China's contempt for compliance with international law calls for rethinking public health diplomacy

The International Health Regulations have been around since the 1960s and agreed to by the World Health Assembly, binding all members of the World Health Organization. But the IHR of 1969 was weak, at best, in terms of obligations on members. There were only four reportable diseases, one being smallpox which dropped off the list in the late 1970s and the remaining diseases, Yellow Fever, Cholera and Plague were not frequent epidemics and all of them had treatment protocols that would contain any outbreak.

The SARS pandemic, often called the first pandemic of the millenia, started in Guangdong, China in November 2002, and was kept quiet by the Chinese government. But in February 2003, a doctor brought the virus to Hong Kong, and began the worldwide spread that resulted in more than 8,000 infections and 800 deaths in 26 countries before it was contained or just disappeared as it evolved. The World Health Organization had only the IHR of 1969 and no obligation for China to report a novel coronavirus, only one of the three reportable diseases. While it had been clear for some time that the IHR of 1969 needed to be updated, the shameful failure of China to report the outbreak and allow it to spread beyond its borders before allowing help to arrive in identifying the virus, pushed the revision of IHR to the top of the WHO Agenda.

So immediately after the spread from China to Hong Kong, and the refusal of China to cooperate with outside scientists, the World Health Organization assembly of members, the World Health Assembly, passed a resolution, WHA 56.29, May 28, 2003, that urged WHO member states to take eleven specific actions to enhance, support, and strengthen national, regional, and international efforts to address the SARS outbreak. But most significantly, they also passed resolution WHA 56.28, to begin revision of the IHR, urging member states to give “high priority” to revising the IHRs 1969 and “to provide the resources and cooperation necessary to facilitate the progress of such work.”
Most importantly, WHA56.28 granted the WHO power to intervene by sending WHO teams to independently investigate and conduct “on-the-spot studies” to determine whether national authorities are taking “appropriate control measures.”

The Washington Post reported that the actions by the World Health Assembly “mark the first significant expansion of WHO power in more than three decades.”  They wrote that WHA56.28 “frees [the] WHO from having to wait until a country officially reports an international health threat before beginning countermeasures . . . and gives the agency the authority to begin ground inspections without a formal invitation.” [Rob Stein, WHO Gets Wider Power to Fight Global Health Threats, Wash Post A15 (May 28, 2003)]. Everyone knew why WHO was granted to the power to enter a country without invitation, and it was clear that China had paved the way for such a sovereignty-infringing regulation and making it acceptable to WHO Members.

China was silent, while WHO tried diplomacy to gain access for scientists to diagnose the disease. After gaining access to enter China around March, by April WHO was threatening to leave and withdraw resources because of lack of cooperation by China. 

Meanwhile, the revision of the IHR was underway and a final draft was signed by the Members of WHO in 2005 and the regulations became effective (and binding) June 2007. China was a signatory, and they agreed to be bound by the new regulations that required reporting within 24 hours of confirming a disease with certain charateristics that would add up to threating global public health, identifed as a Public Health Emergency of International Concern (PHEIC).

Now, twelve years after the IHR went into effect, in 2019, another coronavirus emerges within China's borders; and again, China sat silent, even punishing those who would dare to speak out about the novel deadly coronavirus. But the IHR anticipated this type of secrecy and so it also provided for reports to come from reporters or individuals directly to WHO, alerting WHO of a disease coverup. The country is notified for a response. This is the legal mechanism that allowed WHO to pursue the COVID-19 reports followed by the obligatory response of China based on individual reports leaked from the country. So China failed to comply with its simpliest requirement to send a notification to the WHO within 24 hours of determining they had a disease that met the definition of a PHEIC.  Years of diplomacy to ensure the problem child of the international public health community, China, would comply with regulations so clearly triggered by China's failures during SARS.

So the difference between SARS and COVID-19 for China is clear. For SARS, China was just a morally and ethically bad global citizen. For COVID-19, China violated international law by all accounts and should be accountable in an appropriate judicial or diplomatic forum. Ideally, the IHR violations should trigger the WHO or even the UN Security Council to sanction China for violating international norms and regulations.

What does this say for the value of international law if China is given a pass by the WHO for this history of violating international norms and rules? It makes all international law, weaker.

Maybe WHO as an international diplomatic mechanism is something that is time to rethink, and maybe withholding dues to an organization that has done nothing to enforce its IHRs is not so unreasonable.

Has anything really changed with our way of coping with pandemics in human history?

An excerpt from an 11-year old's journal in 1912 about a smallpox epidemic in her town and how it affects her family was published by a relative in the Coeur d'Allene newspaper today, and the observation that I have to make is that we are dealing with COVID-19 about like we did with smallpox in 1912, without a lot of advancement. Quarantine and isolation is in use, but with slightly less constitutional due process, and family social-distancing is practiced. The same family factors are still important --the father is missing work, and the extended family is buying groceries and leaving them on the doorstep for the sick family.

Let's not stop with the analogy, and continue to travel back in time.

The year is 1350, and the black plague is in full force in Europe. Without any knowledge of germ theory, social distancing is still practiced and is the rule of the day. Some towns are completely quarantined and no one enters or leaves. Some houses are boarded shut -- with the residents inside, who were destined to pass on from the plague. The religious leaders said the pandemic was punishment from God, and flagellating zealots wandered from town to town in hopes of redeeming society, and bringing a close to the largest wave of death ever seen by Europe (in recorded history). Doctors and everyone who could afford a mask, wore one. By the time the plague arrived again in the 1400s, King HenryVI banned kissing in England; and in the 1600s, the iconic doctor's mask with a large beak, made of leather and stuffed with fragrant flowers, was the standard of personal protective equipment.

Nothing much has changed. We seem to be coping with the pandemic much the same way we did with the same tools since the 1300s, with incremental improvements from century to century. Quarantine and isolation are still are best tools to fight COVID-19; masks and "face coverings" are the standard of personal protective equipment for leaving your home, if you can; and some religious leaders are suggesting the world is being punished for its sins. I am not disputing the truth of that, I am simply saying we are still saying the same things and doing the same things in response to a pandemic, as we did since the beginning of recorded history, despite the industrial revolution, the physics revolution and now the biotechnology revolution.

So what, if anything, has changed?

Hope that we can cure it -- a realistic hope. As a society we are not panicked because we know that in infectious diseases of the past, we have followed a process of researching and using vaccines to combat viral infectious diseases, including childhood diseases, and yes, that scourge of smallpox. We also have the benefit of centuries of data on the epidemiological curves (a mid-19th century discovery) and have some imperfect projection of how we will reach a peak, how high the peak might be, and when we can expect to see changes to the infection and death rate. Yes, it is imperfect, but it gives us an edge on predictability, that we didn't have in 1352, or even 1912. There was such a complete lack of hope during the Black Plague, and many thought the end of the world was coming, that there was wild drunkenness and orgies in defiance of the expected coming end of the world.

One other notable similarity -- our counts of deaths during the Black Plague in Europe are fairly accurate; yet, we have no accurate information about the true number of deaths in Asia from the Black Plague. Some things never change.

The compliance and calm has been strikingly successful, leaving us with the final observation that we have a realistic hope for a way to win in this war against COVID-19, in a way, our human predecessors did not. We are also able to adapt to our isolation through the humanity-changing technology, with our worldwide interconnection through the internet. Many (not all) are able to continue working online, ordering food online, and learning online. We are incrementally less disrupted, by these incredible changes to the way that humans connect.

Will this change us when COVID-19 subsides? If the changes after 9/11 and the anthrax attacks are any indication, we will be changed by this forever, in some major ways and some subtle ways. Will we move farther into cyberspace to connect, and thereby be less disrupted by the next pandemic?

Almost certainly. 

Ethics of Selecting who gets a ventilator

This is not a shocking new idea, although it is the next step that we will have to take while we simultaneously try to flatten the curve of the infections.

The predicted shortage of ventilators has raised the question of how hospitals will select who gets a ventilator, and essentially, who lives and who dies?

Some considerations for ventilator distribution is first, to what cities should the stockpiles be sent? Should this be on a per capita basis, or on the actual, not predicted, cases? Now that directives on how to use a ventilator on two people have been discussed, that should be the first consideration before making any choices. Looking to the ethical guidance issued during the vaccine shortage of 2003-4, reveals some of the key considerations for similar respiratory distress risk groups.

During the bird flu outbreak the flu vaccine was in short supply because the U.S. supply had been sourced from a vaccine facility in France that had a contamination incident, and no shipment could be made to the U.S.. The second reason was a shortage of eggs that are used to make vaccine. Bird flu meant a lot of birds were destroyed creating an egg shortage, as well as a concern of contaminated eggs.

The New York Times reported on October 7, 2004, that the U.S. will receive only about 55 of the 110 million doses of flu vaccine ordered.

This led the CDC to convene its Advisory Committee for Immunization Practices (ACIP) to determine who would get the flu vaccine, since not everyone would have access to it.

Although CDC wrote that each group had the same priority, the listing had the effect of suggesting a priority in this order:

1. infants

2. elderly

3. chronically-ill

4. front-line medical workers

Many were critical at the time that front-line medical workers should have been at the top of the list rather than at the bottom. CDC was planning to revisit the hierarchy and mercifully, the flu season ended without being as bad as expected. In 2005, CDC made recommendations again, and healthcare workers were near the top of the list.

Since 1990, flu vaccinations in the U.S. nearly tripled in the 1990s, making the 2004 shortage a real issue (see graphic).

When the ACIP or ethics board gathers to consider who gets a ventilator, let's hope that healthcare workers are at or near the top, because the preservation of life (without question) is directly dependent on healthcare workers.

The Trajectory of COVID-19 cases in Select Countries

The trajectory of COVID-19 shows a very different rate of reported new cases.

The trajectory for Italy is strikingly more steep than for South Korea. Some epidemiologists are offering the analysis that there are more elderly people Italy (23% over 65 yrs)  than in South Korea (13% over 65 yrs) as the primary reason for the difference. 

I would like to suggest it was more related to the policy decisions made to stop the spread of the virus, which included immediate isolation and quarantine as well as some methods that would be unacceptable in the U.S. or Europe, such as contact tracing through cellphone records. The government had data about every contact each individual with a cell phone had, enabling the government of South Korea to reach those contacts of infected individuals immediately to contain the spread by isolating or quarantining those that had come in contact with the infected individual. In contrast, according to CGTN (China Global Television Network) the "Mayor of Florence Dario Nardella has suggested residents hug Chinese people to encourage them in the fight against the novel coronavirus."  That was good in spirit, but resulted in a lot more than hugging one individual, where several people would embrace each other at once -- not recommended public health practice. By having groups of 3-4 people hugging each other, it was the opposite of WHO recommendations to practice social distancing. 

The analysis of public health measures will continue to unfold as the escalation of cases continues. But there is hope with the Italy trajectory. Yesterday, there was a drop in cases, that we hope indicates the end of the second peak that is typical in a highly infectious event. There may even be a third peak, but predictably lower.

"Self-isolation" vs. "self-quarantine". What's the difference?

I have been asked these questions, including the question in the title of this post. I thought it would be useful to share the answers, here.

How do “self-isolation” and “self-quarantine” differ? 

The short answer is “quarantine” is for anyone who does not show symptoms but may have been exposed to a contagious diseases; whereas, “isolation” is for anyone already infected or likely to be infected due to an exposure. Both are done to prevent transmission of the disease to others.

The recommended definitions for “isolation” and “quarantine” in the Model Public Health Act (that is not law unless it is adopted by a state legislature or a form of it) may have been adopted by any state in their public health laws. Keep in mind, every state has their own public health law, these are just recommended standard definitions, not law.

(30) “Isolate,” “Isolated,” or “Isolation” means the physical separation and confinement of an individual or groups of individuals who are infected or reasonably believed to be infected with a contagious or possibly contagious disease from non-isolated individuals, to prevent or limit the transmission of the disease to non-isolated individuals.

(53) “Quarantine” means the physical separation and confinement of an individual or groups of individuals, who are or may have been exposed to a contagious or possibly contagious disease and who do not show signs or symptoms of a contagious disease, from non-quarantined individuals, to prevent or limit the transmission of the disease to non-quarantined individuals.

The World Health Organization also similarly defines these terms in the International Health Regulations (IHR), but includes articles and animals as well as humans, unlike the Model Act definitions:

“quarantine” means the restriction of activities and/or separation from others of suspect persons who are not ill or of suspect baggage, containers, conveyances or goods in such a manner as to prevent  the possible spread of infection or contamination;

“isolation” means separation of ill or contaminated persons or affected baggage, containers, conveyances, goods or postal parcels from others in such a manner as to prevent the spread of infection or contamination;

·  What do we know about the risk of people going out once they are told to self-isolate? How likely are they to spread it? 

Our system of quarantine/isolation has always been based on the concept of the “social compact” that means the government gives you the maximum amount of freedom to protect public health in exchange for your agreement to restrict/burden your own freedom to the degree required to do that. So ethical people agree to this “social compact”. The problem occurs when people do not keep that agreement, that happens more often than you would think. For example. Tuberculosis patients agree to come in everyday for antibiotic treatment in exchange for going about their day with complete freedom of movement. However, TB patients often do not show up for their antibiotics especially if they are drug addicts, so eventually, the court will agree to an order after giving them significant due process to comply with the “social compact”. The consequences of someone with COVID-19 violating their ”social compact” has high consequences. This may indicate a higher likelihood of court ordered isolations or quarantines because when balanced against the harm, the burden on the individual will be reasonable to prevent that harm. But our constitutional due process requires that we give a reliable patient the maximum freedom to self-isolate in their home with only the minimum amount of confinement necessary to protect the public health.

The infection rate is about the same as flu and SARS although with different consequences.

·  Do public health officials have any way of keeping up with all of the people who have been asked to self-isolate or quarantine? Is a court order, required?

Canada did a remarkable job of self-isolation and self-quarantine of people with symptoms or exposure to SARS in 2003-4, when they identified these travelers and sent them home and asked them to call in each day with a reading of their temperature. They communicated via telephone or Skype. This is human resource intensive, but they allowed people to enter their temperature online each day, reducing the human resource burden near the end of the cycle of SARS. We should be able to do that. If someone missed calling in, a human followed up with a phone call or a visit.

The U.S. is asking its citizens to honor the social compact and use social distancing even if it is inconvenient, both for the safety of the individual and the safety of others. The U.S. or its states may even ask for self-isolation or self-quarantine of particular individuals, again asking them to honor the social compact. We can do it.

What is a pandemic vs. an epidemic?

The World Health Organization (WHO) on March 11, finally issued the official decree -- COVID-19 is now a "pandemic".

The WHO has criteria for phases of pandemic influenza and they have applied that criteria to Bird Flu and even SARS. There are three criteria that must be met, which you can see from the WHO graphic. First, that the disease is contagious to humans or animals; second, there must be a sustained human to human transmission; and third, it must have "widespread human infection". Even after 34 countries were reporting cases of human to human transmission of COVID-19, WHO had not yet determined this met the "widespread human infection" criteria and many were wondering what it took to meet that criteria, if not 34 countries?

It took 114 countries. 

The WHO Director-General in his remarks, said that "In the past two weeks, the number of cases of COVID-19 outside China has increased 13-fold, and the number of affected countries has tripled."  Further, " we are deeply concerned both by the alarming levels of spread and severity, and by the alarming levels of inaction."

This graphic shows the decision-framework WHO uses to assess where we are in the phases before and after a pandemic. The announcement on March 11 is the Phase 5-6/ Pandemic phase. Look for WHO to next consider "post peak" status, hopefully in the near future. Since China and the Republic of Korea have 90% of the cases and have now shown declines in new cases, that's a good sign for the rest of the world. The move toward "post peak" for these two major nation contributors to the number infected indicates other countries should follow that drop in reported cases in the coming weeks depending on the controls and government interventions. 

Let's hope for the post peak announcement this spring.

Contact tracing for airlines -- no more excuses

In 2005, after the SARS global incident, and in preparation for a Bird Flu, the HHS proposed a rule requiring airlines to collect contact information for each passenger in the event they needed to be contacted because of exposure to another passenger, that might be discovered after the flight had ended. The airlines objected loudly to this new administrative burden, citing additional costs and even space on their servers would be exceeded by collecting this information. They objected because of stricter privacy laws in Germany, and our reservation system is Amadeus, a German application used by most airlines. Because the information is stored in Germany, the privacy violation happens within the jurisdiction of Germany even though it is transmitted electronically, it is still in the jurisdiction of Germany requiring compliance with German law. 

Graphic of patient zero on a flight and the passengers who were infected with SARS.

Are these issues still a concern in 2020? It is now 2020, and a revised rule is being proposed again, prompted by the risk of COVID-19 spread, as of  Feb 12, 2020, 85 Fed. Reg. 7874. This follows a notice of proposed rulemaking in 2016, 81 FR 54229, following the MERS and Ebola incidents. This proposed rule was published as a final rule, effective Feb 27, 2017, 82 Fed. Reg. 6890, codified at 42 CFR 70-71. The changes in the rule were noted that the domestic portion of this final rule includes new regulatory language clarifying when an individual who is moving between U.S. states is ‘‘reasonably believed to be infected’’ with a quarantinable communicable disease in a ‘‘qualifying stage.’’ These determinations are made when the CDC considers the need to apprehend or examine an individual for potential infection with a quarantinable communicable disease. 

So what does this mean? The rule explanation further clarifies who can be "apprehended": apprehension of an individual is based on a variety of criteria in addition to an illness report including: Clinical manifestations, contact or suspected contact with infected individuals, host susceptibility, travel to affected countries or places, or other evidence of exposure to or infection with a quarantinable communicable disease. 

Since the Paperwork Reduction Act is triggered by the collection of information, and MERS and Ebola were cited as a need for the regulation, there is a directive on the time for collecting this information: While HHS/CDC currently has approval to collect certain information concerning illnesses and travelers under OMB Control Numbers 0920–0134 (Foreign Quarantine Regulations, expiration date 05/31/2019) and 0920– 0488 (Restrictions on Interstate Travel of Persons, expiration date 05/31/2019).

Now, back to the current interim regulation, the collection of information is an enforceable rule when final, but it requires an order from the Director of CDC to begin collection of personal information: By this interim final rule, CDC requires airlines to collect and submit via electronic means to CDC, beginning within 24 hours of an order from the Director, certain data regarding passengers and crew arriving on flights arriving in the United States from foreign countries. CDC believes that this is the only mechanism by which it can efficiently obtain the information it needs for a public health response to outbreaks of communicable disease and that current regulatory requirements are not sufficient, especially in public health emergencies. CDC will exercise enforcement discretion where appropriate.

So, on Feb 18 2020, the CDC ordered the airlines to begin collecting personal contact information for passengers and crew traveling from China (or having been in China within the last 14 days), citing the proposed rule published Feb 27. 

How is contact tracing for airlines working in the U.S. for domestic flights? Here's my personal story. Yesterday, March 11, 2020, while on a flight, I spoke with a passenger who had been on a flight with a passenger who tested positive for COVID-19. I asked him how he found out --- was contacted by the airline. I had hoped the answer was that he had been promptly contacted by the airline but it was not his answer. He said he heard it on the news.

No more excuses, it is time for airlines to accept their responsibility. CDC has the authority to order the airlines to collect this information. The economic impact analysis states there was found to be no additional cost to the airlines for implementing this rule. 

Update, 3-16-2020: The ICAO, an independent association of international airlines develop common guidance for airlines. Here is their directive on contact tracing: "Airport preparedness guidelines for outbreaks of communicable disease" issued by ACI and ICAO (Revised April 2009):
Note.: To assist contact tracing, a passenger locator card is available on the WHO website (www.who.int/csr/ihr/locator_card) and a copy is provided in the Attachment to these guidelines. The International Air Transport Association, assisted by relevant experts, is evaluating different electronic methods that could facilitate traveller tracing.