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Published since 1940 | Vol.69 No. 7

WHO, Infectious Disease Surveillance and COVID-19

By Joy D. Fitzgibbon

Synopsis

WHO has long been considered the central agency responsible for the global surveillance of infectious disease. The COVID-19 pandemic reveals vulnerabilities within their surveillance system. WHO’s strained surveillance capacity following multiple budget cuts and its dependence upon the surveillance capacity and national reporting of its member states calls into question WHO’s ability to monitor the transmission of infectious diseases within states and across borders—a role that is arguably a core part of its identity and mission. This article will explore these dynamics as they are unfolding in the COVID-19 pandemic, identifying the complex relationships that form the basis of their global surveillance capacity. It will, in particular, discuss WHO’s failure to prevent the global spread of COVID-19 in light of the role played by China’s controversial national public health surveillance actions, the vacuum left by a weakened US Centres for Disease Control under President Trump and the impact of Canada’s curtailed Global Public Health Intelligence Network. The article will conclude with policy recommendations for the WHO and for Canada as we consider our relationship with the WHO and our responsibilities in the governance of global health.

February 2021

Canadian International Council

President and Research Director / Ben Rowswell

Programming Manager / Daniel Lis

Operations Manager / Catherine Hume

Chair of the Board / William C. Graham

Copyright 2021 by the Canadian International Council.

The opinions expressed in this publication are those of the author and do not necessarily reflect the views of the Canadian International Council or its Board of Directors.

Vol. 69 No. 7 | February 2021

About the AuthorJoy Fitzgibbon received her PhD from the University of Toronto. She currently serves as Assistant Professor and Associate Director of the Margaret MacMillan Trinity One Program at Trinity College, is Fellow of College and a Senior Fellow at the Bill Graham Centre for Contemporary International History. Joy’s research focuses on solutions to governance dilemmas in global health pandemics and on violence against women in conflict zones. A recipient of a joint Social Sciences and Humanities Research Council of Canada/ Canada Health Services Research Foundation Grant for her doctoral research on Harvard’s Partners in Health and its policy advocacy at the World Health Organization, she is also the co-author of Networks of Knowledge (University of Toronto Press) with Janice Stein, Richard Stren and Melissa MacLean. She has served as a governance and policy advisor on the board of Food for the Hungry Canada, lectured as faculty in the International Paediatric Emergency Medicine Elective and in the Canadian Disaster and Humanitarian Response Training Program and submitted policy reports to various government agencies including the then Canadian Centre for Arms Control and Disarmament and the Canadian International Development Agency (with Janice Stein).

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consensus on the aerosol nature of transmission, finally acquiescing on July 9 after over 130 scientists sent an open letter to the organization criticizing its inaction. These delays hindered effective national responses.

Certain harmful aspects of WHO’s bureaucracy provide one possible explanation for these failures. The organization often lacks front-line knowledge, complex standard operating procedures delay rapid action and inadequate public health responses are at times tolerated in the name of resource scarcity. It is clear, however, that a more comprehensive and collaborative global surveillance system is required in support of WHO’s efforts. WHO cannot prevent and arrest pandemics without wide-ranging and effective national partnerships. A recent interim report from the Independent Panel for Pandemic Preparedness and Response argues that WHO is “gravely limited” in its capacity to confirm national reports of disease outbreaks and to deploy containment resources locally and that the organization has been “underpowered to do the job expected of it.” Related, the global pandemic alert system is “not fit for purpose” requiring significant technical upgrades to enable immediate access to data and rapid decision making across a network of local clinics and laboratories. Such a system must be accompanied by political commitment by all member states to act immediately and comprehensively following an alert. Undergirding these weaknesses is an impoverished global funding infrastructure for pandemic preparedness which inhibits preventative action.1

Emerging evidence suggests the virus appeared weeks before the story was leaked on Dec 31, 2019 in media reports coming out of China. The Panel confirms what many suspected—there were lost opportunities within China to use well-established public health tools to contain the virus in its earliest days.2 Epidemiological modelling suggests that if appropriate surveillance and comprehensive non-pharmaceutical containment measures were used early on in Wuhan, one week, two weeks, or three weeks earlier, cases in China could have been reduced by 66%, 86%, and 95%, respectively, limiting transmission country-wide.3 The late lockdown in Wuhan on Jan 23 occurred after COVID-19 migrated outside of China’s borders. These failures, and the lack of early warning from China, enabled the spread of the virus across borders.

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The World Health Organization (WHO) has long been considered the central agency responsible for global surveillance of infectious disease. Recent epidemics and pandemics, leading up to the current COVID-19 pandemic, reveal serious vulnerabilities and deficiencies within their surveillance system. Like many pandemics, COVID-19 requires locally responsive and rapid case detection through comprehensive and accurate testing, contact tracing, isolation and treatment in order to prevent transmission between patients and across borders. Such rapid and effective action would have saved lives and prevented suffering, mitigated the likelihood that more deadly strains of COVID-19 would emerge, reduced the burden on our national health systems and averted severe economic loss.

It is necessary, then, to consider what went wrong.

WHO’s core responsibilities include the responsibility to detect wide ranging threats to public health and both alert and mobilize member states to prevent disease transmission. Their infectious disease surveillance capacity has been strained for years, however. The delay in responding to the recent West Africa Ebola epidemic of 2014-2015, in detecting and treating Multi-Drug Resistant Tuberculosis in the 1990s and failures in the 1980s in response to HIV-AIDS have all led to widespread external critique and multiple policy reviews. Despite efforts to re-tool WHO into a nimble and responsive organization, significant weaknesses remain. WHO’s leadership on COVID-19 thus far illustrates these weaknesses.

In the early stages of the pandemic, WHO responded slowly and in ways insufficient for the crisis at hand. The organization first heard reports of a new pneumonia-like virus from its country office in Wuhan on Dec 31, 2019, but delayed assembling their emergency committee until January 22, 2020. WHO only declared COVID-19 to be a global public health emergency on January 30 after COVID-19 had spread outside the borders of China with documented cases in a wide range of countries including Japan, South Korea, Thailand, France, UK, Germany, Canada and the United States. They then belatedly declared the virus to be a global pandemic on March 11, long after other experts referred to it as such and global cases topped 126 000. Likewise, WHO was hesitant to acknowledge scientific data on the efficacy of masks and was far too late in accepting widespread scientific

Vol. 69 No. 7 | February 2021

1Independent Panel for Pandemic Preparedness and Response. Second Report on Progress. January 2021. To be presented 74th World Health Assembly in May 2021. 2 Independent Panel for Pandemic Preparedness and Response. Second Report on Progress.3 Lai, Shengjie, Nick W. Ruktanonchai, Liangcai Zhou, Olivia Prosper, Wei Luo, Jessica R. Floyd, Amy Wesolowski, et al. “Effect of Non-Pharmaceutical Interventions to Contain COVID-19 in China.” Nature 585, no. 7825 (September 2020): 410–13. https://doi.org/10.1038/s41586-020-2293-x.

were issued to international subscribers or to WHO.4

GPHIN issued daily situation reports on the new virus, the first on January 1, 2020 but those reports were only circulated within PHAC and to provinces and territories. In contrast to their sharply focused alert system, daily situation reports included increasingly lengthy media summaries which blunted their utility as a decision making tool. Canada was left shockingly unprepared for the pandemic and continued to erroneously think, well into March 2020, that Canada was not at risk. GPHIN scientists were sidelined by an institutional culture that no longer valued their voices as “scientific detectives” conducting international surveillance of infectious disease.5 These decisions represent a damaging policy error. Had GPHIN’s system functioned more effectively, Canada may have detected the virus sooner, enabling earlier critical assessment of the situation in China and accelerating early warning to states outside of China’s borders. In response, the Minister of Health ordered an independent review of GPHIN, with their report to be presented in Spring 2021.

The failure to detect COVID-19 before it became a global pandemic is one of the most costly public health failures of our lifetime. The results are devastating in terms of human life, personal suffering and economic stability. Those costs were preventable and the blame is not WHO’s alone. We must learn from these failures to reform our international infectious disease surveillance system. Such lessons dictate a re-invigorated, re-structured and re-prioritized WHO that is politically and scientifically authoritative. To this end, WHO would benefit from renewed global surveillance partnerships with a revitalized CDC under the new Biden administration and a well resourced and empowered Canadian GPHIN that provides cutting edge leadership on open source intelligence. Such partnerships support WHO’s surveillance efforts to detect the emergence of more severe COVID-19 variants and protect against future pandemics that could be far more virulent and deadly.

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Further, the collapse of U.S. leadership on infectious disease surveillance and control created a gap in global surveillance efforts. The Centres for Disease Control (CDC) provides infectious disease expertise and is aparter with WHO when addressing emerging pandemics.While the organization was under assault from certainvoices in Congress as far back as the Ebola epidemic,under the Trump administration the CDC was furtherweakened. Aggressive and improperly directed politicalcontrol led to a beleaguered CDC that struggled to shapean appropriate public health response and assist in globalsurveillance—most notably botching testing in the earlyweeks of the pandemic as the disease spread throughoutthe country. The Trump administration’s rejection ofscience in their pandemic response, its decision towithdraw the U.S. from WHO and a weakened, sidelinedand politicized CDC, ensured that authoritative U.S.leadership on global infectious disease surveillance largelydisappeared.

Finally, Canada was the one country with advanced surveillance tools to detect the SARS-CoV-2 virus before Dec 31 through the Global Public Health Intelligence Network (GPHIN). GPHIN is a collaborative effort between the Canadian government and the WHO, tracking biological, chemical, radiological and nuclear global health security threats, including infectious disease outbreaks. A highly regarded partner, GPHIN contributed vital intelligence on the H1N1, Zika and Ebola outbreaks. At the height of its success, GPHIN provided WHO with 20% of its infectious disease surveillance. While struggling with funding and technological advancement in recent years, GPHIN’s vital contribution is its reliance upon open source intelligence—a complex form of intelligence gathering that monitors sources outside of official government channels including social media, national and local news media, internet blogs and hospital and drug procurement data, issuing alerts and situation reports, serving as an early warning system for disease outbreaks. This approach is helpful where governments have low domestic surveillance capacity or are not inclined to publicly share information.According to a Globe and Mail investigation, the Public Health Agency of Canada (PHAC) issued a new directive to GPHIN requiring senior management approval before alerts were sent to an international audience. By May 2019, this action had hobbled the network’s international alert system. Subsequently, no alerts regarding the virus

Vol. 69 No. 7 | February 2021

4Robertson, Grant. “Ottawa Turned off ‘Wrong Tap’ on Pandemic Surveillance, Former Intelligence Adviser Says.” The Globe and Mail, October 1, 2020. https://www.theglobeandmail.com/canada/article-ottawa-failed-to-recognize-value-of-pandemic-surveillance-former/.5 Robertson, Grant. “‘Without Early Warning You Can’t Have Early Response’: How Canada’s World-Class Pandemic Alert System Failed.” The Globe and Mail, July 25, 2020. https://www.theglobeandmail.com/canada/article-without-early-warning-you-cant-have-early-response-how-canadas/.

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Behind the Headlines | February 2021

About the CICThe Canadian International Council (CIC) is Canada’s foreign relations council. It is an independent, non-partisan membership organization and think tank dedicated to advancing constructive dialogue on Canada’s place in the world and providing an incubator for innovative ideas on how to address the world’s most pressing problems.

The non-profit CIC integrates the voices of a diverse and multidisciplinary group of societal actors from academia, business, civil society, government and the media, and endeavours to inform and develop the capacity of the country’s next generation of foreign policy leaders.

One of Canada’s oldest and most respected think tanks, the CIC is not only dedicated to nurturing dialogue on Canadian foreign policy domestically, but also in projecting a Canadian perspective on the international stage. In our rapidly changing world, this effort to promote greater understanding and foster meaningful debate on critical challenges is more important than ever.

The CIC would like to acknowledge the editorial contribution of Wesley Wark and Arne Kislenko in making this series of articles possible.

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