Disclaimer: This editorial was prepared and authored by Sanjay Beesoon in his personal capacity. The opinions expressed in this article are the author's own and do not reflect the views of Alberta Health Services.
The current COVID-19 pandemic is caused by SARS-CoV-2, a novel human coronavirus. The latest reports show that in less than 4 months, the virus has infected more than 3 million people worldwide, killing more 200,0001 and has impacted the whole planet in unprecedented ways. Communities are decimated, travel and commerce nearly halted, and the world economy has reached a standstill with record- breaking job losses all over the world and a global recession at our doorsteps. Although there is a perception that the International public health community was caught by surprise, I would argue that a major contributor to the current catastrophe is the divide and the complicated relationship between science, policy and politics.
According to data published in academic peer-reviewed journals and government reports, the pandemic is thought to have started in November or in early December 2019 in a wet animal market in Wuhan, Hubei Province, China.2,3 This is a classic example of cross-species transmission, where the virus is purported to have jumped from bats (animal reservoir) to pangolins (Intermediate host) and finally to humans, and thereafter transmission within human populations have been exclusively person to person. The current state of science indicates that the virus is transmitted by inhalation and ingestion of viral particles. COVID-19 has unusually high primary and secondary attack rates4 and case fatality rates (range 1 % to 15 %).1
Despite many weeks of mounting evidence suggesting the rapid spread of a new virus, it was not until December 31st 2019 that the World Health Organization (WHO) was informed of a cluster of cases of pneumonia of unknown etiology in Wuhan. From Dec 31st 2019 through January 3rd 2020, 44 such cases were reported to the WHO. The causative agent, a coronavirus, was identified on 07/01/2020 and the genetic sequence of the virus was made public on 12/01/2020. The first case outside of China was suspected on 08/01/2020, confirmed on the 12/02/2020 and formally reported in Thailand on 13/01/2020. Shortly afterwards (20/01/2020) Japan and South Korea reported their first cases and soon thereafter the pandemic started unfurling in other South East Asian Countries. Most of the hard hit countries registered their first cases in late January: Germany (23/01/2020),5 Italy (28/01/2020),5 Canada (27/01/2020),6 USA (24/01/2020),7 France (24/01/2020),8 UK (26/01/2020),9 Spain (29/01/2020)8 and Belgium (04/02/2020).1
Based on of the high number of peer-reviewed scientific papers on Covid-19 published in the past 3 months and the sequence of events as reported by reputable institutions such as the World Health Organization, the Chinese Center for Disease Control and Prevention (CDC), the US CDC and Eurosurveillance, it is plausible to assume that by mid February, scientists had already gathered robust data on the epidemiology, the biology of the virus, and the disease severity in humans. Given the current scale of the pandemic, we can only infer that massive research output on COVID-19 was not effectively translated in public health policies, recommendations, and actions in an efficient and timely manner across the world.
It is unclear why travel restrictions in and out of Hubei Province were not enforced early in the first week of January, rather than on January 23rd, when more than 5 million people in this province had already travelled from Hubei into other areas of China. We can only speculate that the hesitation was most likely due to the upcoming celebration of the Chinese New Year.10 Given the current scale of the pandemic and its dire consequences around the world, it is not surprising that some Western mainstream media outlets are critical in the way China handled the initial outbreak and are questioning whether the WHO is really empowered to investigate and address deadly pandemics like COVID-19. The recent revision of the number of deaths by Chinese authorities, can only boost this skepticism.11
Data from Europe and North America1 show that there is, on average, 35 days between their 1st and 100th case, which seems to be a reasonable time for governments to take appropriate actions, proportional to the biological characteristics and the epidemic behavior of COVID-19. How far and how fast does implementation of science-driven public health policies, impact morbidity and mortality can be exemplified by the relatively low incidence and case fatality rates in Canada and Germany, compared to North American and European counterparts.
In light of the above, there are a few pertinent themes that the International public health community, international law scholars and world leaders should seriously reflect on.
(1) There is no doubt that infectious diseases are emerging and re-emerging at an ever-increasing frequency in different parts of the world, with the potential to decimate populations, triggering economic havoc and destabilizing societies way beyond the geography of the initial outbreak. Is there a need to create a solid and internationally funded Epidemic Intelligence Unit within the World Health Organization? Within this framework, scientists and clinicians from around the world could have the authority under international law to have a presence on the ground and investigate disease outbreaks based on reliable and verified whistleblowing. The Regulatory Inspection Programme of the International Atomic Energy Agency can possibly be adapted to the context of emerging infectious diseases.
(2) By and large, public health response to disease outbreaks essentially involves 4 stages - Early detection, containment, mitigation and eradication. It is increasingly clear that for visible and sustainable progress is to be made, community involvement and buy-in is imperative at every stage. During the current pandemic, irrespective of the type of government in place, different countries have had varying degrees of success in getting their populations to adopt and practice public health recommendations. Given the significant non-compliance rate with public health advisories, local, provincial, and federal authorities in Canada had to quickly and swiftly move from educating the public on best practices to have special public health orders and enforcing them. One of the gaps that the current pandemic has exposed is the lack of a comprehensive and structured strategy of risk communication during emerging infectious disease outbreaks, when the science is constantly evolving. With a view of preparing and consolidating the next generation of public health leaders, academic public health programs should seriously consider integrating concepts of risk assessment, risk tolerance, risk communication and risk management as part of their core curriculums.
(3) Over the course of the past 3 months, from a small outbreak in Wuhan to a full-scale pandemic around the world, leaders in Western democracies have demonstrated different approaches to handing the evolving science around COVID-19 and epidemiological data. With regards to the trust in science and data, some leaders have been plainly dismissive, others have had to re-adjust their positions a few times, and a handful of leaders were very attentive to infectious disease experts. For example, Canada was instrumental in using the expertise of the Public Health Agency of Canada, created shortly after the 2003 SARS outbreak, to drive policies based on objective, up-to-date and reliable data.
How the course of the epidemic unfolded in each jurisdiction depends in large part on how the scientific advice was delivered, received and acted upon. How we manage the relationship between science, policy and politics in the foreseeable future will have a major impact on how much scientists can influence evidence-based public health policy.
1. Dong E, Du H, Gardner L. An interactive web-based dashboard to track COVID-19 in real time. Lancet Infect Dis. Feb 19 2020.
2. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. Feb 15 2020;395(10223):497-506.
3. Cheng ZJ, Shan J. 2019 Novel coronavirus: where we are and what we know. Infection. 2020/04/01 2020;48(2):155-163.
4. Verity R, Okell LC, Dorigatti I, et al. Estimates of the severity of coronavirus disease 2019: a model-based analysis. Lancet Infect Dis. Mar 30 2020.
5. Spiteri G, Fielding J, Diercke M, et al. First cases of coronavirus disease 2019 (COVID-19) in the WHO European Region, 24 January to 21 February 2020. Euro Surveill. Mar 2020;25(9).
6. Marchand-Senecal X, Kozak R, Mubareka S, et al. Diagnosis and Management of First Case of COVID-19 in Canada: Lessons applied from SARS. Clin Infect Dis. Mar 9 2020.
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8. Bernard Stoecklin S, Rolland P, Silue Y, et al. First cases of coronavirus disease 2019 (COVID-19) in France: surveillance, investigations and control measures, January 2020. Euro Surveill. Feb 2020;25(6).
9. Lillie PJ, Samson A, Li A, et al. Novel coronavirus disease (Covid-19): The first two patients in the UK with person to person transmission. Journal of Infection.
10. Fan C, Liu L, Guo W, et al. Prediction of Epidemic Spread of the 2019 Novel Coronavirus Driven by Spring Festival Transportation in China: A Population-Based Study. Int J Environ Res Public Health. Mar 4 2020;17(5).
11. Kuo L. China denies cover-up as Wuhan coronavirus deaths revised up 50%. The Guardian, 2020.