Emma Ross
…our Distinguished Fellow, David Heymann. This week, the institute is marking its centenary with a series of special events, and the guest scheduled for today is Dr Tedros Adhanom Ghebreyesus, the Director-General of the World Health Organization, who needs little introduction, I’m sure. Unfortunately, we’ve just heard, moments ago, that something urgent has come up at WHO and Dr Tedros would not be able to join us for the duration of the webinar. We’re hoping he’ll be able to join us for some of it, but we are still waiting to hear. So, I apolog – apologies for that, most unfortunate, but we are going to carry on nonetheless, and there’s lots that David and I can cover in this for your – and your questions on some of the same aspects, as well as some of the new science that is emerging around the outbreak. David, I thought maybe we could start with you situating us as to where you think we are with the pandemic now, and what the outlook is for the next year or two.
Professor David Heymann CBE
Well, thanks, Emma. As you know, there’s quite a bit that’s been learned already, and this has really helped in getting the world to where it is today, at a point where the virus has been supressed in most countries in Europe, North America, the Middle East and Asia, but it’s still increasing in Latin America, and in Africa, there’s really a question as to what’s happening there, because it hasn’t yet manifested itself in the same way as it has in other parts of the world. So, we’re seeing that, overall, the efforts that countries have made have done quite a bit in supressing virus transmission, and now countries are exiting from that and have a series of questions as to what they need to do going forward. Countries certainly want to keep the virus supressed, the transmission supressed, in the short-term, and keep that heavy burden of patients out of hospitals.
But there are some questions, which are not yet answered that would help in understanding what the future will hold, and that includes whether or not there will be a vaccine, whether or not the immunity that occurs after infection of this virus is an immunity, which lasts and which protects, and is it an immunity caused by antibodies in the blood or by cells – special cells called T cells, which are not manifested in the antibodies that are produced in the blood. So, questions like that continue, but still, the world has done a remarkable job in facing this outbreak. If there were to be one common error that’s been made, it’s been that countries have assumed that this would transmit and be the same as an influenza pandemic, and it clearly is not. This virus causes discrete outbreaks, contact tracing, or track and trace as it’s called in the UK, is important to continue throughout the strategies of dealing with this virus, as well as trying to shield those populations at greatest risk, which include people in care homes, which include the elderly and those with comorbidities.
So, we’ve learned a lot. We’re lacking certain tools to go forward, and what we hope is that those tools will become available, but, in the meantime, we can still do a lot to keep virus transmission low while we’re waiting to see the destiny of this virus. Remember, Zika virus has disappeared from populations at present. Other viruses act in different ways. The HIV virus emerged and continued long-term, and other viruses have various epidemiologies. So, we just need to see the destiny of this and, in the meantime, make sure that countries are doing the maximum effort they can to supress transmission.
Emma Ross
But how should we position ourselves now? Should we be looking at we’ve got to learn how to live with this for the next year or two, three, or do we just say who knows what can happen? What do we need to be doing to position ourselves to cope and get ourselves through this?
Professor David Heymann CBE
Well, as much as I think we’d all like to say we can count on a vaccine being available next year that can be used in the high risk populations, and we can then get on with life as usual, that’s what we would all like to be able to say, but there’s no evidence that that vaccine will be effective, long-term immunity and available. In fact, Tony Fauci, the other day, had said that “If the vaccine is shown to be effective, it may not have a long-lasting immunity, and that would require revaccination of populations at regular intervals.” What’s in favour of this is that this virus is an RNA virus, as is the virus that causes influenza, but this virus mutates less frequently. There’s some type of a control mechanism at the molecular level, which prevents this virus from mutating as rapidly as does the flu virus. You remember, the flu virus needs a new vaccine each year. This virus doesn’t mutate in that manner, and so, if there is an effective vaccine, it probably wouldn’t need to be modified regularly, as has to be the seasonal influenza vaccine. So, we need to get on with doing what we can with the tools we have. We know how to diagnosis infection, we know how to contain small outbreaks when they occur to prevent community transmission, and we know that sometimes, we may need to supress the virus by closing down certain sectors and then opening them up again, as we’ve seen in Asia.
Emma Ross
Okay, thank you for that. I do want to come onto two news pieces today that I can imagine might be keeping Tedros from this call. One is the – Donald Trump’s notification that he’s started the official withdrawal from WHO. What would really happen if they did withdraw? What is the reality of what that means?
Professor David Heymann CBE
Well, first of all, Emma, I would say that, as an American, because my career has been through the Center for Disease Control in Atlanta, based overseas, I’m very disappointed that the US would even be considering withdrawing from an organisation, which has benefited the US and countries around the world. That’s my first statement, and I have to claim bias because I’m an American citizen and I’ve worked on secondment at the World Health Organization. But the US has been behind incredibly important activities of WHO. During the Cold War, it was Russia and the United States who got together, despite these geopolitical tensions, and passed a resolution, through the World Health Assembly, that eradicated smallpox. So, even despite geopolitical tensions in the 50s and 60s, the world moved ahead and eradicated a disease working through WHO. The world is working through WHO on polio eradication, another resolution that was passed by the US, being stimulated to do that by Rotary International, which has mobilised over a billion US dollars to contribute to polio eradication.
WHO also can work in countries that the US can’t work in because of various regulations within the US. By giving its funding to WHO, which it’s done freely in the past, WHO has been able to work in these countries, that are problem countries for US politics, but which are important in the global fight against infectious diseases. So, WHO’s been a remarkable memb – the US, rather, has been a remarkable member of WHO, has been – as has been the UK and many other countries, which have contributed both to the core budget, through their assessed contribution, and also, as well, through extra budgetary resources provided to specific activities. Without WHO’s – without the US’ input into polio eradication, for example, WHO will struggle to keep its surveillance activities going, which are necessary to identify where polio is occurring and where it needs to be stamped out. So, the US contributions have been in – really unimaginable to the general public, but have been basically – along with the UK, Japan and certain other G7 countries, have been the backbone of what the United – the World Health Organization has done.
Emma Ross
But what does it mean going forward? If they’re gone, where does that leave WHO? Especially if they’ve been such a backbone, does that mean the whole thing collapses, somebody else steps into the void, where do we go from here?
Professor David Heymann CBE
Well, you know, I’ve always said, in my own personal life, that things will go on if I go out and get run over by a bus tomorrow, and I think that’s the attitude that we have to have with WHO. If the US does decide, through its regulat – through it’s parliament or congressional procedures, to withdraw from WHO entirely, then WHO will get on with its work, without an important partner, but it can be – but that partner can be replaced by others. Germany has become a very important partner in global health recently, and other countries are stepping up, as well. So, as much as it would be terrible if the US leaves WHO and leaves that expertise that it has provided throughout the years, the WHO would continue to function, and other countries would likely step in to help support it.
Emma Ross
Well, do you think it might fuel some of the moves or murmurings about setting up another agency to tackle pandemics, to cover for WHO’s supposed failures, that without the US inside the WHO, this might pave the way for the setting up of another competing agency or compleme – whether it’s competing or complementary, does this harbinger any of that type of stuff?
Professor David Heymann CBE
Well, I wouldn’t want to make predictions, I don’t know what will happen. I can say, though, that the U – there are many countries now which are against setting up, again, new organisations because they’re trying to focus what they’re doing on a few organisations, and an example would be the UNAIDS Programme, which was set up back in the 1990s. The US – UNAIDS Programme was set up because countries felt that all the UN agencies were not contributing as they should be, and it was set up as an agency independent of WHO, but depending on WHO for certain things, and depending on other UN agencies. That organisation has now been functioning for 20, 20-some years, and it’s not clear what its future will be. I know that many of the partners of UNAIDS would like it – to see it now become, again, a part of various agencies and disband the UNAIDS as it is today, put the biomedical activities back in WHO, the child activities in UNICEF and others, but whether or not that will ever happen, I don’t know. But it – there is a precedent for this, but I know that many countries don’t want that precedent to continue to set up new agencies. But, having said that, if there is an agency that looks like it has a better comparative advantage in dealing with pandemics, then that would be vetted, and it should be decided whether or not to move forward in that direction.
Emma Ross
Well, while you’ve got a massive amount of experience in dealing with epidemics and pandemics, can you imagine a scenario where there might be a better suited structure to deal with this, a better alternative than what we’ve got?
Professor David Heymann CBE
Well, you know, when there is an outbreak that needs international support, WHO is the agency that can not only call together the partners through its Global Outbreak Alert and Response Network, but that can also facilitate the entry into countries of people who are working with that, because WHO has a special relationship with countries, and it has offices in those countries. So, it is, at present, the ideal group for getting – mobilising global partners to work when there is a need to work in outbreak management, and that includes new partners, such as the Africa Centre for Disease Control and other new regional agencies. It’s able to pull those partners together and work within countries in a way that they can facilitate the entry and the visas of those people who come in to work under the WHO mandate.
Emma Ross
Okay. Thank you for that. Just to update everybody, we’ve heard from Dr Tedros’ office and, unfortunately, he’s confirmed that he will not be joining us today, we’re postponing it, and we’ll put together another event with Dr Tedros at another time. So, David, if you’re happy to carry on with us just winging this, regrouping…
Professor David Heymann CBE
Yes.
Emma Ross
…I wanted to go on…
Professor David Heymann CBE
In fact, Emma, I spoke with Tedros the other day about another issue and, at that time, he was really looking forward to being able to speak with us today at Chatham House. It’s not because he doesn’t want to face questions because he doesn’t want to be here. I’ve been in touch with his office today on another issue, not – on an issue that he and I began on Monday, and I was told that he has a series of diplomatic meetings today, which is the result of the US withdrawal. So, you know, I think we can all understand Tedros’ position, and I am sure that he will participate again in an event coming up, but that will be for Robin Niblett and others to be working with him on, and I’m sure that we will have that event, possibly this week, possibly sometime in the future.
Emma Ross
Well, that would be great and look forward to taking up the issues with him at that time. So, I wanted to come onto the second big news of today in the pandemic, and that is this stuff about airborne transmission and the extent to which, first of all, it has been mentioned before that it is possible that it can’t be ruled out, that’s not a new thing. I guess the issue is, to what extent – how seriously is it being taken as to what extent it’s contributing to the spread? So, I know you’re involved in some of the discussions on that. What do we know so far, and if there is – if airborne transmission is more significant than we thought it was, that would appear to have quite a few implications for some of the interventions we’re dealing with at the moment, so where are we with this airborne transmission question?
Professor David Heymann CBE
Thanks, Emma. Before we discuss airborne transmission, it’s probably useful to understand what types of transmission occur from this virus, and we know that there are two types of transmission. Number one is transmission that occurs by droplets, which are coughed, sneezed, talked, or just – or some, when people make movements with their mouth, they create droplets, and those droplets can infect people directly, or they can infect people in a distance of up to over a metre, a metre maximum, it’s thought, directly through an aerosol, and an aerosol is when those particles are suspended in the air long enough to go from one place to another. So, there’s droplet transmission, which is direct, as if someone is spitting on someone else. Then there’s the aerosol transmission, which is droplets propelled, but propelled in a distance that is a metre, so that they can actually land on somebody without direct exposure to the person making those droplets.
And then there’s airborne transmission, which is a form of aerosolised transmission, but it occurs even easier than does this transmission through an aerosol directly to a person. So, I don’t know if I’ve been clear on those three types, but what the people who are talking about airborne transmission are talking about now is an aerosol that could be picked up and retransmitted through an air conditioning unit, or an aerosol that might go through other means into other parts of a room or a place where people are present. And so, what we believe is that there is a possibility that there is this airborne transmission in closed spaces, that an air conditioning unit, especially one on the wall, might be able to pick up an aerosol and then spit it back out if it’s not filtered, into the room and circulated throughout the room. But remember, this is droplets, which surround a virus, and if those droplets dry out, the virus can’t reproduce, it dies. So, there have to be several things that happen. That virus has to remain alive during this process because the droplets have to continue to surround it. If those droplets dry out, the virus is no longer infectious.
So, that’s the thinking that it might be, and there are some ways to determine this, and there are some studies that are going on now, and WHO’s waiting to see these results. One of these is to put an animal that can be infected with this virus into various places around rooms, in hospitals or wherever, to see if those animals are being infected, and that’s being done with hamsters. In the past, it was done for tuberculosis with guinea pigs, but hamsters can be infected with this virus, and there are actually cages sitting around in various parts in experiments that are being done by academic institutions that will give us information as to whether or not this virus is spreading in aerosols around – in airborne transmission further than enclosed spaces, which is where we believe those – that airborne transmission can occur now.
Emma Ross
Have we got any evidence of any cases being tied or suspected of being an airborne transmission, or is this all animal studies, theoretical stuff?
Professor David Heymann CBE
Well, a lot of it’s done in laboratories to see how far the virus can be propelled, and those are laboratory studies, and that’s what they are, laboratory studies. There is some possibility there’s some anecdotal evidence, for example, that people sitting in a restaurant in China, where there was an air conditioning unit on the wall, appear to have become infected and it’s not clear how they became infected because they weren’t – they were spaced, they were physically distanced, and one of the hypotheses is that this was the air conditioning unit that caused aerosols to be recirculated in the room. So, that could – that’s one hypothesis that exists, and that’s what people are citing as evidence, although there may be more evidence coming along. We know, for example, in this famous choir episode in the state of Washington, that people were together for two hours when one person was sick and, during that, people – 32 different people got infected, presumably from this person who was sick, and presumably through aerosols that were created when he sang, or she sang, and infected the others in the room. There isn’t any evidence that there was recirculation in that room, but these aerosols can take the virus along and, if they then can, again, be recirculated, it may be that can be circulated in a way that it infects more people, remembering that those droplets have to remain moist.
Emma Ross
And it’s – is it a likely scenario or is it, kind of, way out there that we can’t rule out the possibility? I mean…
Professor David Heymann CBE
Well, some of the reasons are because you can’t just look in the laboratory, you have to look in the epidemiology of infections, as well. And this infection can be stopped by contact tracing, track and trace, as is being done in the UK, in discrete outbreaks, and countries have shown this time and time again that this can be done, whether it’s Germany, which continued this throughout its lockdown procedures, whether it’s countries in Asia or elsewhere. So, you know, there is evidence in what’s happening that this virus doesn’t act as a virus that would be airborne, such as possibly influenza, which occurs and doesn’t cause discrete outbreaks. So, there’s lots to be put together yet, and it’s ironic that many of the people who signed that letter are actually contributing to many of the different WHO groups, which are investigating this. So, they’re working with the infection prevention and control group, they’re working with other groups, technical groups, in WHO, to try to understand these ideas and, all of a sudden, many of them have felt that they needed to, for some reason or another, be more urgent in what they’re requiring, rather than working through, finding the evidence, and using that evidence to create understanding.
Emma Ross
So, epidemiologically, do you think that if airborne transmission was a significant – I’m not even saying the major driver, but a significant driver, would we not have seen that in clusters or outbreaks already, if that was actually going on?
Professor David Heymann CBE
Certainly in countries with low reproductive numbers, and I’m thinking of countries in Europe, for example. In Switzerland, which now has a low reproductive number, people are walking around on the streets, they’re congregating in restaurants, they’re avoiding close distance, they’re doing physical distancing, Switzerland has closed down major public gatherings, a whole series of things, and they’re requiring mask-wearing in closed compartments, such as trains, yet in Switzerland, over the past four weeks, there’s not been any indication that this is just airborne and spreading in the community, so that if you walk down the street, you could be infected. So, there are epidemiological indicators, in many countries, I used Switzerland as one example, as places where there isn’t this increased transmission that you would think would occur if this is airborne and can infect people walking down the street.
Emma Ross
So, I would imagine that this story, as this unfolds, there may be some people thinking that this will change, again, the thinking on mask-wearing, that maybe if it’s airborne, wearing a mask might protect you from a virus coming in, in addition to you coughing it out. Could this whole airborne transmission story reflect on masks, mask-wearing and the very politicised now issue of masks?
Professor David Heymann CBE
Emma, airborne transmission would mean that the eyes are even more at risk of being an entry point for the virus. The eyes, the nose and the mouth are the common entry points for droplets, and aerosolisation would be circulating this in such a way – or, rather, airborne infection would be circulating in such a way that the eyes could be even more exposed to the virus. And so, if people are walking down the street thinking that a mask would protect them from any type of infection, they’ve got the wrong understanding. Masks are used to protect others. To protect yourself, you need full PPE. You need to be wearing goggles, you need to be wearing a mask that’s got a filter on it, you need to be wearing gloves and you need to be not exposing yourself to this virus in any way. And that’s what happens in hospitals, that’s why masks prevent people from getting infected in hospitals, but walking down the street wearing a mask, to think you’re protecting yourself is the wrong message that people have understood. The message is protecting yourself involves physical distancing, it involves handwashing, and it involves, when you can’t physical distance, wearing a mask to protect others.
Emma Ross
Okay, thank you. I’m going to move – as much as I want to press you even further on this airborne, there’s more I could squeeze out of that, I’m sure, but I’m going to give the audience a chance to ask some questions now ‘cause a lot of people are waiting. I’m going to start – well, actually, it’s a follow-up on this from Ian Sample at The Guardian, asking you “How might the potential for the aerosol transmission change the strategies for controlling the outbreak?” That was one of the ones I was going to press you more on, so let’s give that to Ian.
Professor David Heymann CBE
Well, if there is airborne transmission, we need to better understand it before we can put interventions in place, but there is a group of Engineers at WHO, Sanitary Engineers, who are working to understand what the mechanisms might be of propelling these particles, airborne transmission, and those things will collect the evidence that we need to decide what needs to be done. But, frankly, we’re doing quite a good job at present in supressing this virus, in doing the epidemiological response, which is based on what’s happening when the virus gets into people, so that we know that countries have been successful in supressing virus transmission. And we also know, as recently in Japan, as recently in China, and in Germany, that this virus can then increase its transmissibility or its transmission in certain areas, and there have to be measures done in that area to decrease transmission. But…
Emma Ross
The…
Professor David Heymann CBE
…this is a virus we will likely be living with for quite a while. It’s not clear what the destiny is, but we need to give everybody the opportunity to pull the evidence together and make the recommendations of what needs to be done. I can’t sit here and make them, and no-one else can, either.
Emma Ross
Sure, but – and if it – let’s just suppose we’ve been through the evidence, no-one’s saying which way it’s going to turn out, but say it does turn out to be that airborne is significant and we can intervene to mitigate that, when there are other viruses that are airborne, what are the main differences between a droplet and an airborne in the strategies that you need to take to reduce the risk of transmission?
Professor David Heymann CBE
Well, we know that, in aeroplanes, SARS coronavirus itself, the first SARS coronavirus, did not transmit through circulating air. It transmitted to people sitting next to, or in front of, or in back of people who were infected. So, we’ve already got that information on one coronavirus, which, granted, was a different means of reproduction, it was low in the lungs. This present coronavirus is high in the lungs. We also know that tuberculosis, another infection, does not transmit on aeroplanes. We know that the filtering systems in aeroplanes are useful systems, which are filtering out those particles, if they do get into airborne transmission. What we don’t know yet is whether this virus can get into air systems on an aeroplane, or into air systems on – in an air conditioning system in a restaurant, for example, but there’s no evidence as yet that shows that it does. And so, collecting that evidence over time, maybe doing experiments, maybe putting guinea pigs, or hamsters, rather, on airplanes and flying them around with airborne transmission might be a way of showing those things. But these are complex studies, which need to be developed, in order to understand, and the best is observation. And so, observation will tell us, now that airlines are flying again, whether or not people are getting infected on aeroplanes, and it will tell us whether or not people are getting infected in spaced restaurants and areas like that. So, we can’t just put laboratory studies into operation, we have to put laboratory studies into the hypothesis that is generated by what’s happening in human populations, and then we can make recommendations as to how to change that.
Emma Ross
So, it would seem that people who are choosing to fly right now, with this uncertainty, are the guinea pigs in the aeroplane air conditioning system, I guess.
Professor David Heymann CBE
What I would say is that those people are calculating the risk that they feel might be a risk to them, and they’re deciding whether or not to fly and, when they fly, they do what the airline company tells them to do. If it’s wear a mask, they wear a mask. So, what this whole outbreak is about is understanding your own perception, your own risk and, if you have a risk perception that says that there is airborne transmission, then you should modify your behaviour accordingly. There’s no evidence of that, that WHO has put out yet, that shows how you might modify your behaviour, because WHO’s still trying to collect evidence, but if you, as an individual, and individuals are at the base of how this outbreak will eventually be contained, if individuals feel that they’re at great risk in flying on an aeroplane, for any reason, then they shouldn’t fly on an aeroplane.
Emma Ross
Okay. Here’s a question, an upvoted question, from Dina Mufti. “What is the probability that there will be a future virus with the transmissibility of COVID-19 and the fatality rate of MERS? What needs to be done to prevent it becoming a pandemic?”
Professor David Heymann CBE
Well, I can’t answer that question because nobody can predict a pandemic. What I can say is that there was, in – there are four endemic coronaviruses, and these have entered populations some time in the past, probably in much the same way as this virus has entered populations, but in a way that they transmitted around the world much more – and much slow – more slowly. And there’s an interesting – there’s interesting research that’s been done on one of those coronaviruses, tracing its rate of mutation back to where it appears to be the same as the virus from which it is thought to have emerged, which is from a virus that was carried by cattle. And the – this tracing back of the mutations, which is done by Molecular Biologists, has taken this to a point in 1890 and, during the 18 – late 1880s and 1890, there was a major epidemic or outbreak recorded as having killed over a million people.
So, that’s all circumstantial evidence, it’s just to show what type of work and research is going on now to better understand these infections. Every endemic infection that humans have likely came from the animal kingdom in some way, whether it was HIV, whether it’s tuberculosis, or whether it’s the current coronavirus. And so, we know that they’ve come in the past, and there’s no reason that they won’t come in the future, and we just have to be prepared for them in a better way than we were this time. These events are – occur when a series of risk factors line up in such a way that this emergency occurs.
Those risk factors could be, for example, when there was an outbreak of Rift Valley fever, which is a viral disease, infection, carried by cattle and transmitted to humans, there was a major outbreak in humans in Eastern Africa back in the 1990s, late 1990s. This occurred because of a series of events. Number one, there was an El Niño event which caused flooding, which caused animals and humans to be pushed closer together on dry land. The virus is transmitted from animals to humans either by their blood during slaughter, or by a mosquito. Well, in flooding, there was more mosquitoes, that was the second risk factor. So, people were living closer to animals that carried this virus and, in addition, there were more mosquitoes. But the major risk factor was that vaccination of animals against this virus, which was being done in East Africa up until the mid-1990s, stopped because there was no more vaccine available. So, all of these things lined up in such a way that there was an outbreak of Rift Valley fever in humans. That didn’t spread throughout the world. But that’s what we have to be looking at, risk factors, how they line up, and the emergence of an infection, and that can certainly occur in the future.
Emma Ross
Okay. I’m going to go onto a politics question now, this is another upvoted question from Patricia Lewis from Chatham House. “Can antibodies from another disease, perhaps from another coronavirus, or even a vaccine from an unrelated virus, provide some cross-immunity?”
Professor David Heymann CBE
It’s a good question, Patricia, and yes, antibody to some infections do cause cross-immunity. In the corona – the current coronavirus, there are four different human coronaviruses, and there are antibodies from all of these viruses. There is one hypothesis in Africa, where the outbreak has not been increasing in the same manner of – spreading in the same manner it has in another countries, that possibly there is cross-immunity from some of the coronavirus antibodies in people in Africa. This is only a hypothesis, there’s no evidence for this at all, but there is cross-immunity in some infections and, you know, there could be cross-immunity with this. But, recently, it’s been shown that it might be that the immunity for this virus is not so much antibody immunity as it is T cell immunity, which is a different type of immunity, and, if that’s the case, then we can’t measure antibodies and determine whether or not they’re protecting, but there may be other mechanisms of cross-protection.
Emma Ross
Okay. Sorry, I’ve switched round the order of the questions I was going to ask ‘cause I was going to ask a politics question. Here’s an upvoted politics question from Satwick Maheshwari. “The pandemonium this pandemic has caused in international relations and politics has highlighted the fact that we need to have health centric policies going forward. How can we work towards that?”
Professor David Heymann CBE
Well, you know, if I were to look at one thing that was really dysfunctional in this pandemic, it’s been collaboration nationally between political leaders and public health leaders, and that’s not been functional in many countries around the world. I’m not naming any specific county but, if you look around, you can make your own judgments, but it’s been very difficult in some countries for the public health community to work with – to convince the pub – the political leaders that certain strategies might be effective. Having said that, in countries where they’ve taken a more public health approach, an epidemiological approach, they’ve been able to keep a sustained suppression of the virus, and this includes countries in Asia, where they look to see where transmission is greatest and then they lockdown that sector for a while, then they open it up again, with full sanction by their political – with full endorsement by their political leaders, or where they have to do other things, but it’s always a public health approach rather than a political approach. So, if there’s one lesson from this, it’s – it is that public health and political leaders in many countries need to learn to work better together than they are during this pandemic.
Emma Ross
Well, maybe I could ask you one of the questions I was going to ask Dr Tedros, and that is a report card for the world on global solidarity. Right at the beginning of the outbreak, he talked about the need for scientific, financial and political solidarity. We’ve heard a lot about how the scientific solidarity has gone really well, everyone’s pulling together, but what would you say is our report card on the financial and political solidarity?
Professor David Heymann CBE
Well, you know, political solidarity can be measured in one way by the way the World Health Assembly works together and, in the most recent World Health Assembly in May, a resolution was passed with consensus from countries, it wasn’t voted on, it was a consensus resolution, that there needs to be an examination of the WHO’s structure and to see how that might be modified. I know WHO will now be required to move ahead with that assessment, and it will go ahead with that. So, that shows, in some way, a political solidarity, including in the US, and the US, as I believe, agreed to this resolution and said that they would give a month to WHO, in order to determine whether or not this was moving forward in the way they wanted it to move forward. They made an announcement, though, almost ten days or a week after, that resolution was passed, so I’m not sure that they were waiting until that full month to see whether or not WHO was taking the measures it was obliged to be doing under that resolution.
Emma Ross
Okay, well, there’s two similar questions to this that are upvoted. One from Sunbal Javed, who’s asking “What are some of the lessons learned from COVID-19 on future pandemic handling by WHO and its reform?” And from Graham Lister, “Are there any positive lessons for the reform of WHO emerging from the current crisis?” So, as you said, that assessment will be done, and this happens after every big event, but, so far, what are we seeing that you think might be informative right now?
Professor David Heymann CBE
Well, you know, WHO is pulled in many different directions by many different constituencies, and by resolutions that are passed in the World Health Assembly, and sometimes WHO has been told to do one thing, and then the next year it says don’t do one thing. And so, WHO is constantly at the whim of the political leaders in the World Health Assembly and must do what they say. It’s always, in my view, been a bad idea that a restructuring can be done from top down. What really, in my view, needs to be done is the stakeholders of WHO, whether it’s private sector, whether it’s civil society, whoever it is, must be working together to really define what functions they want WHO to be doing in the 21st Century, and then that those functions would dictate what strategy – what structure should be developed, rather than continuing to have a top down approach to restructuring, which occurred after the West Africa Ebola outbreak, there was a top down restructuring, WHO created its Emergencies Programme. Based on that, that Emergencies Programme is now being criticised by many, and, you know, we’ll see another group get together and, likely from the top down, impose on WHO a new structure, based on what they feel is important, without really understanding what functions the stakeholders need and sticking to those functions, and then developing a structure based on those functions. So, you know, top down is always a difficult issue for organisations to face, and many times it happens, even when consultancy firms come into an organisation, organising a new structure without fully understanding what the real functions are or what the needs are at a lower level.
Emma Ross
So, is there hope that this time any review or assessment could refrain from making those mistakes of top down, and approach in a different way, but still have an official review? ‘Cause we’re going to have one, but that sounds not very encouraging, if we’re going to get more of the same that’s not feasible in your view. Is – do you think it’s possible to have a review from the top, but not impose a top down restructure?
Professor David Heymann CBE
Well, you know, I don’t know what WHO will do, but all I can say is that, for me, structure follows function, and if the functions aren’t yet sorted out because they don’t seem to be, because the Emergency Programme, created just a few years ago, is now the programme that people are focused on as needing a restructuring. So, if it again, comes from the top down, it may not be as effective as one that would come from understanding what functions the stakeholders really want, and then moving ahead with a structure that accommodates that. WHO is also very difficult organisation to work because there are six regional offices, as you know, that are – and the Regional Directors of WHO are elected by the Health Ministers in those different regions, who then come together in the World Health Assembly and make recommendations in the World Health Assembly. So, there are certainly difficulties in the current structure. Many structures have a Director-General elected by an assembly with then names of the regions, rather than having those regions elected independently of the Director-General, and at different times than the Director-General is elected.
Emma Ross
I’m going to ask a question from Sarah Newey at The Telegraph, and this, again, is going back to the US China thing, but I wanted to, kind of, add onto that. Her question is “Could the US’ approach to the WHO result in a surge of influence for China and, if so, isn’t this the opposite of what the WHO wanted?” And I’d add to that a question of to what extent do individual countries influence what goes on at WHO? You could observe that, when it comes to being asked about calling out any individual country, whether it’s the China or the US or Brazil or, you know, some of the leadership decisions that have been taken in this pandemic, WHO tends to shy away from calling out individual countries. Do you think that’s true and, second of all, do you – is – are some countries more influential than others, in reality, honestly?
Professor David Heymann CBE
Well, you know, WHO at the top is a political organisation. It was set up as a technical organisation, specialised organisation of the United Nations system, but at the top it is a political organisation, and the Director-General election process is a political process. So, you know, that’s the first thing to remember about WHO. The second thing is that countries that provide extra budgetary funding do have an impact on how WHO implements its activities. So, if countries are providing extra budgetary funding, that is funding not under their core assessment, but extra budgetary funding for certain activities, then WHO will naturally do those activities because they’re bound to do them by that country that has provided the funding. That’s why polio eradication is moving ahead, with funding from Rotary International, the Gates Foundation, and the United Kingdom Government and the US Government, and many other donors because they’re providing extra budgetary funding and they say, “We want WHO to work in this way to eradicate polio.” That has always been a problem for WHO.
Of course, any organisation would like to be having its money in its core budget, and being able to implement its budget based on what, in this case it’s World Health Assembly, an executive board have said should be done. But the priorities are distorted by extra budgetary funding, if that funding’s necessary to keep the organisation moving. So, it’s – that’s the second issue. The first is a political process to elect a Director-General, second process is extra budgetary versus core funding, and the third is influence can come from countries in many ways. Countries can second staff to WHO to work within the WHO Secretariat. Those people work on a secondment from their countries, but are serving as a link to their countries. There are other ways, by having WHO collaborating centres. The United Kingdom has many, many WHO collaborating centres that provide support to WHO, specialised support, for example, in meningitis, coming from Public Health England. So, there are a whole series of things, which countries do in support of WHO, and that does, in some ways, distort what WHO does. So, you know, when countries step out of both extra-budgetary and core funding, there’s a place for other countries to come in, and I don’t know which countries might come in. Germany is stepping up in certain areas, other countries may step up, and, you know, I can’t predict what China will do any more than anyone else can do.
Emma Ross
Okay, thank you. So, apologies, Sarah, I slightly hijacked that, but David did get around to answering your question fully, I believe.
Professor David Heymann CBE
Well, it’s a hard question to answer, Sarah. It’s a tough question to answer because nobody knows what will happen in the future but, by knowing the ways in which influence can be done made within WHO, you can envision or you can watch for those things that might be happening, as we move forward.
Emma Ross
So, maybe a question I was going to pose to Tedros I could ask you, and that is, do you think that WHO was placed in the middle between this struggle between the US and China of what’s going on geopolitically? Were they stuck in the middle?
Professor David Heymann CBE
Yes, I think…
Emma Ross
Or are they?
Professor David Heymann CBE
…they are stuck in the middle, and they’re stuck in the middle in many other discussions, as well, whether it’s between pharmaceutical companies and it’s World Health Assembly or others, it has to be able to learn and listen to all sides and, many times and by doing that, it becomes at the centre of tensions and discussions. You’re muted, Emma.
Emma Ross
Sorry, sorry, sorry. I’m going to go to another upvoted question now, and this is from Benjamin Stokes. “Does David have any comments on the percentage of people who get COVID-19 and have no symptoms?” 70% I think is the figure the ONS in the UK, and what’s the – “What is the latest view, in light of this, of the percentage of people in the UK or different countries who have already had the virus? And any comments on what these facts mean for managing the virus.”
Professor David Heymann CBE
Yeah, well, there are several sources of information about how many people might have been infected in a country. One of those comes from the modellers who look at the evidence they have available, and use that to fit into their models to determine what might happen, or might have happened in the past, or what might happen in the future. So, modellers give us one estimate of how many people might have been infected in a country, based on their complex activities, and we heard from our modellers last week, in fact, if you want to listen to that. [Inaudible – 47:52] was clear in telling how those models are developed. At the same time, we like to use antibodies to determine how many people have been infected in the past, and the only standard – gold standard test right now is what’s called a neutralising antibody test, which is done in a laboratory, and which shows that the antibody detected can neutralise a living virus. So, that’s a very complicated procedure, but that’s the neutralising test that shows that antibody that’s present can, in fact, neutralise the virus.
What we aren’t sure of, though, is how sensitive these tests are in picking up the virus – the antibody. We know that antibody is difficult to pick up, especially in people who have mild infection, or people who have had even serious infection, sometimes it takes three or four analyses before a confirmed test – a person who had confirmed illness by a PCR shows antibody. Antibodies don’t develop until about the second week but, in fact, people – there are a series of people who are being saved who are PCR positive, that means they had the virus present, and they’re being followed over a series of weeks to see when the antibody develops and when it decreases and, in some of those people who have had good, solid infections, they don’t have antibody even after four weeks. So, it’s all about learning, and then there’s the T cell immunity in addition, which is making it very difficult to understand what immune responses are working, and how many people have actually been infected. So, there are various figures. I think the generally accepted figure right now is that, in some countries, in most urban areas, maybe up to 7 to 10% of people appear to have been infected during the highest period of transmission but, in some other areas, it could be up to 17% or greater. So, that’s a long way around an answer to say what will – what different answers are.
Emma Ross
And there isn’t that much certainty – there’s a little bit of uncertainty around that, isn’t there? Because, if the antibodies only last a few weeks, but you’re getting your antibody test months later, could be missing, so could be a greater proportion than we’re seeing. There are so many things that could be in the way and explaining confounding factors. Is that…?
Professor David Heymann CBE
Absolutely. I would say that, for the serological surveys, they’re probably not picking up all those people who had infection, but they are picking up a good percentage of them.
Emma Ross
Okay, great. We – unfortunately, we’ve only got time for one more question, and it’s a highly upvoted question from Hugh Jenkins. It’s a compound question. “So, it appears that the virus gets everywhere, yet China seems to have had remarkably good numbers. Do we therefore expect there is still a significant wave to come in China, or have they really done an exceptionally good job?” And the other part of that is “Are mortality and hospitalisation rates really falling? If so, is this a function of more testing, the virus becoming less deadly, or better therapies?” So…
Professor David Heymann CBE
Okay.
Emma Ross
…start with one.
Professor David Heymann CBE
The first question – and what was the first question, Emma, again?
Emma Ross
The first question is about the numbers in China look good, can we…
Professor David Heymann CBE
Yeah, okay.
Emma Ross
…expect another wave to come or have they really done a great job?
Professor David Heymann CBE
Well, you know, using the term ‘wave’ is a term that’s used in influenza, because we’re familiar with influenza. It occurs in waves. There can be a first wave and then a second wave, and this has happened in pandemics in the past. This virus does not transmit as does the influenza virus, so it’s really not correct, at this point, to talk about a second wave. What’s more important is to talk about a reoccurrence or a resurgence or a reimportation of virus causing an outbreak, and that’s happened. In Beijing, that’s happened. Two weeks ago, I was in a discussion with the CDC in China about the Beijing outbreak, which has occurred. It’s thought to have occurred from another market. It’s thought that a market worker there was infected, contaminated the environment, other people then became infected, and it spread out into the community and to other markets that purchased goods from that wholesale market, and so those markets were closed down, schools were closed down in the area, and an attempt at suppression again.
That’s not a second wave, that’s a resurgence, and resurgence is occurring in Germany, it’s occurring right now in Japan, it occurred in Singapore, when there was a resurgence of virus in a migrant worker population. And so, it’s more useful to talk about a resurgence and trying to supress this resurgence in the short-term, and while waiting for a better longer-term strategy that can possibly be better sustained, once we know more about the virus and its immune responses. So, you know, speaking of waves is not really helpful. What’s more helpful is to look where it resurges, and then try to identify whether that virus is the same virus was there before – that was there before or not. In the case of Beijing, it appears that that virus was not circulating in Beijing before, that it maybe came in from outside, from somewhere else.
The second is about deaths, and deaths are decreasing in all countries. They decrease because prevention is occurring, especially among those populations at greatest risk of death, which are those people at greatest risk of serious infection. So, seeing a decrease of deaths in the United Kingdom, for example, means that the people who are at greatest risk, those people who are elderly and in care homes, are now being better protected, as are people with comorbidities. They’re either protecting themselves, or they’re being protected by other measures, and we’re seeing a decrease in mortality. So, one of the major ways of keeping mortality low moving forward is to strengthen the protection of those people who are at greatest risk, either by self-protection or by setting up mechanisms within care homes and other places where they can be better protected.
Emma Ross
Thanks, David, and that – sorry, everyone, that was all we had time for with the questions and, again, our apologies for not being able to bring you Dr Tedros, and hopefully, we will be able to reschedule for him, and we’ll let you know, of course, on that. But thank you for sticking with us, with David and I today, to discuss these issues, and please come join us next week, when we’ll be talking with Sir Jeremy Farrar, Director of the Wellcome Trust, about where we are and where we’re going with getting decent COVID-19 drugs and other therapeutics. So…
Professor David Heymann CBE
Emma, could I – yeah, could I just say…
Emma Ross
Ah.
Professor David Heymann CBE
…one more word, that we are – I am confident that Tedros will speak with us at some point, and I think that – I know the audience must be very disappointed, and I’m sorry to have had to fill in, but we will hear his voice at some time in the next few weeks.
Emma Ross
Okay, thank you very much, everyone, and wishing you a great rest of the day.
