What Questions Should Global Health Policy Makers Be Asking About The Novel Coronavirus?

On December 31, 2019, China informed WHO of cases of pneumonia in Wuhan, Hubei province, China, now designated as “2019-nCoV acute respiratory disease” (2019-nCoV). It is also commonly referred to in the press as simply, coronavirus, which is a family of viruses that include SARS, MERS, and the common cold. Since that time, it has spread to four continents and every WHO region, with more than  20 countries reporting travel-related cases, including the United States. Person-to-person transmission has been reported in at least five of these countries, including multiple cases in Germany, and one in the United States. As February began, the number of deaths exceeded 250, with the vast majority in Hubei and all, so far, in China. More than 11,000 cases had been confirmed – more than SARS – though the true figure is likely many tens of thousands, at least. The sheer geographic spread and trajectory of cases ensures that 2019-nCoV will greatly exceed that of SARS.

What do we know about this novel coronavirus and how it differs from other such viruses, like SARS and MERS? Importantly, what is the global risk and how could the risk be significantly reduced? The world needs to be prepared for the possibility that this international outbreak will not be contained in the foreseeable future. Here are some key questions that global health policy makers should be asking:

What Is the Significance Of The WHO-Having Declared Global Health Emergency?

On January 30^th, the World Health Organization declared 2019-nCoV a Public Health Emergency of International Concern (PHEIC) under the International Health Regulations (IHR). The IHR is a treaty that governs preparedness and response for potential international health crises. It grants the final decision on declaring a PHEIC to WHO Director-General Dr. Tedros Adhanom, who makes his decision based on the advice of an Emergency Committee. 

On January 23^rd, the First Emergency Committee was split on whether to declare a Public Health Emergency of International Concern. Although it was reasonable for Dr. Tedros to gather more information, all the criteria in the IHR were already clearly been met, including: the discovery of a novel virus, rising cases with serious public health ramifications, international spread, and impacts on travel and trade.

Dr. Tedros was right to finally declare an emergency on January 30^th, this time with a unanimous recommendation from the Emergency Committee. While 2019-nCoV appears to have a lower case-fatality rate than SARS or MERS, it has caused deaths and serious illness, especially for elderly and vulnerable patients, such as those with co-morbidities. The virus could also mutate to become more transmissible and/or pathogenic. Because there is sustained human-to-human transmission, the crisis continues to escalate, as cases mount in China, Asia, and globally.

The Emergency Committee made a range of sensible recommendations, such as “rational public health measures,” full data-sharing, enhanced surveillance in China, and “active surveillance, early detection, isolation and case management, contact tracing and prevention” globally. While observing that under specific circumstances it may be justifiable to temporarily limit movement, on the whole, the Committee explained, restricting movement is likely to be not only ineffective, but counterproductive, interrupting aid and harming economies. 

Mixed Messages

In light of its recommendations, the Emergency Committee’s praise of China’s response is contradictory and deeply concerning, suggesting one standard for China and another for the rest of the world. The Committee welcomes China’s “commitment to transparency.” And in many ways, China has been more transparent, such as rapidly sharing genetic sequencing data of the virus with scientists across the world. Yet we now know that in the end of December, Wuhan’s health authorities prohibited releasing information on treatment of the disease and “did not inform their own people,” even while reporting to WHO. Wuhan’s tourism authorities continued to encourage visitors. Over a several day period in January, authorities misleadingly reported no new cases. 

Meanwhile, the Emergency Committee notes China’s “strong measures” and calls the measures it has taken “good not only for that country but also for the rest of the world.” The WHO’s messaging has been confusing, if not circular.  WHO’s  caution against restricting movement is at odds with China’s measures in Wuhan and elsewhere in Hubei. Failing to be candid when countries are not fully transparent or overreach could send a signal to other countries that if they act similarly in this or future outbreaks, to their own and the world’s detriment, WHO will not use its unmatched voice to hold them accountable.

Legal Implications of a PHEIC

Unfortunately, the declaration of a PHEIC does not have major legal significance. The IHR does not give WHO additional powers or resources when the Director-General declares a PHEIC. This is a problem with the IHR that should urgently be remedied. Declaring an emergency should unleash new powers and a surge of funding from a well-financed Contingency Fund for Emergencies.

Nevertheless, declaring a PHEIC can mobilize public health resources and galvanize public and political action. It signals that the world must be on alert for a major event. During the West Africa Ebola epidemic, for example, President Obama sent the military to Liberia to provide logistical assistance and secured $5.4 billion from Congress, after already having allocated hundreds of millions of dollars to the response. PHEIC also gives WHO power to make authoritative recommendations. 

In the past, WHO has strongly advised against travel and trade restrictions, as well as large-scale quarantines, demanding evidence of effectiveness. However, WHO has not criticized or made any recommendations related to China’s mass quarantines and restrictions on movement but it should. At a minimum, WHO should rigorously assess the evidence base for China’s mass cordon sanitaire, as well as ensure that the population’s essential needs and human rights are safeguarded. The WHO has a mandate under the International Health Regulations to defend the essential values of the IHR, including public health, human rights, and international travel and trade.

Should WHO Have the Flexibility to Declare an “Intermediate-Tier” Emergency? 

Dr. Tedros indicated he would like the flexibility to declare an intermediate level of a PHEIC, rather than at present, just having a stark “on-off” choice. In other words, he wants a more nuanced WHO capability under the IHR. This idea has been discussed in the scientific literature, and it could have merit. Still, it would be difficult to evaluate whether a middle-tier emergency would be effective without knowing the criteria for such a declaration and what powers or funding it unleashed. Much more importantly, from a legal perspective it would be extraordinarily difficult and time consuming to achieve. The IHR governs the declaration of emergencies. There are 196 states parties to that treaty. Seeking to renegotiate the IHR would be an arduous and long-term prospect, and there is no time to lose in responding to this novel coronavirus.

Is a “Lockdown” in Wuhan city and Wider Hubei Province Justified?

China has severely restricted movement across the province of Hubei, affecting 16 cities and well over 50 million people. Authorities closed public transit, while banning travel to and from affected areas. These quarantines (or technically cordon sanitaire—a guarded area from which people cannot leave) have been erected during the Lunar New Year, which is the world’s largest mass travel event. Wuhan is working rapidly to erect two new hospitals, with both to be opened the week of February 3, and Beijing and Shanghai have postponed the spring semester for schoolchildren.  

The mass involuntary cordon sanitaire in Wuhan and wider Hubei province is unprecedented in human history. Evidence from more limited cordon sanitaire suggests that China’s action could be highly counterproductive. During the West African Ebola epidemic, Liberia blocked off a slum in Monrovia, spurring public anger. This action was shown to amplify the epidemic.

In assessing whether this unprecedented cordon sanitaire is justified, we must carefully consider several separate but overlapping concerns: public health, economic, human rights, and personal/social. It is, of course, theoretically possible that such extraordinary measures could delay spread of infection to wider China and globally. Yet, the available evidence suggests we should view mass quarantines with deep suspicion. Why?

Public Health

The single most important strategy in a public health crisis is to stay calm and to gain the community’s trust. A lockdown of Wuhan and other cities will drive the epidemic underground, provoking fear and panic. Trapping more than 50 million people together in a hot zone of contagion will lead to cross-infection, fear, and social isolation. Individuals and family members who experience symptoms may not seek prompt testing and treatment. The poor, elderly, and vulnerable will be at greatest risk. Many will not have transport to travel to clinics and hospitals. There are already shortages of essential medicines and medical equipment. Food and other necessities are either in short supply or being sold with sharply higher prices. Congregating millions of people together will spread infection, as patients transmit the virus to family, friends, and the wider community. Eventually the travel ban will be lifted, and infected or exposed individuals will leave, amplifying global spread.  

Human Rights

Beyond the public health implications there are deep concerns about violations of human rights. It isn’t feasible to close down a city the size of London or New York without significant violations of human rights, such as freedom of movement, personal autonomy, privacy, and access to health and to food. And we are seeing very visible signs of distrust, even outside of Hubei. In Fujian province and elsewhere, residents and police have clashed when the government decided to locate quarantine sites in a small coastal village, for example, without having first consulted, or even informed, residents. 

Economic

Wuhan is an economic hub for central China. It is a major transportation and industrial center, headquartering the country’s major domestic steel and car producers, and home to offices of more than 300 of the world’s top 500 companies. Its economic growth has exceeded China’s national growth. Yet many businesses are now evacuating foreign employees and suspending operations. Restricting travel to and from Wuhan and other cities in Hubei will have ripple effects throughout China. Retail and tourism industries are among those that will be hit hard.

The economic impact is already extending well beyond Wuhan and Hubei, quite possibly amplified by the image of a city, and a province, on lockdown. More than 70,000 movie theaters in China have closed. Airlines are canceling flights to China – if not stopping them altogether – as tourists and business travelers cancel travel plans to China. Stock markets have been rattled. The lockdown of a province with a population only a bit below that of France or the United Kingdom  will be a blow to the global economy further amplified by the now thorough integration of China, the world’s second largest economy, with the rest of the world. SARS cost the world economy some $40 billion. Yet today, China has an economy 8-9 times larger than it had during the SARS epidemic in 2002 and 2003 and is even more connected to the rest of the world. Even a SARS-sized impact on China’s GDP would wholly wipe out the 0.3% improvement in global economic growth over last year that the IMF was anticipating.

When we take everything into account such as loss of commerce, trade, tourism, and major impacts on global supply chains, the economic impact will be vast both within China and globally. That is what happens when countries shuts down movement in a deeply interconnected world. 

Social. Imagine the feelings of fear and anxiety of being trapped inside a hot zone of contagion. People are feeling isolated, hopeless, abandoned. People cannot visit family and friends, attend funerals, or celebrate cultural or religious events. There is no sport, theater, or entertainment. No social clubs, recreation, or tai chi. There are likely to be profound emotional and mental health harms, especially among the elderly living alone, or those in nursing or group homes. Attending to the social needs of individuals and communities are essential.

China’s public health surge is vital and wise, but its surge of control is not. Instead, it is a reflection of the government’s seeking to portray an image of power and technical competence. China has a social contract with its citizens, which trades off civil liberties with the promise to keep the population safe and prosperous. That image is tarnished as the epidemic spins out of control, and where people feel fragile and stuck in an area with active contagion. Trust, already damaged, needs to be re-established.

Wuhan’s mayor has reported that local authorities delayed disclosing information about the outbreak because of a policy requiring the local government to receive permission from higher levels of government before it could fully disclose information on the virus. This is information that all Chinese authorities, the public, and the global community needed to know immediately.  China must end this policy, and announce that instead, in the future, rapid, transparent, public reporting will be rewarded.

Accepting robust international assistance would be a start at establishing public trust, and a sign of humility in the face of a complex public health threat. WHO will soon send international experts to China to help guide a global response, which is at least a start towards international cooperation. Yet, WHO’s statement is vague, and it is unclear when, and how, WHO’s Health Emergencies Programme would be deployed. These visiting experts are likely to serve as observers and advisors, not as equal partners. Instead, China should invite the program to partner with the Ministry of Health on the ground. 

Beyond WHO, it would be a powerful signal to invite US CDC as additional partners on the ground. CDC offers unmatched expertise and experience for a public health response. But CDC’s presence would have an even greater benefit. It would be smart diplomacy. Such US/China cooperation would show that we can overcome our political, ideological, and trade tensions to come together as a shared humanity to confront a global threat.

What is the Best Public Health Strategy?

If a mass cordon sanitaire is not effective, what is the best way to get the outbreak under control? The answer is we need a surge of traditional public health measures, including those that increase better public hygiene, such as hand washing, health information to see a doctor if symptoms arise, and avoid infecting others. Methodical surveillance and contact investigations are crucial. It is concerning that so many cases in wider China and Asia were not on known contact list held by Chinese public health officials. These public health measures brought other coronavirus epidemics under control, such as SARS and MERS. For example, during the SARS outbreak, there were limited quarantines, such as “work” quarantines in Ontario, Canada, so health workers could only travel between home and hospital. And China, Singapore, Hong Kong, and elsewhere temporarily quarantined apartment blocks. 

The international community should mobilize its funding of research and development of a vaccine and antiviral medications for novel coronaviruses. Political leaders should mobilize funding for a surge public health response. And the WHO should demonstrate leadership by convening an international consensus meeting to develop a Global Plan of Action, including experts in public health, scientific research, health care, and anthropology. The global plan would include rapid discovery and deployment of an effective vaccine, classic public health interventions, health education and communication, and safeguarding human and social rights of affected populations. Mobilizing action under a common global plan would drive international cooperation, transparency, and on-the-ground expertise.

Beyond those response measures, it is vital that the international community focuses on preparedness and prevention. The 2019-nCoV won’t be the last novel infection to make impact globally. It is less expensive and more effective to prepare in advance, especially with strong universal health system capacities, which are required under the IHR. 

It is now common to lurch from complacency to panic. A better way is to invest and prepare wisely before an outbreak gets out of control. This means increasing investments in R&D for known threats, especially the eight infectious diseases that WHO has prioritized for R&D. These include two coronaviruses, SARS and MERS. Countries should invest in strengthening laboratory, surveillance, and other core public health capacities, as required under the IHR, with high-income countries providing assistance as needed to lower-income countries. Beyond IHR requirements, countries should invest, with support as needed, in overall health system strengthening so that they have the health workers, facilities, and other infrastructure and systems to effectively respond to outbreaks without undermining other health services. And countries should ensure a conducive legal environment, including safeguarding the rights to travel and privacy, to rapidly inform the public and WHO where there is a possibility of international spread – of any potential threat to the public health. 

Is There a Significant Risk in the United States or other High-Income Countries? 

High-income countries are increasingly closing their doors to Wuhan, and even all of mainland China, a trend likely to accelerate as the number of confirmed cases skyrockets and we see more cases of human-to-human transmission outside of China. British Airways was the first airline to cancel all flights to and from China; dozens of other airlines are now canceling or suspending all flights, or reducing and selectively canceling flights. Americans and foreigners from a dozen or more other countries are being evacuated from Wuhan. Other than its own residents, Hong Kong is barring residents or travelers from Hubei from entering its territory. 

The US has a sophisticated public health system and the CDC is the best in the world. Although so far seven cases of patients who have contracted the virus have been confirmed in the US, the risk to Americans is relatively low and there is no justification for extraordinary, draconian action, like a travel ban or indiscriminate quarantines. Still, physicians and hospitals must be on alert for cases, report them, and isolate infected people. Health workers need to take rigorous precautions. Failing to protect health workers was our main blunder during Ebola and we shouldn't repeat it.

The CDC now advises, reasonably, against non-essential travel to China. Critically, this is advice to individuals, not an outright ban. The US should not contemplate major travel bans or large-scale quarantines, yet we have now taken steps along that harmful path. 

What is the Legal Basis, and Justifications, for Quarantines of Citizens, Foreign Nationals, and Others Arriving at US Ports of Entry from Hubei and Wider China?

The Trump Administration has put in place various measures to prevent further introduction of the coronavirus into US territory. What is the legal basis for these and the public health justifications?

Quarantining Passengers Evacuated From Wuhan

The CDC announced on January 31^st that it is exercising federal quarantine powers to confine US citizens who were evacuated from Wuhan and now in California for 14 days. This kind of large-scale quarantine by federal authorities has virtually no modern precedent in the US. Most quarantines – from pandemic flu to polio, smallpox, and Ebola – are exercised by states. States have primary public health powers under the US Constitution. The federal government is empowered to act only when necessary to prevent international or interstate transmission of a dangerous disease. 

In this case, however, the quarantine may be lawful and reasonable. The CDC’s highest responsibility is to safeguard Americans’ health using the best available scientific evidence. Individuals returning from Wuhan or elsewhere in Hubei province have a significant risk of having been exposed to the novel coronavirus. Additionally, the maximum incubation period during which 2019-nCoV can be transmitted asymptomatically is 14 days. Thus, using the precautionary principle, it was reasonable for CDC to take action. While CDC’s action was reasonable, a better strategy would have been to have passengers sign a social contract. In exchange for safe return for a zone of contagion, citizens would promise to voluntarily remain separated from the population for 14 days. Most evacuees would understand the importance of safeguarding the common good, and it could avoid the need for compulsory measures.

Quarantining or and Banning Returning Citizens or Foreign Nationals from Hubei and Elsewhere in China.

The same day, Secretary of Health and Human Services Alex Azar announced that he was declaring a national public health emergency. American citizens returning to the United States who have been in Hubei province within 14 days will face a mandatory quarantine for two weeks. Americans returning to the United States from other parts of China – now limited to seven airports – will face enhanced screening and a self-quarantine of up to 14 days.

The cardinal rule of public health is to act based on the best available evidence and to deploy the least restrictive measure necessary to safeguard the public’s health. The mandatory quarantine for American citizens returning from Hubei is reasonable under this standard. Their risk of exposure is significant, and therefore while a quarantine is coercive, it is a reasonable measure to protect the public’s health. Enhanced  screening for anyone returning from China outside of Hubei is reasonable too, as would be self-monitoring. Fever screening and questionnaires at airports are rarely effective in containing the spread of infectious diseases and almost always pick up many more false positives than true positives. Still, such screening is lawful, minimally restrictive, may detect people who are infected (though miss those who are still asymptomatic during the incubation period), and will help reassure the public. 

However, the risk of exposure outside of Hubei remains low. Self-quarantine, while less coercive than a mandatory quarantine, is still a highly restrictive measure that may significantly interfere with individuals’ lives. Given the relatively low risk such individuals pose, screening and self-monitoring would suffice.

Banning Entry Of Foreign Nationals Travelling From China

Along with Secretary Azar’s declaration of a public health emergency, President Trump signed a proclamation that imposed a temporary ban on entry of foreign nationals who have been to China in the last 14 days. This measure, too, is overbroad and a violation of human rights and civil liberties. The order also goes against a specific WHO Emergency Committee recommendation against banning travel. A quarantine for foreign nationals, like US citizens, who have been to Hubei, would have been reasonable. However, since a quarantine is itself highly protective; there is no justification for a complete travel ban from Hubei. And for the same reason that self-quarantine for Americans returning from China outside of Hubei is overly restrictive, the travel ban for foreign nationals from elsewhere in China is overly restrictive. Indeed, if we use the president’s reasoning, how long might it be before we ban travel or quarantine individuals returning from other parts of Asia, or in countries like Germany where there has been human transmission? 

Just days ago, President Trump assured Americans there was virtually no risk of contracting the novel coronavirus on US soil and that China had the outbreak fully under control. And now we are turning to overbroad measures that violate human rights and alarm the public. The US is at a critical junction where it is slipping from complacency to overreaction, from calm to panic.

We know from hard experience that prevention and preparedness are better than reacting after an outbreak has spun out of control. And when the international community does respond to an ongoing outbreak like the one in Hubei province, it should use classic public health tools and avoid draconian overreaction.