and Africa, and which can be intermediate carriers of viruses from other sources.
Vaccine rollout - Of course it is a game-changer and proof of how fast science R&D can move when there really is political will and financing. This is despite the vigorous debate surrounding vaccine nationalism and vaccine equity now underway - driven by the disproportionate number of high-income countries leading the initial rollout stages. One big question now is whether new vaccines will hold up against variants? Initial reports from both Moderna and Pfizer, suggest they will, albeit with lower levels of efficacy. While the studies so far are very small and it’s likely that vaccines may have to be tweaked or updated with boosters, over time, as occurs regularly for influenza shots. This underscores, once more that vaccines need to be part of a broader strategy; they will not make the virus quickly go away on their own.
The virus is coming; this virus may never go away. From the early days of the pandemic, WHO was clear about its warnings that this virus could reach all countries and hit them with equal ferocity. What mattered, however, was the degree of the response. Today, whatever happened in the past year, countries have to come to the hard realisation that the Covid may become just another endemic virus in our communities and “may never go away” , as WHO’s Ryan warned in May. That is the pattern that Ebola and HIV, not to mention the many other diseases like measles, smallpox and influenza that likely emerged from animal sources - after humans created the fundamental pre-conditions for such leaps to occur with the domestication of livestock 9,000 years ago, and the creation of the first urban settlements.
Now, as people crowd even closer together, deforestation and food consumption leads tomore intensive agriculture and more contact with wildlife, those pre-conditions are better than ever. As older groups of people are vaccinated, die or develop natural immunity, the new and more infectious SARS-CoV2 variants are also beginning to infect proportionately more young people. This is a trend already being seen in Israel - where 40 per cent of new Covid infections are now being reported among children under the age of 18 - as some 70 per cent of people over the age of 60 were vaccinated. That, too, is also part of a natural cycle that epidemic viruses may follow, historians suggest. It’s a cycle that led to the development of the current set of “childhood diseases” against which we now routinely immunise.
The question remains - what lessons will countries, and WHO, will take from the first months to move forward in the new year?