June 7, 2020
Hunger Notes editors Peter Morris and Steve Hansch interviewed pandemic expert Dr. Ron Waldman (RW), Professor of Global Health at George Washington School of Public Health and long-time point person for international health in emergencies for USAID and the Centers for Disease Control and Prevention (CDC).
What should the World Health Organization’s (WHO) role be in pandemics, given all the recent controversy about WHO?
RW: WHO should always be in charge at the start of a pandemic. They need to be the one to identify the pandemic, to begin to issue guidance on a variety of aspects of control including prevention of transmission, diagnostic means, and treatment, and they should start and coordinate the R&D effort for vaccine development, production, and distribution. But we saw how quickly a pandemic touches all sectors of society. There needs to be a whole-of-society response that goes far beyond the health sector alone. There should have be plans in place for when schools should close and when to close and re-open businesses. What to do about travel shutting down, and so on. There needed to be a clear safety net for low-income countries. As we are seeing, it is really not all about health. The economy is important and this cannot be a fight between averting COVID-19 deaths and averting deaths due to increased poverty, including increased food insecurity. But there won’t be that kind of across-the board, whole-of-society preparedness if only WHO is in charge – they won’t always be able to effectively move from “their” lane, which is focused almost exclusively on technical aspects of health and its determinants, but not sufficiently on its broader consequences.
What is the relevance today of the International Health Regulations (IHR)?
RW: SARS was the impetus for the revised International Health Regulations (IHR). We know what a political organization WHO is. Its policies and decisions are very much influenced by politics. The governance is political, being that it is comprised of Ministers of the Member States. That’s not necessarily a good way to do science. Most of WHO’s budget is funding tied to “extra-budgetary” programs that are dictated by governments like the US, or by the Bill and Melinda Gates Foundation.
But this is part of the criticism of WHO because they did not declare an international emergency of public health concern. I think this whole public health emergency of international concern concept has become somewhat meaningless and devoid of teeth. The IHR has not lived up to its potential. Polio is now part of it. Ebola was not before, but then it was. Even for COVID-19, the declaration was delayed and WHO did not even declare it to be a “pandemic” for quite some time because they did not want to scare people, I guess. If you look at those things that have happened. I guess people don’t feel the IHR has the chops.
There are the IHRs, and they do call for early reporting. And there is a lot of controversy about the degree to which China complied in their reaction to the outbreak of COVID-19. They delayed excessively. They declared the first cases on the 31st of December, though the first cases had occurred at least 3 weeks before. The origin story of this pandemic will remain shrouded in mystery. The Wuhan Seafood Market is not particularly convincing as the origin because there were cases prior to the ones that were first announced that had no connection there. But I don’t think it’s of great importance. I know a lotof people like to speculate about whether the virus escaped from a laboratory.
The point is that the bio-safety of those laboratories that deal with highly pathogenic organisms has to always be a major priority. It was, it is, and it shall always be. I don’t see what an escape would change in regard to the amount of care that has to be accorded, and certainly the BSL-3/4 labs in Wuhan are among the world’s best. In addition, looking at the genomic sequences of the SARS-coronavirus-2, virologists feel it is unlikely that the lab was the origin.
If something should be done about it should be done on a multilateral basis. Pointing fingers drives the problem underground. It’s a good way to make sure the truth never comes out.
What is your view of the current tension over lock-down versus opening the economy?
RW: There’s a lot of wishful thinking out there in the non-virology community. Everyone knew that opening early, or May 1, as the President had wanted, or even earlier, by Easter, was a pipe-dream.
It’s kind of sad in a way to see the kind of leadership we are getting and the divisiveness it has caused.
The only way this epidemic is going to stop is if there are serious limitations to individual liberties. From a strictly public health point of view, you can’t let people decide what to do. You have to be instructive and enforce implementation of the right things. You can’t let people just walk into supermarkets and cough on the produce. When I say “you have to …” I mean from the public health point of view. But societies can choose for themselves. They certainly can choose “liberty over lockdown,” but they then have to be able to accept the public health consequences of that decision”.
The late Dr. Jonathan Mann was a champion of “health and human rights”. I know it’s sounds terrible, but at times it is a question of health or human rights. But, in any case, draconian measures should be in place for only the shortest time necessary. You can’t ask people to not die of COVID-19, but to be driven into poverty and food insecurity through unemployment. Quality of life counts too. Not to mention that there are many other causes of death out there that are ignored if the singular focus is on COVID-19. Lockdowns need to be compassionate and sympathetic, not punitive. Again, it requires unusually smart leadership, and very enlightened follower-ship, to do it right. We have been shown by some countries, such as South Korea and New Zealand, that it can be done right.
In public health we’ve proposed or done this for a long, long time. Now people are saying “you can’t do that; you can’t restrict m
ovement.” But we’ve always done that. It is how the word “quarantine” came into our language.
The traditional treatment of tuberculosis was to put people into what effectively were p
rison. We called them sanatoria. In the second half of the 19th century one of the leading sources of revenue in Colorado was renting out little gazebos that people would construct in their backyards for TB patients. People with Hansen’s Disease [aka leprosy] were plucked out of society and put into special “reservations”. People with mental health issues were locked up. That what Thomas Szasz meant when he titled his book, The Myth of Mental Illness, not that there is no such thing as mental illness, but that it is a myth that we treat it as an illness as opposed to treating it as a crime.
How do you foresee this outbreak hitting in developing countries?
RW: The outbreak in India (and now S. America) is more advanced than in other places. The pandemic will also affect how other health problems are addressed. It will have a devastating effect because the consequences of any lockdown undertaken will affect a much greater proportion of the population in places where people need to be out and about on a daily basis to have money and food. Specific strategies have to be designed for those places – it does not seem right that those policies that were developed and implemented in China and Singapore should be transplanted to Peru or Zambia. And the best strategies will be those that are designed locally, and with the participation and compliance of the affected population. It’s a tall order.
From all your past research and planning, what do you anticipate may be the secondary impacts in terms of people no longer receiving treatment or hospital care for other conditions, for example in Africa or Asia?
RW: In fact, I would go a step further. I would expect the secondary impacts to be greater than the immediate health outcomes. I would say there is extremely little vaccination taking place right now because of the pandemic. I would expect to see new outbreaks of measles as a result. There may be outbreaks of meningitis, and so forth, down the line. I think in terms of maternal mortality, we will see an increased proportion of babies born at home and not in facilities, with the neonates not getting adequate attention. Domestic violence is undoubtedly going to increase.
These extra health problems are further neglected as donors, such as Mr. Gates and others, are both urging and acting to transform everything they do and fund to be COVID-19 specific. Some public health experts are concerned or very critical of this trend.
So, companies like Abbott are no longer making malaria diagnostics, as they focus instead on COVID-19. HIV testing is grinding to a halt as those companies are moving to COVID-19 technologies.
What are your thoughts about how the pandemic is being measured?
RW: It’s a problem with COVID-19 reporting. I can’t get very excited about the numbers coming out. The distribution is heterogeneous. There are places within countries that are not represented at all by the numbers. The US has had for the last few weeks a plateau of about 30,000 cases a day. But that obscures that it’s growing in 30 states.
Even in Portugal, on the downside of the curve, most of the cases are in the country’s north. Although the whole place is on lockdown. The distribution is uneven. You can’t say one place is like this and another like that.
How well might the Red Cross Movement – the IFRC in particular – contribute?
RW: There is a reasonable model for pandemic preparedness and control, which is a major thrust of the International Federation of Red Cross and Red Crescent Societies (IFRC). IFRC is implementing in 8 countries in Africa, and now they are going to expand their community Pandemic Preparedness Program (CP3) which is, by the way, funded for the most part by the US Government. It’s in Mali, Guinea, Sierra Leone, Cameroon, Kenya, and a few others. It’s an effective model because the Red Cross works at multiple levels, including the existing volunteer component at the village level, and each level up from there with the governments.
They have volunteers in every village. They can take and apply a broad strategy from Geneva and adapt to the local level. It needs to be passed on from generation to generation.
What do you think may be new problems in international health in emergencies that could arise, such as in malnutrition?
RW: I would be waiting to see whether under-nutrition increases as a result of job losses and other impacts on income generation (self-employment, remittances, etc.). The biggest problem with nutrition is if it is an underlying risk factor for severe COVID-19. There are a number of publications that indicate that obesity is a clear risk factor for severe disease, independent of diabetes and age. There is literature, and anecdotes about that. But it isn’t known yet whether under-nutrition is in any way a contributing factor to severe disease.
Above that, how much of the immune reaction to this virus, especially in children, is hyper-immunity, so-called cytokine storm, in which case malnutrition may even be protective, in that it would blunt a hyper-immune event.
The social consequences of the COVID-19 outbreak may be greater than in other places. India has major nutritional problems, exacerbated by COVID-19.
The nutrition problem in Yemen was so dramatic before COVID-19, it can only be made much worse. Yemen is a good case in point about COVID-19, which is that a lot of the national strategies for control seem to be more or less cut and pasted from a generic WHO approach, with a focus on case management, expansion of intensive care facilities, and the procurement and distribution of mechanical ventilators. The other side is testing, isolating, and quarantining contacts of cases. It makes no sense to me that countries like Yemen should be adopting that kind of approach. A modified approach should address an active war zone facing famine.