This is a post heavily revised from an initial one (since retracted) where we expressed substantial outcry over the warning failure of Jordan. After years of monitoring the world for infectious disease crises, even an analyst feels the need to push the chair back from the computer, run hands through hair, and give a good yell of anger. The point of frustration is a continually demonstrated inability to protect through the action of warning, a problem that has been resident in the global public health infrastructure since at least World War II.
Here we present a case of nested warning failure involving multiple source countries associated with what is now known as “novel coronavirus” who resisted reporting of an international health event of serious potential public health impact… and allow the International Health Regulations to do what they were supposed to do: provide warning. Here we define the word warning as:
When originally conceived, the International Health Regulations provided a mechanism of simply expressing disease notification priorities for the international public health community. This community, when considered on a routine operational basis, functions in parallel but separately from daily clinical medicine. When it comes to the issuance of warning, information is withheld due to a variety of reasons:
- permission to distribute the information given by the source;
- concerns about instigating “panic”, with specific concern for economic disruption;
- protection of the involved public health agency’s credibility in a situation of high uncertainty;
- concerns about disruption of diplomacy;
- security concerns related to questions of attribution or proximity to a highly charged conflict zone or area of political instability;
- lack of appropriate professional competency in the analysis of infectious disease event signatures and issuance of warning;
- lack of diagnostic confirmation;
- ineffective leadership;
- potential for embarrassment to political leadership that public health answers to, be they funders or hierarchical governmental authority (or both);
- and so on.
Several key events in modern times such as the emergence of HIV/AIDS, outbreaks of Ebola, translocation of West Nile virus to the western hemisphere, and so on highlighted the need to update the process of international health event reporting into a framework that offered more agility in reporting... that served the public health community and its trappings within its political sensitivities. The time period was the late 1990s, amidst a new marketing effort that encompassed and combined the concerns of emerging pathogens, antimicrobial resistance, and bioterrorism.
The latter topic evoked a demand to integrate national security interest (on the part of the UN Member States) with that of public health to produce the concept of health security. Many of the jaded old guard in public health felt this would represent simply the old "hat trick" of the late 1990s: “give me funding to ‘stop Ebola’ and I will reroute the funding to higher public health priority areas such as cholera”. Indeed, there remains tremendous debate about prioritization of those infectious disease threats that are truly disruptive to society writ large... and that overlap with national security concerns. Here we offer the same viewpoint in the President's recent perspective of biosurveillance, which acknowledges what those of us in the profession knew for years: that the concerns of attribution (i.e. intentional, accidental, or natural etiologies) are irrelevant from the perspective of warning and immediate response. In other words, the trite phrase, "Mother Nature is the worst terrorist." Of course, there were exceptions to this rule, as exemplified by the political exploitation of knowledge that the UN accidentally introduced cholera to the Haitians. Such exploitation can interfere with emergency medical response efforts as politically motivated conflict erupts.
In the late 1990s, a small group of individuals filled the gap left by a lack of bureaucratic recognition of the need for more agile reporting. This was an important pre-institutionalization period, where the International Health Regulations had not been updated, and there was a fair amount of unstructured agility in infectious disease event reporting. This was the time period that GPHIN, ProMED, and the GOARN were born. This was a time when it was recognized the bulk of unusual infectious disease reporting to WHO was via media reporting due to lack of indigenous public health infrastructure, lack of Member State willingness to report, among other reasons. Since SARS, however, bureaucratization of the process has now resulted in a mechanism that certainly can not be called "agile".
The tension has always revolved around encouraging a Member State to report versus maintaining trust by respecting their wishes whether to report. This has been a problem for years. Unfortunately, the events of SARS showed the world the incredible socio-economic disruption that may result when dealing with a lethal pathogen that had not been previously recognized. In other words, the curse of a very real biological hazard that is associated with tremendous uncertainty regarding transmission patterns, clinical features, lack of diagnostics, etc. Needless to say, this was an issue of failure to recognize blatant signature patterns in publicly available Chinese media sources that were present for months prior to WHO awareness. Such events are particularly dangerous for the world because of problems with signature recognition (emphasis on human recognition versus automated collection of the information) combined with inevitable bureaucratic hesitation to report.
However, that is precisely what happened again in the case of Jordan in April 2012, where in a manner similar to the emergence of SARS a blatant signature appeared in publicly available media. This signature described an unknown respiratory agent that killed patients and staff in a Jordanian ICU, which was also associated with clear social disruption. This signature was obliquely referenced by WHO and ECDC in their weekly reporting at the time as a non-prioritzed surveillance topic, and the amateur group Flu Trackers reported the thread to ProMED on April 22nd. ProMED at the time declined to post the event.
As WHO has publicly indicated, the US Department of Defense was called in to assist in diagnostic evaluation but were unable to identify the pathogen. The Jordanians elected not to formally report the event, perhaps because there was no apparent evidence of further spread in the community. As a consequence, no medical responder in any of the countries connected by direct, non-stop air traffic was appears to have been notified. We look back to the events in Hong Kong and Toronto, where patients and medical staff, unprepared and not pre-empted to prepare, were infected unknowingly by a previously undescribed pathogen that resulted in unnecessary loss of life and massive socio-economic disruption. The key to any community’s sense of socio-economic stability in the context of such events is the integrity of their indigenous response capacity and capability- which effectively is “flying blind” with out warning.
It was only two days ago that the ECDC stated:
The limited information available about this outbreak does not allow for an assessment of whether human-to-human transmission has occurred or indeed whether the cases in this cluster had the same cause.
Here we note that WHO gave limited insights into what happened in Jordan seven months after the fact. Here we note ECDC’s above assessment is provided also, more than seven months after the fact. Here were the megalopolitan cities and countries placed on the line:
- Frankfurt, Germany
- Paris, France
- London, UK
- New York City, NY, USA
- Budapest, Hungary
- Addis Ababa, Ethiopia
- Bucharest, Romania
- Kyiv, Ukraine
- Madrid, Spain
- Boston, MA, USA
- Tel Aviv, Israel
The connected events in KSA and Qatar involving novel coronavirus must also be addressed in this context, as lives were again put at risk. It remains notable that had it not been for an Egyptian in the employ of the Saudis, ProMED would not have reported unusual respiratory disease that originated in KSA. It may be then pointed out that Irene Lai of ISOS might not have been prompted to remind the international community of the curious events in Jordan.
The combination of the above reveals a nested warning failure involving multiple source countries who hesitated to report and allow the International Health Regulations to do what they were supposed to do: provide warning.
So, we have three countries over the span of seven months associated with a previously unknown lethal pathogen, possibly transmitting human to human, and associated with tremendous uncertainty regarding transmissibility, ecology, pathogenesis, etc. Bottom line, there were no guarantees that translocation to other countries would not happen during all of this… hesitation… to warn.
Meanwhile, physicians, nurses, patients, and the humming economy of cities around the world were placed on the line while a gamble on translocation was placed. As an emphasis of just how big this exposure footprint was, we offer the much more extensive list of countries connected by direct, non-stop air traffic to Jordan, Qatar, and KSA:
- Cairo, Egypt
- Dubai, UAE
- Karachi, Pakistan
- London, UK
- Beirut, Lebanon
- Paris, France
- Kuwait, Kuwait
- Islamabad, Pakistan
- Frankfurt, Germany
- Mumbai, India
- New York, NY, USA
- Calicut, India
- Chicago, IL, USA
- Hong Kong, SAR
- Bangkok, Thailand
- Amsterdam, Netherlands
- Colombo, Sri Lanka
- Manila, Philippines
- Tel Aviv, Israel
- Peshawar, Pakistan
- Kuala Lumpar, Malaysia
- Abu Dhabi, UAE
- Cochin, India
- Alexandria, Egypt
- Riyadh, Saudi Arabia
- Zurich, Switzerland
- Trivandrum, India
- Damascus, Syria
- Hyderabad, India
- Lucknow, India
- Rome, Italy
- Madrid, Spain
- Cross-connectivity between Jordan, Qatar, and KSA
- And a multitude of other cities and countries
The Saudis pointed out the tremendous risk involved with issuance of a warning just prior to the Hajj. But played out where warning was provided back in April during the events in Jordan, there would have been plenty of time for the Saudis to craft an appropriate message for Hajj pilgrims. This is the key. Warnings (and forecasts, the work I am currently focused on at Ascel Bio) create opportunities – indeed new obligations to craft better pro-active guidance. Armed with tornado, micro-burst, and hurricane warnings, we don’t fly airplanes into these hazards any more, we guide them along safer paths. Informed of bad weather, we guide the population to wear raincoats, and take precautions.
What this experience shows, as now an ever-increasing list of experiences show, is that public health may not be the appropriate custodian of such functions and that there continues to be a role for non-government institutions and the private sector. In America, private industry has stepped into such gaps historically, with success. The example here is private meteorology. Here in this case (and has been shown in other cases such as the 2009 H1N1 influenza pandemic), it is apparent this is a necessary step to protect our medical infrastructure and by proxy, our communities. Private enterprise should at least be given the same opportunity and benefit of the doubt to protect communities that governments have been given, albeit with limited success, for the past 50 years.
Let me be clear, there are forecasts available to the public today by my firm Ascel Bio. We recently proved this with our forecasts regarding the now-recognized spike of cholera in Haiti and the early appearance of influenza in the US. We have operated the National Infectious Disease Forecast Center here in the US for the last two years. It functions independently of official public health mechanisms and supports a professional forecast and warning culture. It is possible to do a better job recognizing high-threat indicators and communicating warnings to the public. In the United States this very statement should be a serious wake-up call to any public health official wondering which way the wind is blowing, and what the right side of history is.
In the United States, government readers would be wise to examine precedent of NOAA’s partnership policy and pick up a copy of Michael Smith’s excellent book Warnings, with an eye towards the future. Now is the time for these same readers to review case law relating to the use of weather forecasts and warnings, and reconsider what their obligations and liabilities really are. There are many relevant precedents both in policy and in case law relating to the use of forecasts and warnings.
Indeed, any US enterprise that claims “pandemic risk” or “influenza” as a “key risk” (for example in Section 1.A. of 10-K annual reports to shareholders) may wish to inform itself on the issues and precedents from meteorology – examining obligations established, for example, in the wake of the Delta Airlines Flight 191 crash.