By ANISH KOKA, MD
COVID is here. A little strand of RNA that used to live in bats has a new host. And that strand is clearly not the flu. New York is overrun, with more than half of the nation’s new cases per day, and refrigerated 18-wheelers parked outside hospitals serve as makeshift morgues. Detroit, New Orleans, Miami, and Philadelphia await an inevitable surge of their own with bated breath. America’s health care workers are scrambling to hold the line against a deluge of sick patients arriving hourly at a rate that’s hard to fathom.
I pause here to attest to the heroic response of the medical community and the countless more working to support them. At the time of this writing, despite 368,000 confirmed cases in the United States, 11,000 deaths have been reported. A horrid number, but still a far cry from Italy with 130,000 cases, and 16,523 deaths, and Spain with 14,000 deaths amidst 140,000 cases. Italy and Spain may be a few weeks ahead of the United States, but at the moment, Italy and Spain have case fatality rates (12.5%, 10%) that are multiples of the United States (2.5%). If this rate does stand, it will be a testament to the tenacity of medical workers toiling under extenuating circumstances.
With the scale of the tragedy now obvious, the take from some very smart people is that the people who should have been paying attention were asleep at the wheel. The easy target is the bombastic New York real estate developer and current President of the United States who repeatedly assured raucous campaign crowds and the nation that the virus was under control before it wasn’t.
The charge is made that the President ignored warnings and painted a rosy picture of an unfolding crisis in a short-sighted attempt to preserve the economy and a beloved stock market. He may be guilty of the latter charge, but the real question relates to ignored warnings. Where were the warnings? Who was sounding the alarm that was ultimately ignored?
Detecting pandemics would appear to be well within the purview of the World Health Organization (WHO), an organization that gained much credibility from its global, decades-long fight to eradicate smallpox, with a stated mission to “detect and respond to new and emerging health threats.” But the focus of the WHO seems to have shifted: from disease eradication to public health do-gooding that has struggled to respond to global health emergencies. The easy, made-for-New-York-Times lede is to blame the failures of institutions on a lack of funding. The real problems run much deeper.
Founded in 1948, the WHO is governed by the 194-nation World Health Assembly, with expansive public health goals. The world may need virus hunters, but the WHO has a larger mission as evidenced by the reading of its constitution: “Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity,” apparently best achieved through a “New International Economic Order,” according to the WHO’s “World Health for All by 2000” statement. Health, as even a cursory reading of the WHO’s 1998 World Health Report suggests, is best achieved by an embrace of economic egalitarianism that narrows the gap between rich and poor. The ideology is evident in the WHO’s World Health Report that tortures logic to place the United States Health System 37th out of 190+ member nations, behind countries like the United Arab Emirates and Oman.
With these lofty goals, it is easy to see how the WHO has struggled to handle outbreaks of not-so-mundane infectious pathogens. In February 2003, Italian doctor Carlo Urbani was called into a Vietnamese hospital in Hanoi to examine Johnny Chen, an American businessman, ill with what local doctors thought was a bad case of the flu. Urbani quickly suspected a novel infectious virus at play and immediately notified the WHO. Analysts suspected Mr. Chen’s illness was related to an apparent pneumonia outbreak in China. Tragically, Dr. Urbani died a month after contracting the very disease he had diagnosed. It wasn’t until April of the same year that a corona-virus named SARS-CoV, ultimately traced back to Chinese bats, was identified. The first cluster of patients had appeared in Guangdong Province, China as early as November of 2002.
From the get-go, the response by local members of the Chinese government was to obfuscate and hamper all efforts to shed light on the problem. The world may still be blind to the actions of Chinese officials if not for an elderly partially retired physician named Jiang Yanyong, who emailed concerns of official undercounting of cases to Chinese and Hong Kong Television stations. But it bears emphasizing here that the WHO was blind to what was happening in China. SARS was only discovered after it had escaped. Local health officials in Guangdong had attempted to inform the central government of a fast-spreading pneumonia-like illness in late January. Officials sent a bulletin in response to local hospitals, but did precious little else. In the meantime, SARS was infecting hundreds of patients, moving rapidly throughout China, Hong Kong and ultimately 16 other countries. It took until April for China to allow the WHO to even go to Guangdong and neighboring Hong Kong. Stability, in the form of tourism, trade, and continued foreign investment were on the line. The potential for a global pandemic, even in 2003, was a secondary concern.
The WHO at first glance seems an innocent bystander to Chinese obstruction until one considers the story of SARS in Taiwan. Around the same time Dr. Urbani was being infected by this virus in Vietnam, Taiwan was reporting its own series of suspicious cases. They attempted to inform the WHO, but were rebuffed and asked to report their findings to the central government in China instead. You see, the allegedly apolitical, humanitarian, and guided-by-science WHO doesn’t think Taiwan exists because China doesn’t recognize Taiwan’s independence. The WHO even refused to publicly report Taiwan’s cases of SARS until public pressure prompted numbers to be published under the label of “Taiwan, province of China”. Interestingly, the respect for sovereign nation’s rights doesn’t extend to Israel. Public health concerns apparently motivate the WHO to champion the cause of a sovereign Palestinian State! Taiwan, China, Israel and Palestine are all matters worthy of debate, but one wonders why the WHO should feel the need to put its thumb on the scale. The answer, increasingly obviously, is that the WHO is a political organization that attempts to give its political preferences the veneer of objectivity using the label of science.
Missteps with Ebola
The politics of nation-states may be a theatrical exercise, but politicization in other arenas by the WHO has been lethal. Take for example the Ebola epidemic of 2013 that was marked by a number of controversies, chief amongst them: how the virus spread. An excellent 2015 New Atlantis article dissects the controversy of transmissibility and concludes the available evidence at the time could not rule out through-the-air transmission. Of particular concern was the real-world evidence from the field with regard to health care worker infections. Health care workers who did not wear maximal Personal Protective Equipment (PPE) in the form of respirators to filter out airborne transmission were infected with Ebola at a high rate. Doctors Without Borders treatment centers that mandated full-body hazmat suits and respirators only had 23 of their 3300 staff members infected, while local hospitals with significantly less PPE saw 869 health care workers infected.
Despite the fact Ebola has a 40% case fatality rate, the WHO continued to maintain Ebola did not spread via the air, and that the “evidence was insufficient” to recommend more than a surgical mask for protection of health care workers. With its position staked out, the WHO has closed ranks to disavow or ignore any evidence to the contrary. A literature review published in February 2015 that concluded it is “very likely that at least some degree of Ebola virus transmission currently occurs via infection aerosols” went unacknowledged, and one of the original authors is believed to have been pressured by the WHO to have his name removed from the paper. This puts the type of PPE in high stakes situations on uncertain ground. Rather than channel this uncertainty and err on the side of safety, the WHO over and over again chooses to take an approach to safety based mostly on a wing and a prayer. Local health officials, and administrators follow the lead and take a similar approach in their hospitals. The first responders pay the price. The SARS outbreak in Canada was notable for the number of health workers that were infected and succumbed to the disease, in part, because the initial responders to the crisis relied on PPE guidance that wasn’t adequate.
To be fair, what’s on display here is a broader institutional malady. The US version of the WHO, the CDC, took a similar stance with another controversial topic—quarantines for health care workers returning from treating patients with Ebola. Four states—New York, New Jersey, Florida, and Illinois—instituted policies to quarantine anyone who had contact with someone infected with the Ebola virus while in west Africa, including medical personnel who cared for patients. No less than the Obama administration, backed by the CDC, attempted to squash these policies, arguing that this would serve as a disincentive for US health workers to travel to Africa to combat the disease at a time this help was sorely needed. The states acted after a New York physician, Craig Spencer, was found to have contracted Ebola nine days after returning from treating Ebola patients in Guinea. Dr. Spencer had been taking his temperature twice a day after returning but had also gone out jogging, bowling, eaten at a restaurant, and traveled by subway and cab before being admitted to the hospital. The argument made by many, including the now-famous Dr. Anthony Fauci, was that Ebola could only be transmitted by those who were symptomatic, and so it was anti-science to consider mandatory quarantines. This argument was repeated by Dr. Spencer himself in an editorial he penned for the New England Journal of Medicine. Not mentioned is when one crosses the threshold from asymptomatic and not infectious to symptomatic and infectious.
As history repeatedly shows, science also has a habit of evolving, so it may make sense to choose caution when dealing with a highly lethal virus that has no known therapy. The head of the CDC at the time, Tom Frieden, had initially recommended that health care professionals did not need respirators when taking care of patients with Ebola. It took two health care workers in Dallas contracting Ebola from a patient for the CDC to change its recommendations in October 2014. An important recurring theme when it comes to viruses may be to follow what people do rather than what they say. This is “Tom” (see picture below) visiting a Doctors Without Borders Ebola treatment center in August of 2014, at a point in time when the CDC was saying a surgical mask was adequate to care for these patients.
The charitable take is that institutions like the WHO and CDC are simply coming down on the wrong side of contentious scientific debates. But there is a persistent directionality to these mistakes that betrays a current of ideology. Organizations like the WHO can’t concern themselves with only medical matters when matters of social and economic equality are competing interests. A review of the timeline of announcements by the WHO after the COVID outbreak shows an organization equally or even more concerned with avoiding a panic that might disrupt economic life and avoiding stigma when naming the virus.
The tenor here was clearly to calm rather than sound an alarm that may reduce tourism or trade or anger politicians of member countries the WHO relies on for its funding. This is precisely backwards. When it comes to global health emergencies, the public and the political class need organizations like the WHO to sound the alarm and to do so free of politics.
And they can’t.
In the 2015 New Atlantis article about the mishandled Ebola outbreak mentioned above, Ari Schulman, wrote:
“ the broader institutional factors that led to the failures of public health in 2014 remain unchanged. We must understand and fix these problems, for the next outbreak may be of a disease more contagious than Ebola, and even worse understood”
Tragically, these were prophetic words. There were no urgent missives addressed to the people or the politicians of the United States with warnings of what was to come with the coronavirus, because the WHO was too busy reassuring the world from its perch in Geneva that the situation was under control.
China loses track of COVID
It was in late December that multiple doctors in China first learned of a cluster of cases of pneumonia related to a Seafood Market in Wuhan. News circulated via physician WeChat groups of a new pneumonia with entreaties to wear masks and avoid the market. Shortly after, a Chinese lab in Shanghai isolated and sequenced a then-unknown virus on January 5th, a full two days prior to China’s official announcement that mysterious pneumonia cases in Wuhan were caused by a novel coronavirus.
Recognizing the importance of the findings, the researchers reported results to China’s National Health Commission the same day. After six days without a response, the Shanghai lab made its finding public January 11th, and released its data on open-access data repositories for the world to see. It was only then that the Chinese National Health Commission announced it would release the genome of the virus to the WHO. The following day the Shanghai lab found itself shut down for ‘rectification’. The ill patient the samples had been derived from had been admitted to Wuhan hospital December 26th.
As an ever-increasing number of patients swarmed local hospitals, no evidence of larger public health measures to mitigate the virus were evident. A lunar year banquet scheduled in Wuhan proceeded as planned January 18th, and 40,000 families gathered to share home-cooked food. According to a New York times study of cellphone data from China, 175,000 people left Wuhan on January 1st alone. It was not until January 20th that the lead physician in China in charge of the virus response confirmed that human to human transmission was possible. By then, local Wuhan hospitals were being flooded with patients and the virus was popping up all over China. Scrambling to contain a situation spiraling out of control, China imposed a lockdown of 60 million people in Hubei province on January 23rd. Tragically, one of the first physicians to signal alarm at the turn of the new year, ophthalmologist Li Wenliang, was infected with the virus and was fighting for his life. He died shortly after.
The unprecedented actions taken by China should have been a signal to the WHO and the rest of the world that everything was most definitely not ok. The WHO actually did convene January 30th to declare a “Public Health Emergency of International Concern”, but the public comments were focused on signaling to the world that China had the situation under control, that the announcement was not cause to institute travel or trade restrictions with China, and that the declaration was only being made out of concern for the health systems of developing countries the virus may spread to.
Repeatedly, and predictably, the WHO steadfastly recommended against travel restrictions at every point of the crisis. It’s possible that a clearer picture of what was actually going on in China with respect to the caseload and deaths was needed for anyone to decide anything, but I’m not sure what information the brain trust of the WHO would have needed to say anything different. The position of the WHO with respect to travel did not change a whit according to a tweet sent on January 10th (before there was known human to human transmission) another sent January 30th (after declaring an international public health emergency, 60 million people being quarantined by China, and the first US case report of a traveler from China sick with the virus):
As late as February 4th the WHO continued to express confidence that 99% of cases reported were in China, and persisted in advising against travel bans.
Over and over again, the world’s health police, whose main function is to alert the globe to impending epidemics, repeatedly violated basic common sense when dealing with imperfect information: In the face of a novel pathogen where the mode of transmission, the ease of transmissibility, and the lethality of the virus was unknown, the WHO chose to stick its head in the sand.
The black comedy in all of this is that the WHO seemed much more focused and concerned at the time with “disinformation” surrounding the impending pandemic. The organization that repeatedly opposed travel restrictions, opposed the widespread use of masks, and asked people around the world to go about their daily business because China had everything under control wants to be the “trusted” source of information on pandemics. The unfortunate fact was that the credibility the wider world gives to the WHO made them one of the chief sources of disinformation as the pandemic unfolded. It is no accident that local health officials and doctors parroted the WHO talking points. Local officials don’t spend much time thinking of viral pathogens that can turn into pandemics on a daily basis. They rely on institutions like the CDC and the WHO that are supposed to have public health experts focused on threat assessment. Little did they know that the WHO based their risk assessment on what China was telling them. We now know without a doubt that the numbers out of Italy and New York point to an outbreak in China that was orders of magnitude greater than what was officially stated or known.
The reality was that China had bungled the response badly. Clearly the people on the ground felt a sense of urgency when a potentially novel SARS-like virus was identified, but they were let down by a bureaucracy that was lethally slow. When it was clear the extent of the outbreak couldn’t be hidden any longer, the Chinese Communist Party (CCP) quickly moved to preserve itself by launching a public relations campaign framing the story as an unprecedented crisis, turning the narrative into lives saved in China and the world because of the bold actions of the CCP. The WHO, constantly concerned with the appeasement of China was a willing cheerleader.
The WHO: Consistently Wrong
The multi-billion-dollar budget of the WHO translates to interminable meetings, meaningless declarations of emergencies, and many tweets of the importance of handwashing. At no point did they lead the response, leaving countries big and small to figure it out on their own.
Small countries like South Korea, Singapore and Taiwan had an infrastructure and urgency driven by the prior brush with SARS and started widespread testing, as well as aggressive contact tracing and isolation of positive contacts. The WHO frequently mentions the success of South Korea, and amplifies Korea’s test everyone strategy, but leaves out the fact South Korea banned travel from Hubei Province in early February, and used apps downloaded to phones on arrival in the airport to track visitors. The forgotten country Taiwan (in keeping with the WHO’s OneChina policy) also has been remarkably successful in controlling the outbreak. Not surprisingly, Taiwan began to screen passengers from China December 31st, banned Wuhan travelers January 23rd, suspended tours from China January 25th, and restricted all Chinese visitors February 6th.
Perhaps, Taiwan’s exclusion from the WHO is a good thing. It didn’t wait to take its cue from the organization that didn’t label the worldwide explosion a pandemic until March 11th. Comically, and in keeping with their prime directive to reassure, they immediately followed the announcement by meaninglessly pronouncing:
“Describing the situation as a pandemic does not change WHO’s assessment of the threat posed by this #coronavirus. It doesn’t change what WHO is doing, and it doesn’t change what countries should do”-@DrTedros #COVID19
The mantra emerging from the WHO was monotonic and it was everywhere. The overall threat level is low. More people die of the flu. Don’t wear masks unless you’re sick. Wash your hands. Don’t stigmatize people. And like robots, local health officials (New York included) regurgitated the message.
There was a motley group of individuals that registered concern because they paid attention to what China did, rather than what they said. This included the well-respected former head of the FDA Scott Gottlieb, some biotech investors, and Steve Bannon. The face-saving from others in the public health/epidemiology community now is that they couldn’t have predicted the lack of surveillance testing that was taking place in the United States. But they did know that the United States wasn’t testing. Why not act as if a novel pathogen the population had no immunity to was headed in our direction? Clearly there was more to be gained by taking the default position that would not restrict the flow of international trade. How else were political masters to be assuaged?
The major problem here is not so much the WHO as it is the masses of local health officials that take their guidance from the soothing ‘evidence-based’ proclamations of the organization. This is why in the midst of a pandemic, school officials are worried about free lunch programs, and adequate home internet access while progressive politicians are rushing to local Chinatowns to have photo-ops to discuss stigma and xenophobia. It becomes a little harder to get angry at Donald Trump for reassuring his fans everything was going to be just fine when the WHO was saying the same thing. What warning exactly was the President ignoring? Recall that it took the WHO until March 11th to even declare a pandemic. Reports of intelligence officials warning Trump and Congress of the danger of the unknown virus have been leaked, but if anything, bolster the claim that Trump was listening to the scientists on the level of threat posed.
It may be the case that this pandemic was unavoidable. The lessons learned here have been very hard ones with tragic costs. The usual culprits are easy to see – the need to scale up testing rapidly, improved contact tracing, and local supply chains that allow rapid scaling up of essential medical needs among many others. But the more important lesson here is to break the institutional groupthink that dulled our senses. It was late December when Chinese physicians warned their family members of a potentially new dangerous disease. It was January 5th that a local Chinese lab identified and sequenced the genome for a new coronavirus. In the absence of evidence, the WHO began to blindly reassure everyone almost immediately after and persisted down this road until it was too late. It’s clear that this is a plan that worked until now because the viruses that emerged to date were simply not as infectious as COVID.
The fervent hope is that the health system bends but does not break with the test it has been given. Reasons for optimism abound as the medical community and the nation exert a massive effort to overcome this public health crisis. The failure of the responsible institutions will hopefully not fade from memory anytime soon. If we are to avoid the next pandemic, it will be because we listen to those at the coalface and ignore the empty suits from Geneva and their even emptier proclamations.
Anish Koka is a cardiologist in Philadelphia. He is currently hard at work attempting to avoid COVID. He can be followed on twitter @anish_koka.