Emma Ross
Good morning, and thank you for joining us for this week’s Chatham House COVID-19 briefing with our Distinguished Fellow, David Heymann. Today, we have with us Professor Devi Sridhar, who is Chair of Global Public Health and Founding Director of the Global Health Governor’s Programme, University of Edinburgh. She’s also advising the Scottish Government on their response. If you’re following the wider commentary on this pandemic, you will likely have come across Devi. She’s been watching closely the proceedings over the last two days of the World Health Assembly, the annual meeting of the Member States, the decision-making body of the World Health Organization. So, we’ll be talking a little bit about that first, before moving onto other things.
So, housekeeping stuff briefly first. This briefing is on the record and you can tweet using the #CHEvents. Questions can be submitted using the ‘Q&A’ function on Zoom, and upvoted questions are more likely to be selected.
So, normally the World Health Assembly, which brings together the 194 member states, discusses a range of topics, including WHO’s priorities and it sets new health goals, but this year it took place virtually, over two days, and was completely devoted to COVID-19. Just to briefly outline, one of the key outcomes was the adoption, by consensus, of the COVID-19 Response Resolution, which WHO is calling a landmark. One of the aspects getting a lot 0f play out of that is the call for an independent evaluation of the international response, including WHO’s performance. We also had calls for WHO to have more powers of investigation in investigating outbreaks. A lot of discussion on equitable access to any products that are developed during this pandemic. But, given that the World Health Assembly concluded last night, I thought that we’d start by getting each of your perspectives on, firstly, the basics, as what is the power of the World Health Assembly, and especially in this pandemic? Is it a particularly important one this year, do you think? David, why don’t you start? You’re muted, David.
Professor David Heymann CBE
Thanks, Emma. The World Health Assembly works on resolutions, and that is forging political will among the 194 member countries. That requires consensus on certain issues, and it requires a lot of behind the scenes, as well as direct interaction of the various country delegations that are participating in the World Health Assembly. Resolutions are very important because this political will then is translated into action, and just to give you a couple of examples. In 1988, the Polio Eradication Resolution set a target of the year 2000 to eradicate polio. That target wasn’t met, yet that resolution is still in power and still working to unify work throughout the world, through 194 countries, to eradicate this disease. During the SARS outbreak, there was another resolution that was passed, much as was going on this year in the World Health Assembly, in May of 2003, and that resolution led to a whole change in the way WHO operates what’s called the International Health Regulations. So, these regulations – these resolutions, rather, are very important because they express forged political will among 194 member countries. They’re not binding, but they do permit countries to put peer pressure on each other, because all of those countries have agreed to the resolution.
Emma Ross
Devi, I was hoping you might be able to, since you were following this quite closely, share your thoughts on the importance, or not, of this particular assembly in the pandemic response, and the highs and the lows of the meeting, kind of what the hopes and opportunities were going in, and what you think it delivered, or failed to deliver, that you would have liked to have seen come out of it.
Professor Devi Sridhar
Well, I think, going into it, it was a big question whether we would see consensus emerging among countries about the importance of WHO, and what I found useful, and perhaps it was a good moment to have it, is that there has been this simmering tension between the United States and China over COVID, you know, they’re both using it politically as well within their countries, because everyone is looking for someone to blame, something to blame, and WHO has been caught in the middle of this. And so, in a sense, the Health Assembly, you could see it either it was derailed by the United States being critical of WHO, President Trump, you know, tweeting out a letter that he had sent to Dr Tedros about what he felt were mishandling. But on the flipside what you saw is a lot of countries supporting WHO and a resolution coming forward that actually said that, you know, this is a very important agency. We need to work together, solidarity was the word, over and over repeated, and a real feeling that actually, we need to pull together and co-operate to move forward. And so, it was good that was aired and it was good it was, in a sense, resolved, that the US is alone, at least on this. There’s going to be, you know, an inquiry into what happened earlier, but the idea that it’s not a blaming exercise, it’s an exercise of how do you do better for the next time, which we’ve always done in previous experiences and learned from in the past. So, I’d say it’s positive, it was quite, I think, a positive step.
Emma Ross
And on that previous – this call for an independent inquiry on the international response and WHO’s performance, that has had a lot of play in the last day or two, but isn’t that quite a usual thing after most crises, this happens? We had after Ebola, and we’ve -after flu pandemic, isn’t this a normal thing to examine? But, I guess, in this case, what I wanted to ask is, is a WHO-led effort going to cut it, given the political climate and what’s going on right now? I don’t know who wants to – Devi, why don’t you start and then David.
Professor Devi Sridhar
Yeah, so I think an inquiry to also protect WHO, I mean, I think there’s a lot of misunderstanding of what WHO is. It’s a member state agency, where different governments delegate it responsibility to do certain functions. And so, if different governments want to delegate WHO the responsibility to do an inquiry, but WHO is expected to do an inquiry of its own actions, it’s, of course, not going to be seen as independent. And so, I think there has to be probably a higher level up in the United Nations, an international grouping that’s seen as acceptable to all the different parties, and is seen as independent, seen as apolitical as possible, in terms of actually trying to come up with concrete recommendations. So, yeah, and the last – I guess, the Ebola crisis, there were so many panels, and David was involved with quite a few of them, but I think there were, like, 16 panels, last time I counted, WHO had one, the UN had one, different agent – you know, different think tanks had some, and actually, to a certain extent, I think it was useful because many of the mistakes with that were not repeated in this situation. So, let’s see, I’m sure there will be many, many inquiries, that’s not going to be the thing that will be neglected.
Emma Ross
David, what are your thoughts?
Professor David Heymann CBE
And, Devi, just – yeah, okay, just to add onto what Devi has said. Yeah, these inquiries are very important for WHO. they give new guidance, they give a way forward, and, for example, at the inquiry for Ebola outbreaks in West Africa, at the UN level, the UN then setup an overarching committee, which is watching the management of WHO in this outbreak, watching it very closely and making recommendations during the outbreak itself, and there was an independent advisory group, which was also setup to the Emergencies Programme, as a result of the recommendations that came out. This independent advisory group is providing, on a regular basis, information to WHO, questions are answered by the advisory group, and it’s important to remember that the advisory groups and the various committees of WHO are all geographically representative, which is extremely important because that gives an equal voice to countries from around the world. So, WHO works by consensus, it works on these individual advisory groups, and when there’s a recommendation coming out of an assessment or an evaluation, such as happened after Ebola, those recommendations are welcomed by most countries. So, I think Devi’s right in saying that this will be a positive – and eventually a positive impact on WHO, having an inquiry to look and see what went wrong, but, more importantly, what went right and what to build on.
Emma Ross
Another notable point in this, this resolution dealt with was who should get what when it comes to COVID products? Apparently, countries fought off attempts to remove the idea of equitable and universal access and there’s specific reference in the resolution to the right of countries to override medicines patents. So, yes, as, Devi, as you said, there were strong calls for global unity and the resolution recognised that extensive immunisation against COVID-19 is seen as a “global public good.” And, despite that the US wanted to remove that language, but it passed by consensus, I’m wondering what the implication of that, in terms of what we can expect to see playing out, and what is the power of labelling something a global public good, what does that mean for what might happen, as a result of that being in the resolution? David, do you want to start?
Professor David Heymann CBE
Sure, I’ll start. You know, we have had universal coverage for two vaccines. Smallpox vaccine was made available to populations that needed it, based on a resolution from WHO, and that eradicated smallpox. Polio vaccine is also being made available, as a public good, to every country that requires polio vaccine, in an eradication programme that, again, has a resolution behind it. And then, there’s influenza pandemic vaccines, which haven’t had a resolution behind them, but which have had endorsement of what WHO calls an intergovernmental working group, which has setup a framework, called the Pandemic Influenza Preparedness Framework, in which industry voluntarily has agreed to provide percentages of its production of a pandemic influenza vaccine to developing countries, through WHO. So, there has been progress made in coverage of global goods and that’s come from resolutions or intergovernmental groups at WHO. And I think Devi will now be able to talk about possibly, about what she feels this resolution will do for availability, should there be a vaccine against COVID, what that might mean as far as getting it equitably distributed. So, I’d turn over to Devi at this point. Devi,
Professor Devi Sridhar
Yeah, thanks, David. I guess it’s fantastic to see so many countries committing to this, including China and, you know, France, explicitly saying that, you know, a vaccine, even if domestically produced, would be – and manufacture would be shared across the world. I guess the worry I have is seeing how the US, which is such a crucial actor in global health, I think that’s what’s quite astonishing, and, David, I mean, I’d be curious to hear your thoughts on this, seeing the United States, which is such a crucial actor in global health, you know, for decades it’s been a leader, and suddenly not willing to play by these rules, that we saw ventilators being stolen, that were meant for Barbados, we saw PPE being hijacked, that we can try to have rules, but we also need to anticipate that there could be member states that don’t follow those rules, and it’s – there’s going to be political pressure by citizens who want to have access to this vaccine to understand the logic of these agreements and who gets it first. So, as much of preparatory work can be done ahead of time, before a vaccine is available, I think can help avoid some of these really tricky – which in the end are going to be political decisions.
Emma Ross
Well, the global public good thing, does it – and having that in the resolution, does it allow any overriding of business as usual? As you said, this seems to be all being worked out voluntarily, but what actually can WHO do on this front, in the timeframe of this pandemic? Because previous agreements on sharing have taken years of negotiation, but in the timeframe that we have, that would make this stuff useful, what can WHO actually do, and what recourse do – will disadvantaged countries have at their disposal, if the voluntary system is not working as committed? David, start.
Professor David Heymann CBE
Okay, yeah. So, you know, I think that we have to, first of all, put vaccines into perspective. We don’t know whether there will be a vaccine that’s effective or not. They’re being studied, hopefully there will an effective and licenced vaccine, so countries need to now be concentrating on what they need to do as they exit, if they’ve been European or North American countries, or to continue activities that they’ve been doing, if they’re in Asia and in other parts of the world. So, first of all, a vaccine is not a given. What might occur is that there could be a drug, or an antibody preparation, which would be effective, and that would be under the same rules, that it would be hopefully considered a public good and countries could then work out a way of dividing the spoils among all countries, as has been done with the influenza pandemic vaccines. So, I’m very optimistic that countries will continue to work together. As an American, I’m very disappointed in the US view on WHO at this point, because my career was with the Center for Disease Control, and many of those years were being seconded to the World Health Organization by the US Government, to work on technical issues with them. So, I’m very disappointed in the US strategy, but I’m sure that, in the end, WHO will be able to work out a means that will ensure more equitable distribution of any public good which comes available, which can have an impact on the pandemic. Over to Devi.
Professor Devi Sridhar
Yeah, I think – I always find it hard to go after David, it’s like there’s so much in your thoughts and I have to process it all.
Emma Ross
You can go first next. You’ll go first next.
Professor Devi Sridhar
I guess, it’s – yes, I think David’s completely right on a vaccine and, right now, the focus should be, instead of going for silver bullets and, you know, moon shots, doing the hard slog of public health. So, I agree with that completely. I think, you know, there’s a lot – there have been countries who have delayed doing, I guess, the hard public health infrastructure, hoping for some kind of solution, whether it be a lot of people exposed to the virus already, or a vaccine readily available, and there are other countries who are doing the slog. I mean, look at South Korea. The effort the government’s putting into testing thousands of people, trying to find every case to control the outbreak. On products, yeah, I guess I’m a little more sceptical than David, just looking at – again, going back to the 2014 Ebola outbreak, when you had ZMapp, this new experimental therapy, and it was in limited supply and who got it, and what you saw was actually, there was not equitable access to this product. But if you were a European or American, you were – would get access to it, whereas if you were a national of a different country, who perhaps couldn’t afford it, or didn’t have access to it, you wouldn’t have had that drug. And so, again, I hope we’ll learn from that and there have been new guidance put in place since then and WHO is an essential part of that, to make sure we don’t repeat that mistake.
Emma Ross
Can I just press you, well, first, David, on what recourse countries have at their disposal, can we talk a little bit about whether the World Trade Organization flexibilities around intellectual property rights are relevant here and how that might play out for this pandemic? Is that a road that could be gone down for this?
Professor David Heymann CBE
Well, you know, there is a precedent being set with remdesivir, which is a drug which has been shown, at least, to shorten the time to recovery in those people who recover. It hasn’t been shown to be effective in curing infections, or in stopping progression of disease, but recovery is a little bit more rapid in those who have been treated with remdesivir, based on the studies in the US. So, taking into mind, I believe, the company that produces remdesivir has begun to licence this to companies that produce generics throughout the world, in an attempt to get them to be producing this, so that they can satisfy national demand. So, I think there are ways that are being developed, and industry has to be a player in all of this, that will permit a better distribution of goods as they become available. That’s, again, an optimistic view, but we’ve seen a little bit of what’s happening now, and we hope that that continue to – can continue to happen. But then, there is, behind this, the World Trade Organization and, of course, licencing procedures that have been mandated by the World Trade Organization, in the case of an emergency. Over.
Emma Ross
So, that means can – will countries be able to, if the industry is not generous and we find ourselves – you know, who knows what will happen, but say we find ourselves in the situation where they’re not as generous as countries would like, will they be able to activate some of these things? Is it a possibility, or not, or does it not apply?
Professor David Heymann CBE
Well, it will – I think it will depend, Emma, on their interactions with the World Trade Organization and whether the countries come together behind these regulations, which say that forced licencing can occur. I’m not an expert on this, by any means, but Devi may have more ideas about this than I do, but my feeling is that countries will band together and will try to use every mechanism that they can, including mechanisms through WHO, through the World Trade Organization, and other places, including the political bodies, such as the G20 and the G7, to make sure that, in the end, there is a more equitable distribution of these public goods. But, as I said, I think Devi will have a much better idea than I on this. Devi?
Professor Devi Sridhar
Yeah, no, I agree with you, David, ‘cause what came to mind was actually the debates about anti-retrovirals and about basically, when the argument can be made by governments and by their publics that this drug can save lives, and that industry and the private sector, because of certain policies, are preventing access to it and it has a direct consequence for people’s lives, you do see the tide changing, in terms of flexibilities being used. And so, I would be hopeful here that, you know, trips would not be used as the main barrier to people getting this medication. I think the issue will be about prioritisation of countries, you know, manufacturing capacity, and, even within countries, which groups get this first. Same for a vaccine, for all of these products, and so I think, again, WHO has an important role, helping governments think through the process of prioritisation. Do you start with health workers, frontline staff, do you start with those who are most vulnerable, in the at risk groups? Do you start with, you know, children, if we see more of this, you know, delayed immune reaction? So, I think it’s going to be about – less about do we have access to it, yes or no? And more about how do you prioritise the process of getting this out to people?
Emma Ross
Okay and I wanted to move away from the World Health Assembly a bit to where we are with what we’re learning about this virus and how the pandemic response is going or is best approached. Are there any real lessons, real lessons emerging already, not just the odd report that hasn’t been peer reviewed, or – from the experience? Devi, why don’t you start with whether you think there are any lessons so far that are safe to say we have learned?
Professor Devi Sridhar
I think what’s been clear so far is the delicate balance for countries is between preserving their economies and their societies and their health service, while also controlling the virus, and this is the whole delicate balance being played out. And the countries that have successfully done this moved very early and very rapidly, very aggressively and have gone after the virus by increasing their diagnostic capacity to what was needed and following up with contact tracing and getting on top of this virus. And so, I think one clear lesson is if we can look at countries like South Korea, and even Germany, I was hearing today that they have no new cases in a couple of their states within the country, and they’re having – you know, they feel quite comfortable, in terms of their diagnostic capacity and their tracers are now trained up and ready to go after it. But if we’re going to have to live with this virus for months, possibly years, depending when a vaccine or a therapeutic comes along, the lesson is to build up your public health infrastructure in a way that you can keep stamping out clusters of infections. That you have monitoring in place and that you can just keep doing this. I think the real costs are in building it up. I think keeping it running, once you have it up and running, and this is what you’re seeing from the countries that have been quite efficient in getting it built up, you reach a comfortable level, ‘cause then you have your capacity, you have your testing stations, you have your tracers, and you have a public, which is very aware about this virus and about this delicate balance. So, for me, that’s the key lesson, that actually, in the long run, even if – in the short and the long run, ‘cause we don’t know when we’ll have science delivering, you’ve just got to build up your public health infrastructure and stay on top of this virus, so you can get people back out of their homes again.
Emma Ross
Is there anything we’ve learned about whether – when you find positive cases, whether it’s safe to have them isolate in their homes, or whether you have to pull them out of the home? What has experience so far shown us, if anything, that we can conclude about that? Devi, why don’t you start, and then David come in?
Professor Devi Sridhar
Well, I think what we’ve learned about this virus is it transmits very well indoors and among close contacts. So, household transmission is extremely high. So, ideally, people should be able to be at home, but if they are living with other individuals and they don’t want to expose themselves to their families, or to elderly parents, or to either children or for anyone, you need to provide alternative facilities, and I think the countries which have done that – I don’t think you can mandate it. I think there’s, of course, individual choice, but offering people alternative facilities where they also get support, it doesn’t have to be treatment, but some kind of support and monitoring, I think, is advisable, because if you’re going to tell people you have the virus, you’ve been exposed to it, the next question people want to know is can I go home if I’m living with others, or with flatmates? And you have to provide some kind of alternative, though, again, I don’t think it can be forced, it has to be a choice that’s given to individuals, based on their circumstances at – in their living arrangements.
Emma Ross
David? Mute, unmute.
Professor David Heymann CBE
Coming back to the lessons that Devi was speaking about, I think it’s very clear that the epidemiological approach to outbreaks is what worked in Asia, what worked in Germany, and what was abandoned in many other countries when they locked down. And I think the lesson is, for these countries that locked down without continuing with their outbreak containment activities, is that they now find themselves having to start those activities again and reinforce those activities at the expense of having lost some time in not doing it, but in order to keep the reproductive number, that number of people infected from one infection, below one. And so, these countries have learned that lesson and we’ve all learned that lesson, that it’s really very important that outbreak containment never be abandoned, if it is having an effect.
With influenza, it doesn’t have an effect. With this, it does, these outbreaks occur in discreet areas many times where they can be stopped. In addition to this, I think we’ve also learned that people – the basics of making sure that outbreak containment activities are successful and continue, because if they understand the importance of physical distancing, of socially distancing, of staying away from mass gatherings, as Devi said, and in general about how to keep themselves – wash their hands and keep themselves clean from any contamination that may have occurred, they can play a major role in stopping these outbreaks. So, the population, either by protecting themselves, or protecting others by wearing a mask, if they can’t physically distance, is very important, and countries that instilled this in their populations, especially in Asia, are finding it much more easy to control these outbreaks than countries that haven’t done that.
Emma Ross
So, it sounds like the classic epidemiological response that has always been used, and that was recommended from the start, has shown to still be the way forward for this, and that maybe…
Professor David Heymann CBE
Yes.
Emma Ross
…to have a second chance to start again, coming out of lockdown, and get back to what was ideal in the first place. So, a lot of what we were discussing on the earlier webinars and what WHO has been repeating, on and on, has that kind of proven to be still the right way, is that what we’re saying?
Professor David Heymann CBE
That’s right. In this infection, outbreak containment is still possible and should still be used. It can stop discreet outbreaks, it can – for example, out in the State of Washington, there was a choir where one person infected 80% of that entire choir at their choir practice in two weeks. If that person had been wearing a mask, or hadn’t gone because he was sick, or she was sick, then there would never have been this outbreak, but the outbreak was rapidly traced and stopped. And so, it’s very important that we not abandon these basic principles, when they’re still working for a disease.
Emma Ross
Okay, thanks both of you, I need to go onto questions now, and for me not to hold the time. The most upvoted question at the moment is from Charles Clift, and his question is, “How do you assess WHO’s performance in the pandemic to date? Are there things it could have done better?” Devi, do you want to start, please?
Professor Devi Sridhar
Well, this is going to sound funny because I’ve been one of WHO’s harshest critics in the past, but I think they’ve done a reasonable job and quite a good job, especially with the communications, the daily briefings, trying to issue technical guidance, and sharing the knowledge of the very experienced Health Emergencies Team, and trying to keep all countries at the table. A lot of the criticism has focused on January and whether WHO was overpraising China and whether it was playing to China. I read that situation in January and in February, when the report was issued from the mission, as diplomacy, which is the cost of keeping, you know, China at the table, keeping it reporting, sharing genetic sequencing, letting a mission in, was public praise. That’s the price you pay, and you have to keep positive incentives for countries to report. If there are negative incentives for countries to report because, you know, WHO comes out and, you know, grabs a headline saying, you know, they did that badly, they did that badly, what other country is ever going to come forward and report when they have an outbreak going on? And so, we do need an agency that’s able to balance this. And WHO praises lots of countries, that’s how they work, they’re not going to take a stick and tell countries they’re not doing things right. So, I think some of the criticism comes from a misunderstanding of what WHO can and can’t do, and also what its role is, which is a normative technical agency that also plays a diplomatic role in the sharing of information.
Emma Ross
David, do you want to come back on that, or add anything?
Professor David Heymann CBE
Yeah, no, I agree with Devi that it’s a diplomatic or a political organisation, as well as a technical organisation, and I’ve been quite impressed with the ability of the technical people and, remember, WHO has some of the best experts in the world in public health and in various other fields of medicine. And I’ve been very intrigued and interested in how easily it’s been for WHO to get information from all countries, even those that are highly critical of WHO, as it works with others around the world to better understand the virology of this infection, to better understand its epidemiology, and also to better understand the natural history, how serious the illness really is, and how to combat the outbreaks when they’re occurring. WHO’s technical arm is working very, very well, and continues to work well with some of the best experts in the world, whereas the political arm is a political arm and that overshadows many times what’s really going on in the good, as Devi said. So, I would give WHO also a very high score on the fact that it’s been able to work so readily with all countries in providing the information that the rest of the world needs, in order to move ahead in containing this outbreak.
Emma Ross
So, on the political arm, are you saying that they have done less well? You seem to be separating the technical arm, the political arm, with high praise for the technical arm, by implication, the political arm not so great, or what are you trying to say on the political arm?
Professor David Heymann CBE
Well, I think Devi said it, that the political arm was a diplomatic arm, which is trying to work with 194 countries to forge consensus, and if the World Health Organization is any indication, they were able to forge a consensus of 194 countries with the current resolution. So, I would go back to what Devi said, that political arm is also a diplomatic arm, and that’s what it is, it works through Embassies, it works with Ministers of Health, and it’s been quite successful in getting a resolution that everybody agreed to. So, I would say it is succeeding in its political arm as well.
Emma Ross
Okay, thank you. I’m going to go to another upvoted question from Michael McGlynn, and this is to Devi, “What has the biggest mistake been in our handling of this pandemic, and what can we learn to stop or minimise the risk of another pandemic?” And, David, you would probably have something to say on that as well afterwards.
Professor Devi Sridhar
I think it was the variable lesson from this, so far, is that the countries that moved quickly have done better. The countries that, in January or February, you might have said are overreacting. So South Korea are starting to build labs before they even had their first case, Taiwan shutting down, you know, and going onto high alert before they had their first case. So, I think the key lesson is that waiting and watching is not optimal, that actually, it’s better to overreact and prevent something from happening, and then afterwards be criticised by the public, saying, “Oh, you made a big deal about nothing,” than to not react and then later on have to pay the price, especially with it – a virus like this, which does spread very quickly and becomes hard to control, once numbers spiral past a certain level.
Emma Ross
So, are you saying that the biggest mistake was the slow reaction, slow springing into action?
Professor Devi Sridhar
Slow springing to action and the abandoning of containment, I would say, as well. The countries – I mean, every country had to make a choice early on, and I think the countries that tried to contain this virus through traditional test, trace – testing and tracing, which is how, you know, it’s been done for outbreaks for decades, have done better. I think the – in the UK, I think there was an early misconception that this was like flu, and that it would not be as bad, clinically, as it has been shown to be. And so, on a population level, it would perhaps be like a bad flu season and they abandoned containment here very early, where I think the lesson really is, you know, this virus is more like a SARS or MERS-like event, though it’s not as deadly, rather than the flu. I mean, I think it’s also the preconceptions people have about this virus. We focus a lot also on the fatality rate, so people say, “Oh, is it – it might be 0.2%, not too off of flu, or it could be 1%, or is it 3%?” But actually what we’re missing is the long-term health implications and also what it means for recovery and also that even if you do want to say that this is not so bad and you want to have it flow through your population, you’re going to destroy your health services, your economy, and lose a lot of lives on the way. So, any way you look at this, containment is the best option and that’s also a lesson learned, I guess, coming back to your previous question.
Emma Ross
And, David, can you weigh in please on what you think has been the biggest mistake in our handling of this pandemic? And I’m not sure what the “our” means, whether it’s the UK or globally.
Professor David Heymann CBE
Do you know, I’ve been quite disappointed to see the agency where I worked for many, many years, the Center for Disease Control in Atlanta, and then, in addition, Public Health England and other public health institutions around the world, having been almost invisible at certain times from the response and the response then being led by the political leaders of the country. And I think that there’s been a tension between listening to what the public health leaders are saying and the political leaders wanting to show something that they were able to do very rapidly and effectively. And so, political tensions sometimes in countries ended up in locking down, rather than approaching it through an epidemiological lens, which would have been to possibly lockdown certain sectors where there was concern, while at the same time, as Devi said, continuing that outbreak containment activity, which has been so effective in countries in Asia and in Germany, in keeping the reproductive number of the virus very low. So, I think lessons learned are that we have to make sure that our public health institutes, which are supported by governments, must be listened to by those same governments.
Emma Ross
Well, there seems to be quite a bit at the moment, rising, what shall I say, accusations of blame the Scientists, are you noticing that, or are these just blips? There seem to be increasingly, a few comments made here and there about, “Well, we followed the science and maybe the scientific advice was wrong, it’s not that we took the wrong decision, we’re just doing what the Scientists tell us.” Is that right? Is that fair? Is that true? What is going on in that whole dynamic between the decision-making and scientific advice?
Professor David Heymann CBE
Devi?
Professor Devi Sridhar
Yeah, I mean, I think the first thing to say is the phrase ‘following the science’ has been used so often, for so many different things, that it misunderstands what science is. Scientists cannot offer an answer of yes or no. Take the question, should we reopen schools? No Scientist I know will say yes, or will say no. They will give you probably four or five different scenarios, from best to worst case, of what could happen, you know, and then, at the end, political leaders need to listen to, you know, what a public health expert might say about COVID spread to – and talk to – as Child Psychologists might talk about Early Years, and need to talk to an Economist about working – you know, what does this mean for the economy and working parents? And they you need to talk to an education expert, which talks about widening educational inequalities and they have to look across these different experts and different sciences, and decide, okay, how do I balance these? Because what you’ve seen is, I’m pretty sure the same kind of science has been presented to leaders across the world, because Scientists work globally in consortiums, and then those political leaders are listening to probably very similar things, because global health occurs at an international scale. We all work, David and you, I mean, we all work internationally and we’re in constant touch and learning ad then, political leaders have to weigh the costs and benefits and choose which option they want to go down. And so, I’m – I mean, ‘following the science’, for me, has become a phrase. I mean, the key lesson, I think, if we are trying to be optimistic and forward-looking, is about transparency. Sage, from the start, should have published their minutes and their membership, and at any point the media and the public could look at what Sage was saying, what they were – what their minutes offered, what their experts were saying, and they could have looked at what the government was doing, and at that point you could see whether there was alignment or you could see where there’s divergence, and then you could look at why that was happening. I mean, I think that’s the way forward. I think that’s the lesson, is really about transparency and to move away from secrecy.
Emma Ross
David. Unmute, unmute.
Professor David Heymann CBE
Transparency is clearly the way forward, making sure that people understand what the discussions are, what the options are, and how to move ahead, and I think that Devi’s hit it right on the hammer, hit the nail right on the head by saying that. In addition though, what’s happened is this pandemic has become like the proverbial hot potato, and it’s being passed – the blame is being passed from one to another, just as a hot potato is passed from one to another, trying to shed responsibility and let someone else be the scapegoat, and that’s really deplorable in public health, but it’s what’s happening today. People are looking for scapegoats where political or epidemiological decisions that were made are being shifted to – the blame is being shifted to others because they were made and this just doesn’t work in solidarity within a country, or globally. And so, by having that clear communication, you avoid this business of saying, well, he said that and I said this, you know exactly what everyone has said. And the same is true for the World Health Organization, they must be transparent in what they’re doing as well, and I think we’ve seen that they are with their Emergency Committee meetings, which are transparent and which provide at the end what the recommendations were. So, I think the world’s learning that transparency can’t be replaced by anything but more transparency.
Emma Ross
A question from James Meek, the London Book Review, to Devi and David, to both of you, “What is the long-term future of the WHO, looking ahead beyond this pandemic and beyond Dr Tedros’ era? In a multipolar world, with America’s relative sighs waning, is the WHO likely to become bigger or smaller, more or less independent, with more or fewer powers?” Predictions, please.
Professor Devi Sridhar
Okay, I will try this very challenging, very good question, and I think, if anything, it will be the WHO having more power going forward. I think member states have been looking to WHO to do more than it’s actually able to do, over the past few months, and the result is actually, we might need an international institution that has greater power, whether it is to actually investigate outbreaks much earlier, whether it’s actually to, you know, bring different kinds of sources of information forward. So, I think the conclusion for me is actually the world’s going to be looking very closely at how we strengthen WHO’s power, because you’ve seen this is – and it is a trend, if we look at why were the IHR, the International Health Regulations, revised? It was because of SARS and the learnings from SARS and then you saw, with Ebola, what was the outcome? You had a strengthened Health Emergencies Programme, you had different other, you know, CEPI, the Coalition for Epidemic Preparedness, being created. So, I think what we’ve learned is that whenever there is a crisis, the result is actually more co-operation, strengthened multilateralism and a realisation that actually, this is why we need these agencies, and this is why we need to think ahead and get every – all the structures in place before the next outbreak hits.
Emma Ross
Okay, thank you. Here’s another upvoted question from Tim Willasey-Wilsey, “What do the Speakers make of all the optimism surrounding the Oxford vaccine?” Just to add there, wasn’t there some rather disappointing news coming out on that more recently? But, yeah, what do you think of the optimism around the Oxford vaccine? David, you start.
Professor David Heymann CBE
Well, yeah, I’ll start with that. I think, actually, that it’s good to have optimism around vaccines, but it’s not good to make false promises. And so, we have a process, which has been established over the years, for vaccine development, which is being followed now by the Oxford vaccine and other vaccines, and the regulatory agencies are working very closely with the Researchers to make sure that, when that vaccine is shown to be either effective or non-effective, the appropriate measures will be taken by the regulatory agencies. So, we’re seeing a way that’s brought regulatory agencies and developers of vaccines closer together, moving forward together, and we’re also seeing that governments are willing to invest in developing and further developing and actually producing some of these vaccines that look promising. So, optimism is good, but it’s also important to realise that we don’t understand a lot about immunity to the coronaviruses, and in particular to this coronavirus, and what we want is a vaccine which will be effective in the longer-term, which will protect people, which will not require too many boosters doses, if it does require boosters, and a whole series of things that we hope to have. Remember, the first generation vaccines that we develop sometimes aren’t the final vaccine, but they’re a step on the way. So, we could even see that there is a vaccine, which is effective maybe in a percentage of population, which will be a step forward, which would permit it to be used in certain populations, but in the end then, we need to be sure that that vaccine is a vaccine, which is suitable for all people that are at risk. So, optimism is good, what’s not good is to make promises based on that optimism when there are so many uncertainties.
Emma Ross
Devi, what’s your thoughts on the optimism around this?
Professor Devi Sridhar
I agree with that completely. I think the other thing that we should, again, not put too much blame on the Scientists, if this vaccine doesn’t work, and say, “Oh, they didn’t – they misled us.” I think that’s not true. I mean, this is a vaccine team, which are doing their best. We’re hopeful, in monkeys, that offer some protection, and I guess others were less hopeful because it showed that you still contract the virus, and so I think this is why it was kind of mixed results. But I – the thing I would hate to see is that so much money is put into it and so much political stake put on this working, that actually they see a vaccine that isn’t that effective, that has mixed results, and push it to manufacturing, push it out because they need to have a product, and you can’t put the, what is it, you can’t put the cart before the horse, I think, in a sense. We need to make sure it works and the public needs to be aware that, you know, there’s no false promises, this is science and science will ultimately deliver, but it needs time.
Emma Ross
That’s a sensible answer. Here’s another upvoted question from Naime Merchant, “As an NHS Doctor, I have had many positive interactions with Public Health England and got the impression there was good competency and capacity. Given that PHE’s contact tracing and quarantine processes failed to mitigate the spread of COVID-19 during the early phase of the UK’s response, what systemic issues led to this very poor performance? What can be done to renew PHE’s reputation and capability?” And I just want to just out that David was previously Chair of PHE, he is no longer, but that there is a previous connection there. So, Devi, do you want to start, and then David can come in?
Professor Devi Sridhar
Yes, I think the Doctor is completely right that, like the CDC, Public Health England has a reputation of being of very high, you know, excellence and very strong technical capability. And what this points, to in both the States and the UK, what it points at least me to is that you need very clear leadership at the top, co-ordination among agencies that all are aligned behind one agenda, and a clear strategy of actually, what do you want to do and how do you take the different parts of the different agencies that you work with along on that agenda. So, I think, again, lessons learned, one is about coherence, and the countries, I think, that started with a very clear strategy. S New Zealand, there was a vision from the Prime Minister, we are going to try to eliminate this, and many people thought it was crazy at the time, but she said, “We will try.” And then, of course, it’s easier for agencies to get behind that because they have to find a way to make that vision work. South Korea said, “We are going to do what we did for MERS, but we are going to ramp it up and we’re going to build it and we’re going to build it and we will do everything we can,” where I think I’m sometimes confused, when I listen to the press briefings and I read the documents, what is the strategy? And I – obviously, it’s also hard, if you’re working within one of these agencies, to know who’s actually the leader, like who is taking responsibility for this, and this is why, in the States, you had an Ebola Czar, that was appointed when President Obama was there, you need someone taking responsibility and trying to co-ordinate. So, I see this as a coordination issue as well.
Emma Ross
David, what are your thoughts on that question? Please unmute.
Professor David Heymann CBE
I think the central – Chatham House is putting me on mute, so maybe they could stop that for now, and what I would just like to say is that I’ve not seen evidence of what Public Health England was doing was not effective. What I saw was that there was an attempt to contain outbreaks at the very start and that was having an effect, as far as I understand, but then, when Italy had its very difficult situation of increased mortality, because their hospitals could not accommodate all the patients that had developed, in their initial outbreaks, the government switched its policy to one of mitigation, without continuing that activity. So, I don’t think that anyone can say that Public Health England was not having success, or was having success. I just haven’t seen the evidence.
I know that the public health agency in Germany, in Berlin, the Robert Koch Institution, continued those activities and ended up with a very low reproductive rate, without great effort and without a surge in hospital capacity. Their government changed policies, but also continued with the epidemiological approach. So, I’m not certain what’s happened in the UK, whether or not Public Health England was or wasn’t performing at the start. I haven’t seen the evidence, but I know that they didn’t have a chance to continue because the policy then changed to one of mitigation, clamping down on the industrial sector and the school sector, on the small business sector, and at the same time, closing down massive gatherings and forcing physical distancing. So, I think the jury’s still out on whether PHE did have success or not, and, just like the CDC in Atlanta, hopefully, they will be able to regain importance in having an ear at the table when decisions are made.
Emma Ross
And here’s a question from a Journalist from India, Aditi Khanna from Press Trust of India, and it’s directed at Devi, “Could you please share some thoughts, from an epidemiology point of view, on India’s handling of the pandemic, and any areas of concern, as it gradually eases its lockdown? Measures that can be taken?”
Professor Devi Sridhar
Yes, I think, first to say, that this is an – what we’ve seen throughout this outbreak is countries that are smaller have found it easier, so, Iceland, Faroe Islands, you know, Singapore and New Zealand. And so, what this points to me, the lesson is, is you need to have a very local response and a very community-led response, and it’s very hard in large countries, like India. But I think, in India, there are – there is huge variation between states, and so I think Kerala has done extremely well and it’s, again, using, not rocket science, just, you know, traditional, you know, testing people, tracing their contacts. The challenge is to do this in a country that is the size of India ad so, again, all you can do is break it down to state level. At the state level, break it down to district level. At the district level, break it down to the walk level, and so on and so forth, ‘til actually, you are making this manageable at a community level to do also tracing.
I think lockdowns – my worry about lockdowns and the way they’re used, they’re not a solution, in the sense that the virus doesn’t disappear because you’ve locked down, and I think this is – and people see, you know, these graphs and they say, “Oh, look, we went into lockdown, the daily deaths have dropped, you know, the virus is – has, you know, disappeared and it’s gone.” But, no, because there’s still a lot of people who are susceptible to this virus and this is going to keep spreading, so you’re going to get multiple peaks, rather than having it be gone forever. And so, lockdowns needs to be used to actually build up the infrastructure and in very poor places, when people have to decide whether they’re going to have a 10% chance of getting COVID or a 90% chance of going hungry, because they’re not being able to earn that day, they’re going to not choose to stay at home, and you can’t force people to stay at home, otherwise you get mass rioting, as we’re seeing in Chile. So, this is the really difficult decision. I guess, no easy answer, but at least some kind of way to start organising thinking.
Emma Ross
Okay. Here’s a question from David Mongeau, and this has had ten upvotes, so it’s the top question right now, “How can international travel resume? Is it through immunity passports, air bridges, or will it need to wait for a vaccine, should we have one?” And if we’re not getting one, that means never, I guess. So, what are each of your thoughts on how can international travel resume? David, do you want to start with that?
Professor David Heymann CBE
Well, I think we’ve already seen an example of how international travel can resume between two countries. Australia and New Zealand have agreed to increase their travel and trade between the two countries, and they’ve done that because they have an equalisation of risk. In other worse, they both feel that they have the same risk of becoming infected in the country, and at the same time, they have the same level of response capacity available, and that means outbreak identification and containment. So, these countries have established, if you would, an equalisation of risk and equalisation of response capacity, and therefore, feel comfortable in travelling between the two. That may be the key to the future, in Europe, I know already, countries in Europe, and in North America and others, are beginning to think about how can we equalise our risks and equalise our activities in containment of outbreaks? For example, Germany, Austria and Switzerland, I believe, are already speaking about whether or not they have an equalisation that will permit them, with confidence, to do the same thing that Australia and New Zealand have done. So, it’s all about equalising the risk and equalising, in addition, the response capacity. Devi.
Professor Devi Sridhar
I think you’ve said it perfectly, so I won’t add anything to that answer.
Emma Ross
Okay, thank you. We’re coming towards the end, so I wanted to circle back, just on one thing. I don’t know if either of you are aware of this, but going back to WHO’s responsibility, and I wanted to get your take on something that Keiji Fukuda, who was the WHO Assistant Director General for Health Security during Margaret Chan’s 2006 to 2017 years at the helm, so during the Ebola outbreaks, he said this earlier this week, “The difficulty that I have with a lot of calls for reform is that it suggests that the actual issue is in WHO, that that is what has to be reformed, when in fact many of the fundamental issues are with the countries themselves, and that this – that is the unstated part of the reality, and this is the part which, you know, countries really don’t like to focus attention on, but in fact they are a big part of the problem. But if countries want a better-performing WHO, they can do two things: provide the agency with the adequate budget, and act upon the decisions that they adopt at the World Health Assembly. This includes following commitments to the International Health Regulations.” I wanted to end with that, ‘cause kind of to circle back to our theme, but to what extent do each of you agree with that? Devi, you’re nodding, so why don’t you go first.
Professor Devi Sridhar
Yeah, no, I agree with that fully. WHO is a member state organisation and it is delegated responsibility by different governments. And so, if governments are unhappy with what the WHO is doing, they have to delegate it a different kind of function and different kind of work, but that must be member state led. Coming back, I guess, to COVID itself, WHO alerted the world January 30th. we can dispute whether that was a week later than it should have, but it was in January. At that point, countries could respond or they could not respond, they could prepare or they could not prepare, the ball, in a sense, shifted. WHO had done what it could at that point, right, ‘cause that’s the limit of the International Health Regulations, it alerts the world, it rings the alarm bell, and then it tries to share information and support countries, particularly those in low and middle income countries, to respond. And so, I think, to look back now and say, “Oh, WHO didn’t let us know,” or, “It wasn’t sharing information at that point,” is not true, because January 30th, that is the highest level, and this whole focus on the word ‘pandemic’ is a distraction, because the word ‘pandemic’ doesn’t have any operational meaning. The key moment was, legally, January 30th. So, I’ll stop there.
Emma Ross
David, do you want to leave final thoughts before we wrap up on that?
Professor David Heymann CBE
Yeah, no, I think what we’ve learned is that countries want to do their own risk assessments and risk management in certain types of outbreaks, such as this one, and I think WHO has facilitated that, in providing information and there’s many other sources of information also, in peer reviewed articles that are put out by the medical journals in front of the paywall, lots of information around. Countries have shown that they want to do their own risk assessment. They no longer need WHO to say, “Well, there’s the yellow fever outbreak in this country, everybody be careful.” That was in the past when there wasn’t this massive flow of information, when countries could make their own estimation of whether that yellow fever outbreak, for example, is important in their own countries. So, that means that the IHR may need to be nuanced in such a way that it does provide more opportunity for countries to make their risk assessment and decisions on trade and travel, but WHO does have a role in making sure that trade and travel continue for humanitarian purposes and for trade, so that people can have the goods they need. So, there are still some ways that WHO and the IHR, International Health Regulations, can operate in the 21st Century. But we’re learning that they’re not the same as they were in the last century, when WHO did the risk assessment and everybody said, “We agree.” Now, they want to do it themselves with the data that’s so frequently available and so freely available outside. So, I would just end by saying that Keiji’s comments were exactly right, the WHO needs to be financed, member countries need to decide what they want, and then they need to be able to articulate that in such a way that the World Health Assembly, together, comes to a consensus on new ways of working, if that’s what’s necessary. The last thing WHO needs is another reorganisation or another reform.
Emma Ross
Okay, well, on that note, we’re going to wrap up and thank you both for a great conversation today. The full recording of this will be on the Chatham House website this afternoon, as well as on YouTube, and for Journalists who may want to follow up with either David or Devi, please go through the Press Office to book an interview, and please join us at the same time next week. Thanks very much all and have a great rest of the day.
