The WHO’s COVID-19 pandemic declaration may be late
Declaring a pandemic has complex consequences, as does failure to do so
The World Health Organization (WHO) declared the coronavirus disease outbreak (COVID-19) a pandemic yesterday. Until this point, the organisation had resisted using the term despite COVID-19 reaching all continents apart from Antarctica and a growing external scientific consensus that the outbreak was already a pandemic. The reasons for this delay include past criticisms, concern over inducing public panic and a fear of triggering an inappropriate change in approach to the outbreak. However, continued avoidance of the term has created its own problems.
What next
Although the WHO has now declared COVID-19 a pandemic, the apparent delay may have undermined its credibility. The organisation will continue to stress that the virus can be supressed and controlled, citing examples such as South Korea and China. Part of the reasoning for the declaration may be to trigger a more effective response among countries that have been slow in enacting measures to control the outbreak, such as the United States. However, the pandemic declaration is also likely to trigger fear among publics, and countries will need to divert attention and resources to managing the associated behavioural changes.
Subsidiary Impacts
- Countries will begin to shift focus from their current containment campaigns to mitigation efforts, and prepare for worst-case scenarios.
- Distrust of the WHO and healthcare organisations could hamper future initiatives to limit the outbreak.
- Fear and uncertainty associated with the pandemic declaration will be reflected globally on an economic level.
Analysis
The WHO says a pandemic is simply "the worldwide spread of a new disease" to which we do not have immunity. It does not have a fixed definition with set criteria, which leaves the appropriate point to make pandemic declaration open to interpretation.
The US Centers for Disease Control and Prevention (CDC) describes three broad criteria that must be met for a pandemic: the virus is displaying sustained person-to-person spread, is causing illness and death, and has worldwide spread.
Towards the end of February, the CDC announced that two of the three were present -- person-to-person spread, and causing illness and death -- but even with the virus confirmed in over 100 countries, an official pandemic declaration was still not forthcoming.
Terminology escalation
The declaration of a pandemic is a clear escalation from the WHO's previous terminology. On January 30 it stated that the outbreak of COVID-19 was a public health emergency of international concern (PHEIC). It went on to elevate its global risk assessment to 'Very High' at the start of March, which constituted its highest possible level of concern. Director-General Tedros Adhanom had previously referenced the "pandemic potential" of the outbreak, but now believes that this has been realised.
However, he insists that there is still an opportunity to reverse the current direction of travel (see INTERNATIONAL: Science may shorten COVID-19 duration - February 28, 2020). After suffering the worst impact from COVID-19, China prevented a similar outbreak in the rest of the country and has slowed new cases to single digits in the epicentre of the outbreak, Hubei province.
History
A significant factor in the WHO's reluctance to use the term pandemic was the fallout from the 2009 H1N1 'swine flu' outbreak. The organisation was widely criticised for 'over-reacting' and declaring a pandemic prematurely, which triggered pre-orders for pandemic vaccines and allowed industry to switch to manufacturing these.
The WHO was criticised for calling H1N1 a pandemic
The outbreak proved to be far less deadly than had been feared -- governments were left with significant quantities of the vaccine and shouldered substantial financial loss. The Council of Europe (CoE) led an enquiry into the WHO's handling of the outbreak and its report was markedly critical of the WHO's decision-making processes.
Although the situation with COVID-19 is very different to H1N1, the organisation's fear of what an incorrect pandemic declaration could do to its credibility probably skewed its evaluation of when to use the term.
Shift in approach
The response to disease outbreaks of this scale can be broadly divided into containment and mitigation. Declaration of a pandemic often heralds a switch between the two.
Containment strategies are designed to halt the spread of the virus and include contact tracing, isolation and quarantine. Even if these fail to stop the outbreak, the reduction in the rate of spread is still extremely important as it provides countries with an opportunity to prepare (see INTERNATIONAL: Focus will be on slowing COVID-19 - March 5, 2020). Most governments' pandemic plans are designed for influenza outbreaks and require time to be tailored to COVID-19: for example, medications stockpiled are meant for flu symptoms; there is no vaccine for COVID-19, unlike seasonal flu; and much is still unknown about this new virus.
Traditionally, mitigation efforts signal that containment no longer appears possible and the aim is to minimise the severity and consequences of community spread. Strategies include social distancing, cancelling mass gatherings, and shutting schools. Countries such as Italy and China are already employing these methods.
Declaring a pandemic could shift resources from containment to mitigation, such as social distancing measures
The WHO remains extremely concerned the pandemic declaration will trigger a complete switch in mentality and resource allocation from containment to mitigation, thereby losing potential opportunities to stop the outbreak. It wants responses to be a dynamic combination of the two, determined by the situation at local levels. This has been a major factor in its decision to delay a pandemic declaration but encourage countries to start exploring mitigation efforts.
Fear
One of the core objectives of healthcare organisations is to avoid mass panic and anxiety. These can make communication of important public health messages significantly more difficult through distraction, over-thinking, and effects on working memory.
Panic also leads to individuals stockpiling items such as medicines, foods and face masks, depriving those most in need. The WHO is aware that the word 'pandemic' has many connotations; pandemics are the subject of numerous hyperbolic films and literary works.
The 'Spanish' flu pandemic of 1918, in which it is estimated over 50 million people died, is frequently cited in COVID-19 conversations even if comparisons are not apt. Key differences include the sophisticated state of health systems currently, medical advances and improved health among the vast majority of the global population.
One of the criticisms in the CoE's report on the handling of the H1N1 pandemic was that the WHO generated ''unjustified scares". The organisation's previous avoidance of the term pandemic is part of a wider strategy to avoid repeating this.
As such, the WHO delayed a declaration, even though leading scientists have been arguing that pandemic status was reached weeks ago. This has added to the confusion of the COVID-19 'infodemic' and created a climate in which further misinformative content will gain traction (see INTERNATIONAL: Falsehoods undercut COVID-19 responses - March 2, 2020). It has given the impression that the WHO has tried to withhold information from the public, adding to growing distrust of the organisation: some 460,000 have signed a petition asking for Tedros's resignation.
Declaration consequences
The declaration of a pandemic has little legal consequence. Declaring COVID-19 a PHEIC, and raising the alert levels to very high, already ensured that the necessary powers and resources were available to all key stakeholders in the fight against the outbreak. It does not affect any pay-out of the World Bank's specialised 320-million-dollar pandemic bond to assist developing countries combat COVID-19, which is dependent on objective criteria.
Unintentionally, reluctance to declare a pandemic may have elevated the importance of the eventual declaration, fuelling public concerns and potentially adding to panic.
