INSIDE THE WHO -- BATTLE TO CONTROL SARS
03 May 2003
Source: Wall Street Journal, May 2, 2003
Inside the WHO as It Mobilized To Fight Battle to Control SARS
U.N. Agency's Envoys Argued In Hanoi, Cajoled in Beijing
By Margot Cohen in Hanoi, Vietnam, Gautam Naik in Geneva and Matt Pottinger in Hong Kong.
In late February, Olivier Cattin, a doctor at the Hanoi French Hospital in Vietnam's capital, found himself stumped by the case of an American businessman with a fierce respiratory illness. He knew just whom to call: Carlo Urbani.
The outgoing, 46-year-old Italian was a physician with the World Health Organization. He was well-known in Hanoi's close-knit medical community as a skilled diagnostician who loved good food and organ music and was devoted to his work de-worming Vietnamese schoolchildren.
Dr. Cattin's hunch was that his patient, Johnny Chen, was suffering from some sort of avian flu. He had heard reports of a mysterious flu outbreak in southern China, where Mr. Chen had been. But Dr. Urbani, after examining the patient on Feb. 28, wasn't sure. Those doubts would balloon into dread as 10 hospital employees quickly contracted the mystery illness soon to be known as severe acute respiratory syndrome.
Alarmed, Dr. Urbani and his colleagues at the Hanoi WHO office harangued Vietnam's rigid communist bureaucracy and helped spur its aggressive measures to contain SARS. When Hong Kong reported its own eruption, officials at WHO's Geneva headquarters had heard enough. On March 12, the agency issued a rare world-wide health alert.
At a time when the effectiveness of multilateral approaches to global problems has become a hotly debated subject, the SARS saga so far reflects well on one United Nations bureaucracy. The disease remains mysterious and could still prove devastating. But by taking a zero-tolerance approach to the disease with governments as disparate as China and Canada, the WHO may well have limited the toll of SARS at the crucial early stage.
"Say what you will about U.N. agencies, but here's a group that acted forcefully and quickly," says Dr. Jeffrey Koplan, the former head of the U.S. Centers for Disease Control and Prevention in Atlanta.
The WHO's decisions haven't been easy. It angered Toronto officials when it slapped a short-lived travel advisory on the city after a nurse there took SARS to the Philippines. It urged people to avoid Hong Kong and southern China, chilling corporate travel to the world's hottest destination for investment dollars and badly damaging the regional economy. Its careful probing of Beijing hospital wards made liars of senior Chinese officials who tried to conceal the extent of the disease within its borders -- and got sacked. At the same time it drew criticism for moving too slowly to publicly criticize Chinese authorities.
The WHO has no regulatory or police powers. Its chief asset is highly motivated people such as Dr. Urbani and the personal relationships they cultivate in corners of countries many diplomats never see. These crucial ambassadors sometimes pay the ultimate price: Dr. Urbani died of SARS in a Bangkok hospital after raising the critical red flag in a war that is now seeing its first apparent victories. Earlier this week, the WHO declared Vietnam, the country he loved, free of SARS.
Established in 1948, the WHO's mission is to improve international health -- whether by mass vaccination campaigns, helping countries respond to outbreaks, or by acting as a clearinghouse of information. For years the WHO had a reputation as an often slow-footed bureaucracy, especially when it came to emerging diseases. By the time the WHO hosted its first meeting on the international implications of AIDS in November 1983, the disease had already been reported in 33 countries on five continents.
When AIDS surfaced, "we were completely unprepared," says Dr. Guenael Rodier, director of the WHO's Department of Communicable Disease Surveillance and Response. "We reacted in a noninnovative way by slowly building a program" instead of trying to prevent the virus from spreading world-wide.
People inside the WHO say Director General Gro Harlem Brundtland, 64, deserves credit for making the agency more responsive and relevant. Previous directors had included good doctors and technocrats, but Dr. Brundtland, a former prime minister of Norway, brought new political clout to the organization when she took over in 1998.
Under her stewardship, the WHO has pushed drug makers to make AIDS drugs cheaper for poorer countries, has made significant strides in ridding the world of polio and is now going after "life-style" diseases -- heart disease, obesity, diabetes and certain cancers -- that are rapidly becoming the planet's biggest killers.
"She got health off the back burner and made it a globalization issue," says Jim Palmer, a Washington-based consultant to the WHO.
One of WHO's longtime assets is privileged access, through high-level government contacts in its 192 member states, to the health authorities in most of the world's countries. That access would prove critical when Dr. Urbani alerted his superiors on Feb. 28 to what was happening in Hanoi.
At that time, Dr. Keiji Fukuda, chief of epidemiology for the influenza branch at the CDC, and Hitoshi Oshitani, a WHO officer based in Manila, were in Beijing looking into reports out of southern China of an outbreak that resembled an extremely deadly strain of avian influenza known as H5N1. But the Chinese were stonewalling, blocking a trip to Guangdong in the south and restricting the two doctors to meetings with health officials in Beijing.
Then Dr. Urbani called from Hanoi. Dr. Oshitani urged him to collect blood and respiratory samples. Maybe Mr. Chen was suffering from H5N1. Yet the disease didn't resemble avian flu in its symptoms or transmission patterns. Every test for the influenza had turned up negative.
Meanwhile, the disease was rapidly affecting health-care workers at the Hanoi French Hospital. Dr. Urbani and his boss in Hanoi, 57-year-old Pascale Brudon, decided they needed to enlist the government's help to contain the bug.
By Friday, March 7, the bureaucratic feedback wasn't good: Officials might meet with them on Monday. The WHO officials worked the phones and finally reached Nguyen Van Thuong, vice minister for health. At a four-hour meeting on March 9, the WHO officials argued that the new disease merited systematic preventive measures and outside backup.
But Mr. Thuong got a different message from Vietnamese experts, who believed the disease was influenza type-B and, being limited to one hospital, not particularly worrisome. The talks grew heated, Ms. Brudon recalls. Ultimately, Mr. Thuong sided with the WHO -- a pivotal decision that would place Vietnam and China in stark contrast.
By Monday, March 10, evidence of a potential pandemic was gathering. The mystery disease had cropped up unmistakably in Hong Kong and Toronto. That day, Dr. Urbani called Dr. Klaus Stohr, the WHO's influenza-project leader, in Geneva. Dr. Stohr, who is German, recalls him saying, "We're losing control of the hospital," referring to Hanoi French Hospital.
Hours earlier, Hong Kong's health director, Dr. Margaret Chan, received a call from an official at the city's hospital authority who said that an unusually high number of health-care workers at Prince of Wales Hospital were calling in sick with flu-like symptoms. On March 12, local investigators told Dr. Chan the situation was serious. That afternoon, she called the WHO in Geneva.
Officials there quickly met to decide whether the WHO should issue a global health alert. It was a tricky decision. The last time the WHO had issued such an alert was in 1994, when plague had reappeared in India.
"We wondered: 'Are we mad? Are we going to panic the world?' " recalls Mike Ryan, an amiable Irishman who coordinates the WHO's Global Alert and Response team.
That evening, the WHO issued the alert. The main victims at that point were health workers -- the most vital group needed to deal with the outbreak of an infectious disease. Moreover, "the cause was unknown, we had no clue where it came from and people were dying like flies," Dr. Stohr says. By issuing such an alert, the WHO was essentially asking its member countries to warn their citizens about the atypical pneumonia, and also suggesting they, too, gear up for a potential outbreak.
The alert provoked immediate response -- and some criticism. Health ministries of several countries "asked us why we hadn't informed them first," says Denis Aitken, Ms. Brundtland's right-hand man.
More cases appeared. China, where officials suspected the disease originated, was the most worrisome site. The WHO wanted to send in experts, but Chinese officials put them off, citing an important national political meeting lasting through March 18. "It's never been different," says Dr. Stohr, who in the past had to deal with Chinese authorities over flu outbreaks.
As he and others mulled how to crack the China problem, the stakes were suddenly raised halfway across the world early on Saturday, March 15.
At 2 a.m., Geneva time, Dr. Ryan was awakened by a phone call from Dr. Oshitani's boss in Manila. "He said something important was going down in Singapore," recalls Dr. Ryan. A health official in Singapore reported that a 32-year-old Singapore doctor, who had treated the country's first two mystery-pneumonia patients, had boarded a flight from New York City to Singapore. Shortly before stepping on the plane -- a Boeing 747 carrying 400 people representing 15 nationalities -- he had described his own symptoms to an alert medical colleague in Singapore, who notified health officials.
At 8 a.m., several WHO specialists in Geneva, clad informally in T-shirts and jeans, held a series of impromptu, emergency meetings in a room converted into a war room to plot the agency's next move. They were a hard-core, experienced bunch. Dr. Rodier, a Frenchman who was Dr. Ryan's boss, had buried Ebola-stricken corpses in Uganda. David Heymann, the American head of the WHO's communicable-diseases group, had headed to the Congo in 1995 to contain a deadly outbreak of Ebola. He rushed back from a camping trip to make the meeting.
They decided to quarantine the 400 Singapore Airline passengers in Frankfurt, an intermediate stop. That decision may have proved crucial in preventing the spread of the disease more widely across Europe. "Ten years ago, without mobile phones and e-mail, you couldn't have done this," says Dr. Ryan.
The next key question: Should the WHO issue a rare global travel advisory -- a decision that would have huge implications for world business and tourism. Dr. Heymann pushed hard for the alert, but some others objected. "What if we're wrong?" Dr. Stohr recalls one person saying.
As the hours went by, everyone had become convinced they had a new and deadly pathogen on their hands, and it was spreading ominously via air travel across the world. "Before we were saying, 'Be careful.' With the travel alert we were saying, 'This is a crisis,' " says Dr. Stohr.
With a draft of the news release ready, Mr. Aitken suddenly said: "What are we going to call it?" This was a subtle, but important issue: By giving the disease a name, the WHO would be telling the world that it was something new, something to be feared.
Someone suggested "atypical pneumonia of unknown cause," but that was rejected because the word "unknown" might scare people. Finally, Dick Thompson, a former science journalist and now press officer for the WHO, nailed it. "How about: 'severe acute respiratory syndrome?' " he asked. SARS case definitions and recommendations to hospitals and airlines quickly followed.
As the disease continued to spread in Hong Kong, Vietnam, Singapore and Canada, public annoyance was mounting over China's silence about the extent of its infection. The WHO was going to have to get tougher. But it would be Monday, March 24 before a WHO team of five experts arrived in Beijing for their first meeting with Chinese health officials.
At first, it looked as though the WHO might face a replay of the frustrated mission led by Dr. Oshitani a month earlier. The team's Chinese counterparts were lower-level health officials. The setting -- with microphones on either side of the table and white-gloved women pouring tea -- was formal and awkward.
WHO inspectors were champing at the bit to get to Guangdong, according to Dr. James Maguire, an epidemiologist and infectious disease specialist from the CDC. But the Chinese asked them to put together lectures for delivery the next day on general topics such as pneumonia and histories of infectious-disease epidemics.
"I guess the conclusion of that meeting was: We were off to a slow start," says Dr. Maguire, who participates in continuing WHO investigations in Beijing.
The next morning the WHO team prodded the Chinese to be more forthcoming, and the Chinese "came through," says team member, Dr. John MacKenzie. That afternoon and during the next couple of days, Chinese officials provided detailed data on the outbreak in Guangdong that had begun in November. But the WHO team was still left with big questions.
The Chinese officials wouldn't provide them with any data about the situation since February, except to repeat that the situation was "under control," according to the WHO team. The officials also seemed wedded to the notion that the outbreak was caused by a rare respiratory strain of chlamydia bacteria, which had been found in a few of the patients. They seemed uninterested in mounting data that the disease was being caused by a coronavirus -- a theory later affirmed by the WHO. Chinese Health Ministry officials did not respond to questions for this article.
On Friday, March 28, the WHO team pressed for access to Guangdong. Dr. MacKenzie said the message was explicit: "If SARS is not under control in China, there would be little chance of controlling the global threat of the disease." After more frustrating delays, the WHO team members were finally told late on April 2 that they could leave immediately for Guangdong.
Meanwhile, rumors were flying about scores of hidden cases in Beijing. On April 3, Health Minister Zhang Wenkang went on television to announce there were only 12 cases in the capital and the disease was under control. That conflicted with press reports days later of a letter from a prominent Beijing surgeon, Dr. Jiang Yanyong, accusing the health minister of covering up scores of cases.
On April 8, the WHO team met with the health minister and Vice Premier Wu Yi to inform them of their findings in Guangdong. Dr. Henk Bekedam, the WHO's full-time representative in Beijing and a natural diplomat, did much of the talking.
He told the officials that Guangdong had put in place a strong system to cope with disease, including tracing potentially infected people, updating numbers of cases, and instituting infection-control procedures at hospitals. But he delivered a blunt message regarding the situation in Beijing. "I said the international community does not trust your figures," Dr. Bekedam says.
It wasn't until April 16, though, at a news conference where foreign reporters chastised the WHO team for evading questions about whether Beijing was covering up SARS cases, that team members finally made their criticism of the Chinese government public. Alan Schnur, a WHO official who had defended the government's handling of SARS, stated the team's estimate that there were 200 probable cases of SARS in Beijing, and a further 1,000 people under observation as possible patients -- far more than the official tally of 37 cases.
Shortly after that, senior leaders, including President Hu Jintao and Prime Minister Wen Jiabao, appeared on television warning of punishment for any officials attempting to cover up SARS cases. The following Sunday, the health minister and the mayor of Beijing were sacked, and the city announced there were nearly 10 times as many cases in the city as the official tally suggested.
Asked if he thought events would have moved more quickly had the WHO made its criticism public at an earlier stage, Dr. Bekedam said working on Beijing officials privately was the WHO's chosen strategy and didn't mean that the agency had "lowered the bar for China."
-- Elena Cherney and Mark Heinzl in Toronto contributed to this article.