The Multilateral Health System Failed to Stop the Coronavirus
Reforms in 2005 were meant to stop nation states covering outbreaks up. They didn't work.
An important soccer match in Milan plays to an empty stadium. Tokyo Disneyland closes its doors. The Mongolian president is under quarantine, and Iran releases 70,000 prisoners rather than risk their spreading the infection. Europe brings the dangerous virus to sub-Saharan Africa rather than the reverse, via infected French and Italian travelers to Senegal and Nigeria. An outbreak of COVID-19 rages in a residential care facility in Washington state. The S&P 500 loses more than 18 percent of its value in two weeks, leading the U.S. Federal Reserve to cut interest rates to stem the global economic fallout from a microbe.
These are not scenes from a novel, but from a world being swept by a virus born just a few months ago. As of March 10, the virus has infected over 115,000 people in more than 100 nations. China has taken extraordinary measures to contain the spread of the virus, including restricting the movement of some 760 million people. While those measures appear to be stabilizing China’s domestic situation and buying other countries more time to prepare for the outbreak, they came too late to overcome the earlier missteps by the Chinese government that contributed to the spread of the virus worldwide.
To date, national governments have borne the brunt of global scrutiny for the outbreak, particularly in China, South Korea, Japan, Italy, and increasingly the United States, where Democrats have criticized President Donald Trump’s handling of the new coronavirus. That scrutiny is healthy, warranted in many cases, and should continue. Yet, that national focus should not obscure that the multilateral system also failed at what it had been specifically redesigned in 2005 to do: prevent the denial and inaction of one nation from putting many other nations at risk of a pandemic of deadly disease.
That redesign was the result of failure in China. In the 2002-2003 SARS outbreak, China’s Ministry of Health was aware for months of a dangerous new type of pneumonia in Guangdong province before sharing that information with other nations or issuing a nationwide bulletin to hospitals and health professionals on preventing the spread of the disease. That virus spread to 29 countries, sickened thousands of people, and killed 774 before being brought under control in July 2003.
After SARS, the International Health Regulations (IHR) were revised in 2005 to grant extraordinary powers to the World Health Organization. First, the IHR authorizes WHO to act upon nonstate sources of information and to question member states on their decision-making. This authority is meant to allow WHO to respond to potential disease outbreaks in a timelier manner, because affected nations have a tendency to cover up their outbreaks for political or economic reasons.
Second, the IHR empowers the WHO director-general to declare an outbreak a public health emergency of international concern, even over the objections of the state or states most directly affected. The WHO director-general may also issue outbreak-specific guidance to inform and influence how other states use trade and travel restrictions, so as to ensure that those restrictions are science-based and do not interfere unnecessarily with public health responses in other nations. These authorities are rare among international organizations, enabling WHO to act on its own initiative to generate and guide the international diplomatic, economic, and political responses to extraordinary events that threaten states.
Third, WHO has the authority to name and shame those nations that do not comply with the IHR requirements on outbreak detection, trade and travel bans, and enforcement of human rights. According to leading political scientists, WHO’s naming and shaming efforts send credible signals that affect member states’ behavior during a crisis situation.
Yet the revised IHR did not stop the Chinese government from actively suppressing information that might have slowed or stopped the coronavirus outbreak. Local police punished and censored doctors and other whistleblowers who sought to raise early alarm over the novel coronavirus. Between Jan. 12 and 20, government officials chose not to report information about the infection of 15 health workers and clear evidence of human-to-human transmission. The government also failed to share the basic public health information that might have helped thousands of Chinese people avoid infection themselves. Instead, it held potluck banquets for 40,000 families to celebrate Lunar New Year and offered tens of thousands of tourists free coupons for events in the city of Wuhan, where the outbreak originated. By Jan. 23, six other countries had confirmed coronavirus cases, but the spread of undiagnosed cases was likely greater.
WHO has also been slow to exercise its emergency authorities under the IHR. Amid reports of Chinese opposition, Director-General Tedros Adhanom Ghebreyesus did not pronounce the coronavirus to be a public health emergency of international concern until Jan. 30, when the outbreak had already spread to 19 countries on four continents and infected nearly 8,000 people worldwide.
WHO has advised against travel or trade restrictions on countries experiencing coronavirus outbreaks, deeming them ineffective, but has done little to criticize the dozens of countries, including the United States, that have nevertheless imposed bans. And instead of naming and shaming China for its cover-up, WHO has opted to focus on events after Jan. 20, lauding extraordinary measures that China took to slow further spread of the outbreak The “world owes China a great debt,” a WHO official recently said, suggesting that other countries should follow China’s lead in containing the virus’ spread.
In fairness, many have defended WHO’s response as pragmatism based on the need to continue to work with China on the coronavirus and as a measure of solidarity amid a costly and tragic outbreak. Those defenders also rightly note that WHO has done much that deserves commendation. WHO has shared timely and science-based insights about this novel virus, warned against international overreaction, shared its technical expertise with affected countries, demonstrated transparency in its daily, livestreamed press briefings, and worked diligently to marshal resources to help prepare low- and middle-income nations for a potential pandemic.
The problems of the multilateral systems for global health security are not specific to the coronavirus outbreak, China, or WHO’s current leadership, which is hardworking and well-intentioned. Critics have pointed to China’s role in funding WHO, but even with smaller and less influential countries there have been political issues. Similar delays in WHO exercising IHR authorities also occurred in the current Ebola virus outbreak in the Democratic Republic of the Congo and the West Africa Ebola outbreak between 2013 and 2015. For example, the delay in the West Africa outbreak was reportedly the result of deference to pressure from the government of Guinea, which feared the consequences of prematurely declaring the outbreak a public health emergency of international concern.
Member state-driven decision-making explains why WHO tends to defer to national governments’ wishes and agendas, even when they might contradict the organization’s primary mission. Yet, deference to the sovereignty of one member state does not work if it puts other nations and their people at risk.
Like the Ebola virus outbreak, the coronavirus outbreak has exposed the deficiencies of a system built around a member state-driven institution like WHO, which, irrespective of the IHR, defers to the sovereignty and preferences of directly affected nations. But more than Ebola did, the coronavirus has revealed the dangerous consequences of that approach. The coronavirus spreads much more easily than the Ebola virus, and it may already be at pandemic levels. The case fatality rate for the coronavirus may fall as testing reveals more undiagnosed cases and the scale of the global outbreak becomes more apparent, but it is currently estimated at 3.4 percent.
In the aftermath of this outbreak, nations will need to consider new options to improve global health security. For instance, there is already talk of the G-7 or G-20 creating a new funding institution, akin to the Global Fund to Fight AIDS, Tuberculosis, and Malaria, to fund country-level pandemic preparedness, surveillance, and response. Those are promising ideas, but more money alone will not solve the structural problems that have slowed early control efforts and permitted nations to impose unscientific travel bans. To fix those problems, we may need a new mechanism to respond to dangerous disease events, a mechanism that has greater independence from affected member states.
The world has changed in ways, from expansions in global trade and travel to warming temperatures and fast-growing cities, that have increased our risk to the threat of emerging infections. The coronavirus is going to bring a reckoning in global health governance. Let’s make sure we heed its lessons.