January 24, 2020
Lawrence O. Gostin, O’Neill Chair in Global Health Law, Georgetown University and Director, WHO Collaborating Center on National and Global Health Law
Should the WHO Have Declared 2019-nCov a Public Health Emergency of International Concern?
It was reasonable for WHO Director-General Dr. Tedros Adhanom Ghebreyesus to wait for more definitive information before declaring a Public Health Emergency of International Concern (PHEIC) under the International Health Regulations (IHR). Nevertheless, all the criteria in the International Health Regulations have been met, including the discovery of a novel virus, rising cases with serious public health ramifications, international spread, and impacts on travel and trade.
While the coronavirus that emerged in Wuhan, China (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. The virus could also mutate to become more pathogenic. Because there is sustained human-to-human transmission, I expect the crisis to escalate, as cases will mount in China, other parts of Asia, and globally.
What is the Legal Significance of a PHEIC?
The significance of a PHEIC is that it can mobilize public health resources and galvanize public and political action. It signals that the world must be on the alert for a major event. It also gives WHO power to make recommendations. I believe WHO should come out against draconian travel or trade restrictions. However, the IHR do not give WHO additional legal powers or financial resources, which it should.
Is a Transportation Lockdown in Wuhan and other Chinese Cities Justified?
On Jan. 23, transportation in Wuhan, China, the epicenter of the outbreak, was shut down. Subsequently, transportation in other cities in the same province was halted impacting a total of about 20 million people. The mass involuntary quarantine in Wuhan and its neighboring cities is counterproductive. There is no modern historical precedent for shutting down a large metropolis. Smaller quarantines such as in the West African Ebola epidemic spurred public anger and unrest.
The most important strategy in a public health crisis is to stay calm and to gain the community’s trust. A lockdown of Wuhan will drive the epidemic underground, provoking fear and panic. Individuals and family members who experience symptoms may not come in for 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 will be shortages of medicines, food, and other necessities. Already Wuhan inhabitants are experiencing empty shelves in the supermarkets, inflated food prices, and concern about essential medicines. Wuhan clinics and hospitals are overrun with sick patients and the “worried well.”
Congregating 11 million people together will spread infection within Wuhan, and eventually people will leave the city causing further spread. The Lunar New Year, which begins Jan. 25 with a week of festivities, also is a time of year when millions travel. It isn’t feasible to close down a city the size of New York or London (both nearly 9 million) without significant human rights violations.
What is the Best Public Health Strategy?
The best way to get the outbreak under control is through a surge of traditional public health measures, including public hygiene (e.g., hand washing) and reliable health information (e.g., urging people to see a doctor if symptoms arise and avoid infecting others). Rigorous surveillance and contact investigations are crucial. It is concerning that so many cases identified in wider China and Asia were not on known contact lists.
These public health measures brought other coronavirus epidemics under control such as SARS and MERS. During SARS there were limited quarantines, such as “work” quarantines in Ontario, Canada, so health workers could only travel between home and hospital. Well-targeted measures targeted toward health workers proved effective in Ontario. China, Singapore, Hong Kong and elsewhere temporarily quarantined apartment blocks. Home quarantines in Asia were part of the package of measures that brought SARS under control. A mass quarantine on the scale of the Wuhan lockdown, however, has never been tried before, nor is needed now.
The 2019-nCoV outbreak is far from under control. China should invite the WHO’s Health Emergencies Programme to partner with the Ministry of Health on the ground. There would be both diplomatic and public health value in inviting the U.S. Centers for Disease Control and Prevention (CDC) to join as a partner in the fight against the outbreak in China and wider Asia. The international community should mobilize its funding for research and development of a vaccine and medications for novel coronaviruses. And political leaders should mobilize funding for a surge public health response.
Beyond those response measures, it is vital that the international community focus on preparedness and prevention. This coronavirus outbreak won’t be the last novel infection to have a global impact. It is far less expensive and more effective to prepare in advance, especially with strong universal health system capacities, which are required under the IHR.
Is There a Significant Risk in the United States or other High-Income Countries?
The United States has a sophisticated public health system and CDC is the best in the world. The risk to Americans is miniscule and there is no justification for extraordinary measures. Still, physicians and hospitals must be on the alert for cases, report them, and isolate infected people. All health workers should ask patients with flu-like symptoms if they have traveled to China or been exposed. Health workers also need to take rigorous precautions. Failing to protect health workers was our main blunder during Ebola and we shouldn’t repeat it. Fever screening and questionnaires at airports rarely work; border screening almost always picks up many more false positives than true positives. Still, such screening is lawful and will help reassure the public. But the US should not contemplate major travel bans or large-scale quarantines.
Public health officials should advise the public to practice good hygiene, like hand washing, go to a doctor if they have pneumonia-like symptoms, and avoid contact with people who are sick or have been exposed. While the flu shot won’t protect against this novel coronavirus, people who haven’t been vaccinated should get their flu shot to reduce their risk of flu, which causes similar symptoms and could be confused with coronavirus. The elderly or vulnerable should also ask their physicians about a pneumonia vaccine. Beyond that, people should live normally. The risk is miniscule.
The bottom-line message is to invest in prevention and biomedical technologies; prepare with universal, strong and resilient health systems; and respond with traditional public health measures to bring nCov-2019 quickly under control. The international community must act decisively and cooperatively, but calmly and in a measured, evidence-based manner.
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