IN SARS AFTERMATH, THE WHO'S IN CHARGE
13 Jul 2003
Source: Los Angeles Times, July 13, 2003
In SARS Aftermath, the WHO's in Charge
The health monitor's 'revolutionary' use of travel warnings to tame the outbreak has given the once-plodding bureaucracy new might.
By Charles Piller, Times Staff Writer
GENEVA — The doctors and scientists begin at 9 a.m. sharp, filing into room M405 at the World Health Organization's headquarters. They crowd around a conference table surrounded by computers churning the latest data on diseases from every corner of the globe.
This is the daily outbreak meeting, and the first case for discussion is an unknown fever in South Asia that has killed 34 children with severe diarrhea and convulsions. There are nods of concern, but not alarm. They move on to the next cases: 46 deaths from yellow fever in northern Africa, one from encephalitis in Asia, then plague in Africa. "All bubonic, due to flea bites," notes one man. It's only a local scourge.
The team is searching for a particular pattern of lethality and cross-border virulence — the alarming confluence they found in SARS. Such a disease rarely emerges, but when it does, this outbreak nerve center can trigger a new kind of power that transcends politics and armies.
During the unsettling weeks of the SARS outbreak, which infected 8,437 people and killed 813, the WHO issued a series of unprecedented warnings against travel to Toronto, Hong Kong, Taiwan and parts of China. The moves helped freeze SARS in its tracks, but they also drained away billons of dollars in lost trade and tourism.
Using this seemingly innocuous tool, the agency was able to force nations to take drastic public-health actions out of fear of the ultimate penalty in an interconnected world — isolation.
Now, in the aftermath of the outbreak, the WHO — once considered a weak and plodding bureaucracy — finds itself in the unlikely position of being an imposing world force able to shake economies and rattle even the most recalcitrant governments.
"The manner in which the SARS outbreak was handled borders on the revolutionary," said David P. Fidler, an international-law expert at Indiana University.
It is a transformation, however, that has also brought swift and withering criticism.
Some of the countries most severely affected by the travel warning have bristled at the use of so harsh a tool when they believed they had their own means to control SARS, or severe acute respiratory syndrome.
Allison McGeer, a leading Toronto infectious-disease specialist who is also a recovered SARS patient, said the disease might have waned on its own, following a seasonal pattern like other coronaviruses — fading during summer, resurfacing when cold weather drives people inside and promotes transmission
Others, such as Su Yi-ren, chief of the Taiwan Center for Disease Control, complained that the WHO acted rashly and unfairly — brutally depressing economies, showing leniency to some countries while cracking down on others.
"The panic created by this kind of travel advisory may be bigger than the real problem," Su said.
But the WHO's supporters say its actions are crucial an era of deadly emerging diseases that can span the globe in hours.
For scientists whose world revolves around the memory of such devastating pandemics as the 1918 Spanish flu, the Hong Kong flu of the late 1960s and AIDS, the power to spare millions requires little justification.
"This role is one we have to take on," said WHO Director-General Gro Harlem Brundtland. "There is no alternative."
Brundtland, a diminutive 64-year-old dynamo, has led the far-flung agency's 14,000 staff members in 147 countries for five years, providing the force behind the WHO's transformation.
As former prime minister of Norway, she brought prestige to an organization that had settled into a bureaucratic malaise, buffeted by demanding and inflexible member states.
The United Nations established the WHO in 1948 after the horrors of World War II and the medical advances they prompted. The agency's early years were focused on smallpox — eradicated in 1980 after a global vaccination campaign.
The agency also played a key role in fighting polio and immunizing millions of children against killers such as measles.
More Talk Than Action
But in the 1980s and 1990s, the agency had fallen prey to the stodgy bureaucracy that had rendered other international agencies ineffective or irrelevant. Perennially short of funds, the WHO became known more for talking than acting. It set lofty goals to reduce rising death tolls from the intractable problems of malaria, tuberculosis and AIDS. Those epidemics have worsened in many areas of the world.
Brundtland vowed to streamline and focus the organization on major health problems: tobacco, AIDS and emerging diseases. As her five-year term as director-general ends this month, Brundtland's efforts are finally bearing fruit.
The WHO has pushed through a landmark tobacco convention that curbs tobacco promotion, sets indoor air standards and promotes legislation to reduce smuggling.
But Brundtland's tenure will undoubtedly be remembered for her handling of SARS.
The WHO caught its first hint of a crisis Feb. 10, when David Heymann, director of the WHO's communicable diseases section, received an alarming e-mail from the son of a former WHO employee in southern China.
"Am wondering if you have information on the strange contagious disease which has already left more than 100 people dead," the man wrote. "The outbreak is not allowed to be made known to the public but people are already aware and there is a 'panic' attitude."
The next day, Heymann's team met in the outbreak center to review the evidence. The Chinese government discounted the problem as relatively minor and under control.
Yet by early March, a drumbeat of reports of similarly mysterious pneumonia cases in Hong Kong and Vietnam began to arrive.
On March 14, the agency heard unofficially from Canada and Singapore. It was also seeing such cases. "It was a scary day," said Mike Ryan, the burly Irish epidemiologist who directs the WHO's global disease surveillance network. "We knew it was going global."
The final piece fell into place the next day, when Ryan was awoken at 2:30 a.m. by a Singaporean health official. A Singaporean doctor with a probable case of the mystery illness was flying from New York to Frankfurt.
Ryan contacted Heymann and other colleagues, and they determined that before the plane landed they would warn the German authorities to prepare a quarantine, then issue a first-ever global travel warning.
"Suddenly, nobody felt distant from the problem. This wasn't Ebola in some dark corner of the rainforest," Ryan said.
He recalled the frenzy to decide what to advise when much about the illness remained obscure. Do you kill the animals that carry the virus? Do you close borders?
They agonized over how to limit economic damage but concluded that the conservative course — consulting with national governments — had already failed.
To the contrary, China's efforts to hide the extent of the problem had helped to propel a local outbreak into a global one.
Brundtland agreed to a sharply worded travel warning advising the identification and isolation of possible SARS carriers — followed in ensuing weeks by specific recommendations to avoid nonessential travel to affected areas.
"The world had no choice. We didn't know what this disease was, and the world had to stop it," Heymann said.
Ray R. Arthur, an infectious-disease expert for the U.S. Centers for Disease Control and Prevention, called the actions "a historical event."
In essence, the organization has assumed "police" powers for controlling outbreaks that put it above national governments, the traditional guardians of public health, Arthur said.
The World Health Assembly, the body that oversees the WHO, went one step further, allowing the agency to take action without approval from national governments — previously unthinkable autonomy.
"It changes the whole way in which sovereign states exercise their sovereignty in the context of infectious disease," Fidler said.
But even if the strategy worked with SARS, the problem is that such great power is perilously difficult to exercise effectively, say some of the nations affected by SARS.
'A Very Blunt Tool'
Canada's McGeer agued that although travel warnings are powerful, they are also haphazard and of unproved effectiveness. "[The warnings] are a very blunt tool," she said. "You want to be sure they are also having positive impact."
And in any large bureaucracy, scientific judgments are inevitably tainted by delays and vacillation, critics said.
Canadian authorities were outraged when the WHO issued its Toronto warning in late April because they believed it came after the city already had turned the corner on SARS. The travel warning's brevity — it was lifted a week later — confirmed that it should never have been made, they said.
The WHO's poor timing devastated the local economy but had virtually no effect on the outbreak, said Paul Gully, a top official at Health Canada. "It's appropriate to look at those travel warnings and ask, 'Did it make any difference?' "
Taiwan's Su said the inherent danger in great power is that it can be swayed by political pressures and suspicions.
He said that the standard for lifting the Taiwan travel warning was higher than that imposed on the far more influential nations of China and Canada. The reason, he said, was pressure from China, which had blocked Taiwan from becoming a WHO member. The WHO said all of its actions were based strictly on the available evidence.
In one case, Su deployed 50 staff members and gathered data requested by the WHO within 12 hours, but he believes the WHO accepted data from China gathered in minutes without similar care.
Yet given the new public-health realities, Su said, he still supported the WHO's right to make such warnings. Gully called the WHO "courageous" in spite of his misgivings.
WHO officials say they will exercise their new powers cautiously — and consult closely with governments. They also warned that scourges such as AIDS or malaria will require other approaches and massive new funding.
But Brundtland's policy of aggressive action will probably continue — and perhaps expand — under her successor, South Korea's Jong-Wook Lee, because SARS will almost certainly be followed by other new and deadly outbreaks.
She was "willing to take the political risk," Ryan said. "That was an epiphany for me A Rubicon has been crossed. There's no going back now."