Q & A: Dr Deoraj Caussy
Dr Deoraj Caussy practices as an Independent Epidemiologist (Integrated Epidemiology Solution at drdeorajcaussy.com). After completing doctoral studies in Virology in the UK, he proceeded to North America where he worked in various laboratories, including with the US Centers for Disease Control. He joined WHO as an epidemiologist and retired as Regional Epidemiologist in Asia, based in India. He was recruited by the Ministry of Health and Quality of Life in 2009 when the AH1N1 pandemic was declared and helped to elaborate the Pandemic Preparedness Plan. Here he gives us his views on the ongoing COVID-19 global health emergency.
How do you find WHO’s approach to the COVID19 epidemic so far?
In Sherlock Holmes’s ‘Adventure of the Silver Blaze’, a story about the disappearance of the titular race horse, on the eve of the titular Race – the watchdog did not bark. It is believed that a stranger stole the horse, but Holmes was able to pin the horse’s disappearance on the horse’s late trainer because the watchdog at the horse’s stable did not bark on the night of the disappearance, implying that the dog was known to the person who stole the horse. The entire attitude of WHO in managing the COVID-19 crisis is characterized by the ‘dog who did not bark syndrome’ of Sherlock Holmes because WHO has not declared an ongoing pandemic of COVID-19, was late in declaring an international emergency and has had nothing but praise for China.
* Give us an idea of the core role of WHO.
WHO was founded as the embodiment of health for all through its normative role of formulating guidelines and shaping global health policy. Public policy is high on WHO agenda and WHO’s classic work includes, among others, the eradication of smallpox from the face of the world. With the disappearance of smallpox and the emergence of new health threats including SARS and Ebola, the functions of WHO shifted to ensure Global Health Security by updating the International Health Regulations (IHR-2005), to which all Member States including Mauritius are signatories. This allows WHO to assess the gravity of any health-related events and, as the case maybe, to declare it as an event that represents a public health emergency of international concern.
* Could you elaborate on some aspects of IHR and its application in recent times?
The IHR (2005) is the end result of milling various strategies over the years to find a ‘one size fits all’ policy on global health security, and as such, in principle, resonates the core values of public health: equity, empowerment, effectiveness, evidence-based, fairness and all-inclusiveness. However, in practice, since its first test-case during the H1N1 pandemic influenza in 2009, and its subsequent applications for wild polio, ZIKA, and Ebola, many public health scholars have argued and challenged the merits and limitations of Public Health Emergency of International Concern (PHEIC), especially for effectiveness, evidence-based and fairness.
For instance, the speed with which an emergency was declared for H1N1 has led to the belief that WHO was in collusion with the pharmaceuticals to produce vaccine. It eventually led the then DG of WHO writing to British Medical Journal and Lancet to exonerate herself from the accusation. Controversy also surrounds the 2006 outbreak of Ebola virus disease, when WHO protracted the process of declaring an emergency, resulting in countless deaths before an emergency was declared.
Under other circumstances, WHO was quick to declare an emergency for Zika virus disease, leading people to believe that it was a move to help President Obama get Congress support to develop a vaccine for Zika that was affecting North American women. Certainly, politics, science and power are vested in the IHR-2005 each time it wields its weight to declare a public health emergency.
* What were the steps leading to declaring COVID-19 as a global health emergency?
In the wake of the COVID-19 epidemic, WHO initially quivered in declaring a PHEIC immediately, then after a week, when the epidemiology of the disease had not substantially changed, WHO finally declared a PHEIC. Do we need to revise the risk assessment process to reflect a more dynamic and realistic process, as for instance WHO does for pandemic influenza comprehensive risk assessment based on the virological properties of the pathogen?
Under the IHR, SARS belongs to a group of pathogens which invariably lead to declaration of PHEIC. Admittedly, COVID-2019 is not SARS, but the genetic analysis quickly demonstrated it as a member of SARS family, and we know how SARS was highly infectious and lethal, so these features could have been considered by the expert committee of WHO.
Many epidemiological parameters of COVID-19 were ignored and the PHEIC committee was split during its first debate. Is this evidenced-based if the members using the same criteria cannot come to the same decision? Surely, it speaks for the lack of objectivity of the criteria used for declaring a PHEIC.
* So there was a delay in declaring the emergency? Why?
One may legitimately ask why did WHO quiver in declaring an emergency for COVID-19. It is abundantly clear that WHO did not want to single out China because declaring an emergency would have led to many countries closing borders to Chinese citizens as happened during the SARS outbreak. A repeat of the situation 17 years later would reflect badly on China and would be perceived as the failure of its public health system to detect, assess, report and mount a response in a timely manner.
This 10-day grace period in declaring an emergency effectively gave China an opportunity to remedy the situation and shine once again on the world stage by implementing draconian public health measures and building new hospitals in record time. But there is more to it than meets the eyes: China is a big contributor to WHO in times when US is threatening to reduce contribution to WHO. It is no small coincidence that the DG of WHO is an Ethiopian national and Ethiopian Airlines is currently the only operational carrier between Africa and China. China has a lot of interests in Africa. The plot gets thicker. China is building a multi-million-dollar public health facility in the form of African Centre for Disease Control that is located right in Ethiopia.
Despite what WHO stands for, one has to take cognizance of the fact that global health policy is formulated and practised in the backdrop of science and politics. This politics trickles down to all levels of WHO from Headquarters in Geneva through the WHO Regional Office right to the country office. At the country level, many WHO representatives will play politics and side with the prevalent government to avoid being transferred to harsh duty stations. The representatives may undertake activities beyond their terms of reference and act in a non-impartial manner to support the government. We have witnessed this from the kid-glove manner in which the WHO team praised China and castigated other nations. Do not be surprised if you see this in our own backyards.
* How will this impact our local preparedness?
To complicate matters further, WHO keeps on giving mixed messages: this epidemic has already reached pandemic proportion by the very definition of WHO. But WHO is refraining from calling it pandemic, yet it is broadcasting the repeated message – prepare for an eventual pandemic that will have grave consequences for Africa. Mauritius is in WHO Africa region, so we will have grave consequences.
What are we doing? We are following WHO instructions religiously. Well, WHO is advocating China-style draconian measures of isolation and quarantine that are impractical outside China as amply exemplified by the inability to control the outbreaks in Japan, South Korea and Italy so far. The containment measures are not working because they are focusing on clinically overt cases, when it is abundantly clear that asymptomatic infected subjects are seeding the virus to new territories to create foci of epidemic.
We should learn from lessons gained elsewhere; any surveillance and containment measures heavily relying on symptoms will not be fail-safe.
* And how can epidemiologists assist decision makers in handling such situations?
Epidemiologists study the pattern and frequencies of disease to explain the epidemic and offer options for control measures. It is clear from observations of the pandemic thus far that we have to switch from containment to mitigation strategy to deal with the expected mortality rates that can range from 8% in the 70-79 age group to as high as 14% for the above 80 age group, in China and elsewhere. The role of epidemiologists is to be beacons in providing leadership and supporting the scientific community through collecting, validating, synthesizing and supplying evidence to inform policy options. Additionally, educating the population is paramount to empower the target groups for taking informed decision and not to act in panic or live in fear of the unknown. These are responsible roles and epidemiologists should not be deterred by criticisms aimed at silencing their voices.
In the pandemic of 2009, I have successfully demonstrated the importance of a pandemic preparedness plan in anticipating, predicting and taking control measures to attenuate the impact of the pandemic on the Mauritian population. Have we anticipated the number of persons who will require hospitalization? Do we have sufficient isolation facilities, medical equipment and medication for that vulnerable group? Do we have a plan for social distancing during the acute pandemic phase? I do not see these aspects in the current plan. Why are we still dragging our feet by being stuck on a skeleton operation plan and packaging it as a pandemic plan, when clearly it is not a pandemic preparedness plan. Could we not learn from the lessons of 2009 to formulate a fully-fledged pandemic plan, or would that be too much of an admission that Mauritius is clearly incapable or unwilling to formulate a pandemic preparedness plan? Perhaps we are still awaiting WHO instructions!
WHO delay in declaring a public health emergency and silence in declaring pandemic are reminiscent of Sherlock Holmes’ dog that didn’t bark at the culprit because it is the culprit. Unwittingly, this policy will further increase the global health inequity, and will directly contravene the WHO policy that purports to reduce global inequity in various forms of its Health for All resolutions over the decades. Sadly, this inaction will lead to countless suffering and deaths that could be averted by a more politically sound public health policy.
* Published in print edition on 12 March 2020