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

China Controls the SARS-CoV2 Narrative

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.”

Indeed, from the beginning, while WHO was busy praising China for its fast and efficient response, the voices of scientists who issued early warnings or voiced independent views were muted.  One of the most famous of the early “whistleblowers” was Li Wenliang, who noted the cluster of 7 cases tied to the Wuhan seafood market in December 2019 on a doctors’ WeChat. He was at first detained by police for spreading rumors, then released – only to die of the coronavirus himself on 7 February.   Since then a string of citizen journalists and lawyers who documented the initial chain of events around the Wuhan outbreak have been silenced, arrested or ‘disappeared.‘

The Wuhan virologist, Shi  Zhengli, said in late December that she would welcome a visit by the WHO team to her lab at the Wuhan Institute of Virology; her research into bat coronaviruses has given her the nickname of “bat woman” – but also led to suspicions that the virus could have escaped from her laboratory.  The WHO team, which arrived in Wuhan two weeks ago after months of bureaucratic delay, and was finally seen leaving a hotel after completing a quarantine on Friday. However, behind the scenes, China has mounted a full-fledged propaganda campaign to discredit any evidence that the SARS-COV2  virus originated in China at all.

That is despite the fact that SARS-CoV2 is widely believed to have emerged from the same family of coronaviruses that the Institute was investigating – which infect horseshoe bats in the Yunnan region of China, some 1800 kilomteres away.  Already in 2013, there were reports of miners in the province dying of a mysterious pneumonia that was later linked to cave-dwelling bats in the area – and which harbor coronaviruses that have already been heavily researched, and which share soe 96% of the same genetic material as SARS-CoV2.

While Chinese scientists themselves freely made that link in the early days of the outbreak, they were quickly muzzled as well.  And now any research on that topic must be approved by a task force under the direct command of President  Xi Jinping.  China has begun spinning alternative conspiracy theories, meanwhile – suggesting that it could have originated in Europe or SouthEast Asia, or most recently, that the virus was even imported by the US military.

Given those constraints, experts have held out little hope that the WHO independent team now visiting China to search for the origins of the virus will indeed come upon the genuine tracks of the biggest mystery of all – how the virus first reached Wuhan – via a biosafety leak, or the initially slow and silent spread of a variant strain among bats, wildlife merchats, or other intermediate animals that traders regularly trap, tansport and trade.

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. After an initial strict lockdown and 25 deaths, the country reopened gradually.  It today has no reported infections or local transmission – leaving social and mass gatherings, restaurants, schools and businesses to operating fully and normally.

But New Zealand’s 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?

Meanwhile, in shops, buses and subways from Singapore to New York City, 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.

Covax and Other WHO Successes

While the corporate WHO positions on key scientific questions was overly hesitant and delayed, the WHO Director General himself was also coming under increasing fire from the United States for pandering too much to Chinese influence in WHO’s pandemic response.

At the same time, the DG’s biggest weakness was also possibly his biggest strength.  Resolutely refusing to take sides with either China or the USA, he constantly sought to rise above the fray – and call upon a fractured world to come together.

“Solidarity, solidarity, solidarity” became his calling card phrase.  “No one is safe until everyone is safe” was another one.  “We are family” became another motto, after he recruited pop singer Kim Sledge, to collaborate with WHO in a a remake of her hit classic to raise funds to fight the pandemic.

Emerging directly out of the solidarity message was the ambitious ACT Accelerator initiative. Launched in April 2020 to fast-track development and rollout of tests, treatments and vaccines, to countries around the world has been an ambitious centerpiece of WHO strategy. Funding gathered to date still falls far short of the US$ 28 billion WHO says is needed.  And a “C-Tap patent pool” created to pool intellectual property on COVID health products has failed entirely to get off the ground- much to the ire of access advocates who published an open letter to WHO recently on how to address some of C-Tap’s shortcomings.

Among the various ACT initiatives, the COVAX vaccine facility, which aims to get billions of vaccines to the world’s poorest countries is its hallmark project.  The fortunes of COVAX have also been uneven, with 180 countries joining the project with small pre-procurement vaccine orders initially – only to have most rich countries seal much larger vaccine contracts directly with pharma, in a parallel universe of bilateral deals. That has left Tedros to repeatedly lament the “vaccine nationalism” that had characterized the first stages of the vaccine rollout.

At the outset of the bi-annual WHO Executive Board meeting on 18 January, Dr Tedros warned darkly of a world on the “brink of catastrophe and moral failure” due to vaccine hoarding by other countries. The first 50 countries to begin vaccinating the public were primarily high or middle-income ones – and there were almost almost no low-income countries doling out jabs, he noted.

Those looking at the glass half-full might note that in fact countries like, India, Indonesia and Brazil also have been among those early starters. South Africa hopes to start producing a Johnson & Johnson vaccine as soon as March.  And the African Union on Thursday announced that it had secured a second, 400 million dose commitment of AstraZeneca vaccines for its member states from India’s Serum Institute – following on an earlier pre-order deal for 270 million doses.

“”If you add 400 million doses to the 270 million doses, I think we are beginning to make very, very good progress,” Africa CDC director John Nkengasong told a press conference on Thursday. On the one hand, the AU moves are perhaps a welcome declaration of African  independence from donor driven handouts – countries’ vaccine purchases can be funded by a five-year loan from the African Export-Import Bank (Afreximbank). 

Still, these remain ‘bilateral’ deals of one sort or another that bypass COVAX – the only framework, through which equitable distribution is being organized proportional to a country’s population, and including all of the world’s poorest states.

On 22 January, however, the flagging COVAX facility received a much-needed shot in the arm. Pfizer, producer of one of the most cutting-edge COVID vaccines  joined the initiative, offering 40 million vaccine doses on a no-profit basis. Adding to commitments from AstraZeneca and other companies, the facility should now be able to distribute some 2.3 billion vaccine doses in 2021, said Seth Berkley, CEO of Gavi, The Vaccine Aliance, another COVAX co-sponsor, on 22 January. That, Berkley added, 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. 

By the close of the Executive Board meeting last Tuesday, the WHO DG had thrown down a gauntlet – to his own organization, his partners in the COVAX rollout, and donors.  The highest risk groups in every low-income country in the world should be reached with an initial supply of vaccines in the first 120 days of 2021.   

Solidarity and Solidarity Trials

Early on, WHO also announced its Solidarity trials platform –  linking clinical trials of potential Covid remedies from around the world with systematic protocols so that results could be aggregated into a more powerful finding. By June, the research documented the efficacy of the inexpensive drug dexamethasone in treatment- while debunking the reports about hydroxychloroquine, and later remdesivir, for which WHO found no life-saving benefits.  WHO’s advice would buck that of a powerful pharma company, Gilead, which had developed the drug and received US FDA approval.  Other noteworthy accomplishments have included:

• Tests, training and PPE in Low- and MIddle-Income Countries. Early on in the pandemic WHO began rolling these out physically – as it turned out the pandemic didn’t head south, but rather west toward Europe, but these were important in preparing the way for future waves that hit Africa and the Americas harder.  Millions of pieces of PPE and rapid test kits have since been distributed, while national laboratories across Africa have been trained in more sophisticated PCR testing techniques. Now, WHO is bolstering capacity in those same laboratories to identify virus variants, noted WHO’s African Regional Director Matshidiso Moeti, at a WHO African Region press briefing last week.   
• Clinical guidance – WHO has developed dozens of pieces of guidance about the clinical management of COVID-19, from testing to intensive care treatment. Along with that, it has mounted dozens of courses for health professionals on the free WHO Academy platforms, including smartphone APPS. 
• Media and Fake Media – Moving from the traditionally small, and often insular physical press briefings at Geneva headquarters, WHO has opened its doors virtually to the world with twice a week briefings since late February. WHO uses those meetings to talk about other topics well beyond COVID – such as TB, HIV, and gender equity – leaving the world better informed about the full set of global health issues faced in the pandemic. The formal press briefings have been complemented by Social media Q&As and short, factual videos like the Science in 5 series, and collaborations with celebrity events, like Kim Sledge’s remake of her hit classic “We are Family” to raise funds to fight the pandemic.  In addition, creative new partnerships have been formed with big media entities, such as Twitter and Facebook to combat fake  pandemic news and steer people to validated health information. 

Repeating the Same Mistakes?

Will WHO’s cautious response to the emergence of the new COVID-19 virus variants, lead the agency to repeat some of the same mistakes made in the early days of the pandemic?  The signs are worrisome. For example, WHO initially 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. In a op-ed on 26 January in The Washington Post, Joseph Allen, director of Harvard University’s T.H. Chan School of Public Health Healthy Buildings programme, argued for US adoption of what experts there are calling Hi-Fi masks:

“In the scrambling for information and tools in the early days of the pandemic, it was acceptable to just say any cloth mask will do because it’s true. But we’ve learned so much since then, and we need to adjust our strategy,” Allen said. “A typical cloth mask might capture half of all respiratory aerosols that come out of our mouth when we talk, sing or just breath. A tightly woven cloth mask might get you to 60 or 70 percent, and a blue surgical mask can get you to 70 or 80 percent… while  N95 masks “filter 95%.”

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 recommending that high-filtration masks be reserved for medical personnel only.  Even though inexpensive FFP and N95 masks are now widely available in high-income countries, among WHO insiders who spoke to me, the fears remain almost the same as a year ago. Were the Organization to recommend that the public now adopt high-filtration medical masks, rather than cloth ones, more global mask supplies would be diverted to rich countries and prices would rise.  And that would lead to even less access to such masks in hospitals of poorer countries and regions, where they are still in short supply.

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 the fact that international travel is unquestionably the main vector for the spread of new variants of the disease – which could undermine vaccine efficacy.

This reticence has traditionally been fuelled by fears that testing for travel would divert resources from testing other, much larger, suspect groups, one WHO insider told Health Policy Watch recently – during a time when tests were expensive and in critically short supply.

There are, however, signs that the in-born WHO resistance to travel-related COVID testing may be changing after the head of Africa CDC John Nkengasong, called for a “common approach” to COVID testing last week – framing it as a fairer strategy than other travel measures – that discriminate against travelers based on their national or flight origns.

“We should not be banning people because of their geographical origin, but we should be encouraging people to travel with negative tests and facilitate the testing process so that people can travel with a negative test,” Nkengasong said at an African CDC briefing on Thursday.

Added Mke Ryan, Executive Director for Health Emergencies, in a WHO briefing in Geneva on the following day, “We do need coherent messaging around travel requirements.”

What he didn’t say is whether WHO would provide that.

Yet further on the horizon looms another thorny travel issue – that of so-called “vaccine passports” for people who have been immunized. A WHO expert committee recently said that a policy on this would be premature, in light of the small numbers of people who have been immunized so far. However, it is certainly the time when such a policy needs to be prepared – and it is not without precedent.  For over 15 years countries where yellow fever is endemic have required incoming arrivals to show evidence of yellow fever vaccination – a requirement that is explicitly permitted by the WHO International Health Regulations of 2005.

Cautious Hope 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 a few of the reasons to be hopeful:

• 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 global response to virus 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 of 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 pandemic 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.  “Whether it is pandemics like this or climate change or water access, the world is very vulnerable. There’s no opportunity for the world to go back to a nationalistic past and think you can solve all the problems. The problems are all transnational, and therefore their solutions will be, as well,” declared Jeremy Farrar, Director of the Wellcome Trust during a webinar, ‘Major challenges for global health in a post-COVID-19 world’, hosted by the Liverpool School of Tropical Medicine (LSTM).

Vaccine rollout. Equity issues notwithstanding, the vaccine rollout is still proof of how fast science R&D can move in the real world – with political will and financing.   One other big question is whether new vaccines will hold up against SARS-CoV2 variants, which are causing higher rates of infection and possibly even mortality.  Reports Friday from the large Phase 3 clinical trials of Novavax and Johnson & Johnson vaccine candidates provide the best evidence, so far, that vaccines under development over the past year still pass the bar even when tested against the major variants. But vaccine efficacy was also somewhat lower when the vaccines met the virus mutations which first emerged in the United Kingdom, Brazil and, particularly, the one first identified in South Africa (B.1.351 also called 501Y.V2). Initial data from both Moderna and Pfizer, suggest something similar – although their laboratory-based studies have involved just a few blood sample tests of each variant, and are thus more difficult to analyze. Even so, most of the pharma players and vaccine experts agree: it’s likely that COVID vaccines will have to be tweaked or updated with boosters, over time, as occurs regularly for influenza shots. This underscores, once more that while vaccines are a game-changer – they need to be part of a broader strategy and will not make the virus 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 2020. 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?

Updated from: Covid-19 vs WHO and the world: successes failures and hopes a year on. First published by Geneva Solutions, a news and opinion platform for International Geneva.  

Image Credits: José Mauquer , Nandu News, CGTN, Dipartimento Protezione Civile, Photo by mona Masoumi on Unsplash, China News Service／中国新闻网, Jade Lee , GAVI, Our World in Data, Cross River State Primary Health Care, Nigeria , Paul Adepoju/HealthPolicyWatch, Johnson & Johnson, WHO, Piekfrosch/wikipedia.